Professional Documents
Culture Documents
Volume 6, Issue 3
Tom Daschle
on Healthcare
Reform
The Scoop on
Support
Surfaces
FREE CE!
Bacteria’s
Create a Secret
Homelike Hiding
Environment Spots
HEALTHY SKIN
You, our readers, are on the front lines of everything that for writers and contributors. Whether youʼd like to try your
happens in the healthcare industry – and we want to hear hand at writing or offer suggestions for future articles, we
from you! Have you ever wished you could write an want to hear what you have to say! You never know – the
article that would be published in a large-circulation next time you open an issue of Healthy Skin, it might be
magazine? Nowʼs your chance. Healthy Skin is looking to read your own article!
Medline, headquartered in Mundelein, IL, manufactures and distributes Meeting the highest level of national and international quality standards,
About Medline
more than 100,000 products to hospitals, extended care facilities, Medline is FDA QSR compliant and ISO 13485 certified. Medline
surgery centers, home care dealers and agencies and other markets. serves on major industry quality committees to develop guidelines
Medline has more than 800 dedicated sales representatives nationwide and standards for medical product use including the FDA Midwest
to support its broad product line and cost management services. Steering Committee, AAMI Sterilization and Packaging Committee
and various ASTM committees. For more information on Medline,
© 2009 Medline Industries, Inc. Healthy Skin is published by Medline Indus- visit our Web site, www.medline.com.
tries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
HEALTHY SKIN
Improving Quality of Care Based on CMS Guidelines
Dear Reader,
It is with a sense of anticipation and genuine excitement program presenters, which included Tom Daschle, Dr.
that we launch this edition of Healthy Skin. Never in the Didier Pittet, from the World Health Organization (WHO);
history of this country has there been such an outpour- Dr. Trent Haywood, chief medical officer from VHA;
ing of debate and discussion on just how health care Deborah Adler, known for educational healthcare prod-
should be delivered, paid for and measured. Medline has uct packaging design and Dr. Dale Bratzler, CEO of the
been fortunate to have the opportunity on two different national hospital QIO and representing the Surgical Care
occasions, to bring together top healthcare executives, Improvement Project (SCIP) … and these are just a few
first from the long-term care industry, and then from the of the speakers. We were also honored to host Dr.
acute care industry, to discuss these issues. As a matter Harvey Fineberg, president of the Institute of Medicine,
of fact, the first 18 pages of Healthy Skin are dedicated who discussed comparative effectiveness research and
to these conferences, which were held in Washington, how it will impact the healthcare industry in the future.
DC in July and August of this year.
In this publication, we’ve given you a brief overview of
The meeting in July, The Quality Summit, brought
together executives, both clinical and administrative,
from long-term care facilities. We were grateful for the
what took place at these conferences, but I encourage
you to also visit www.medline.com to hear for yourself
the issues and potential solutions that are being dis-
“
How can we all,
working together,
opportunity to host Dr. Keith Krein, chief medical officer cussed in both the long-term care and acute care arena. provide the best
of Kindred Healthcare; Dr. Andy Kramer, division head of
healthcare policy and research at the University of Col- In August, we also announced our Discovery Grant care possible, to
orado; Mary Ousley, healthcare consultant and co-chair Award winners, listed on page 15. Medline awarded all patients all of
over $700,000 in grant money to stimulate research
”
of AHCA Survey and Regulatory and Wayne Brannock,
vice president of clinical affairs for Maryland Health En- that will lead to the development of new targeted inter- the time?
terprises, just to name a few. The discussions, including ventions aimed at reducing medical risks and potential
a presentation by Senate Majority Leader Tom Daschle, harm associated with hospital-acquired conditions, with
centered around a continuous program of quality assur- a goal of effecting quality care in all settings. This initial
ance. What are the obstacles? What has worked for grant program was so successful that Medline will be
these thought leaders to this point? How will the industry awarding a second round of grant funding. The next
be molded in the future? How can long- term care better grant application period will be from November 1, 2009
integrate with both hospitals and home care? And, how through March 31, 2010.
can we all, working together, provide the best care pos-
sible, to all patients all of the time? This was an open And that’s just the beginning of this magazine edition.
forum discussion, mixed with personal experiences, but You also will find an array of information on palliative care,
centered on defining and offering a plan for executing falls prevention, diabetes care, pressure ulcers, CAUTI,
quality care. our kick-off of our year-round breast cancer program,
“Together we can save lives through early detection,” and
The meeting in August, Prevention Above All, was geared much, much more.
toward chief medical officers and chief nursing officers
from over 100 acute care hospitals from across the All the best to you, until we meet again,
country. The emphasis of the conference was on
prevention, specifically covering innovations in the
reduction of catheter-associated urinary tract infections
(CAUTI), hospital-acquired pressure ulcers and ways to Sue MacInnes, RD, LD
improve hand hygiene practices. The audience was a Editor
powerhouse of talent, but just as dynamic were the
Content Key
Weʼve coded the articles and information in this magazine to indicate which national quality initiatives
they pertain to. Throughout the publication, when you see these icons youʼll know immediately that
the subject matter on that page relates to one or more of the following national initiatives:
• QIO – Utilization and Quality Control Peer Review Organization
• Advancing Excellence in Americaʼs Nursing Homes
Weʼve tried to include content that clarifies the initiatives or give you ideas and tools for implement-
ing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.
4 Healthy Skin
Evidence-based
data makes
it clear.
®
Remedy is like
no other.
Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.
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.
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.
Origin:
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.
The official Executive Summaries for the 9th SOW Theme are available at:
Quality Improvement Organization Program’s 9th Scope of Work Theme
http://providers.ipro.org/index/9SOW_summaries
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
Origin:
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.
The coalition is meeting to consider the following additions for the next two-year campaign:
Advancing Excellence
6 Healthy Skin
The 9th Scope of Work Content Themes
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
1. Community and provider selection and recruitment There will be two periods of evaluation under the 9th SOW. The first
will focus on three Tasks:
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-
ance on Tasks within all Theme areas (Beneficiary Protection, Care
Transitions, Patient Safety and Prevention). The second evaluation will
Theme #3: Patient Safety Activities will focus on six
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
primary Topics:
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
5. Improving drug safety – Move away from projects that are “siloed” in specific care settings
Focus for the 9th Scope of Work
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
Goal 1: Reducing high-risk pressure ulcers < 10% 11% Goal 5: Establishing individual targets for > 90% 36.5%
Clinical Goals: Goal Actual Operational/Process Goals: Goal Actual
Each nursing home participating in Advancing Excellence selects a minimum of three goals (outlined above).
Trends in Goal Selection
The goals – and the percentage of participating nursing homes that have selected them – are listed below.
This summer, while Congress was hotly debating the “The timing of this Medline conference simply could not be
merits of healthcare reform, another key meeting was better,” he remarked. “We are in the heart of this special
taking place in our nation’s capital on improving health care moment in 2009.” But he also expressed disappointment
in this country. in how the reform initiative is addressing the issues in
long-term care. There is “not sufficient awareness and
Just down the block from the capitol building in Washington, recognition of the degree to which long-term care fits into
DC, more than 100 thought leaders from skilled nursing this picture,” Daschle said. “Greater emphasis on wellness,
facilities across the country gathered to discuss the good chronic care management, reducing administrative
changing healthcare policy landscape, industry trends and costs and creating a strong technology infrastructure are
resident-centered quality assurance measures. also needed,” he added.
Former Senate Majority Leader Tom Daschle, architect of the Still, Daschle urged participants to lend their voices to the
Obama administration’s healthcare reform efforts, delivered debate to help craft legislation addressing long-term care
the keynote address at Medline’s inaugural Quality Summit: issues. He also emphasized the importance of quality initia-
A New Era of Quality Assurance in Long-Term Care held July tives to high value health care, outlining three goals he hoped
19-21. Senator Daschle praised the content and opportune reform would achieve: 1) increased access to health care,
timing of the summit. 2) cost reductions and 3) improved outcomes through
quality initiatives.
Continued on Page 10
8 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 in demo at www.medline.com/abaqisdemo.
the traditional process.
®
abaqis is the only quality assessment and reporting
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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.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc., abaqis is a registered trademark of Nursing Home Quality, LLC
The Quality Summit
10 Healthy Skin
Nancy Schwalm,
Mary Ousley, Neil L.
Pruitt Jr. and Keith
Krein at Medline’s
Quality Summit,
July 19-21, in
Washington, DC.
Panelist Wayne Brannock, vice president of clinical affairs for Quality Assurance: Truly a Year-Round Initiative
Maryland Health Enterprises in Ellicott City, MD, said using But the panelists pointed out that truly improving quality
abaqis transformed the quality assurance process at his involves more than annual state survey preparations and
skilled nursing facility. Just like QIS, abaqis requires offers greater rewards than just a successful survey.
facilities to interview staff members, residents and their
families about specific aspects of care. “Systematic quality improvement brings confidence, and it
brings trust,” said Mary Ousley, president of Ousley &
During Brannock’s first resident interview, the resident Associates in Richmond, KY, and co-chair of the American
responded negatively to the QIS question regarding bedtime. Health Care Association Survey and Regulatory. “It brings
Brannock calls the carefully worded question, “Is this confidence in your staff—[confidence] that they really know
acceptable to you?” the five magic words. what they are doing and that they are part of making change,
and it brings trust internally and externally to the organiza-
After receiving the resident’s response, Brannock said, tion from survey organizations and finance.”
“That’s the day we changed QA in our company, because
that’s the day that we started actually communicating to Ousley explained that incorporating quality measures into
residents,” he recalled. “By asking them what they really how a facility operates, versus addressing it only in response
want, we’re finding out what’s acceptable to them, and then to state surveys, was key to ensuring better care for residents
we alter our service to improve their experience.” and ensuring that the facility continuously improves.
When it Comes to Resident-Centered Quality of Care, One Size Does Not Fit All
During the Quality Summit, a chief medical officer from one way it’s supposed to be? Because that ability to vary and tai-
skilled nursing facility raised the issue of how best to define lor care is more about quality than applying that same
quality and whether the term still applied to the latest QIS structured approach regardless of the individual’s needs. We
survey guidance by CMS and resident-centered care have managed over the years to define quality with rigidities
approaches. Summit speakers Keith Krein, Andrew Kramer, that do not reflect quality.”
Mary Ousley and Carmen Shell shared their insights, each
stressing the importance of individualized care and the Mary Ousley. “The totality of services
evolution of the quality movement. that meet or exceed the expectations of
the individual defines quality,” said Mary
Keith Krein, MD. Quality starts by Ousley, president of Ousley & Associates,
recognizing the “heterogeneity of today’s drawing on the definition crafted by the
nursing centers and the fact that we have American Health Care Association and
many different types of individuals— Bernie Dana, chair of AHCA/NCAL’s
young folks, middle-aged folks, elderly National Award Board of Overseers.
folks—coming through our doors with Ousley stressed that maintenance and environmental serv-
different desires, different needs and ices may be of greater importance to one resident, while
different discharge goals,” said Keith nursing care and services rank highly for another. Only by
Krein, MD, chief medical officer at Kindred Healthcare. Dr. taking the resident’s perception and desires into considera-
Krein explained that two individuals with the same diagnosis tion can a facility truly achieve quality.
may request different types of treatment, emphasizing the
importance of taking those differences into consideration Carmen Shell. Carmen Shell, vice
when formulating a treatment plan. president of clinical services at Morse
Geriatric Center, also stressed the
Andrew Kramer, MD. “We need to importance of understanding the specific
work on the definition. The definition of goals and expectations of each resident
quality as a standard set of practices that while creating a workable definition of
are forcefully applied in every case quality. “The mistake that we make is
regardless of whether they apply or not is defining quality for others,” Shell
the wrong definition of quality,” said explained. “We don’t ask the right questions. That’s one thing
Andrew Kramer, MD, division head of about QIS that is beginning to come full circle, and that is the
health care policy and research at the right questions are being answered, but sometimes we don’t
University of Colorado. “You want to try to measure the vari- listen to the answers. The questions are being asked, and
ability in care that exists within an organization. Do you adapt the questions are getting better and better, but what are the
and customize and tailor care to the needs of all the people, answers to those questions? And if we really want to effect
or do you do the same thing every time because that’s the change, what are we doing?”
12 Healthy Skin
Mary Ousley on Quality
Survey Says…
Looking back on her decades of To get a handle on the key issues facing our nation’s nursing
experience in long-term care, homes, the more than 100 long-term care executives at
Mary Ousley believes the the Quality Summit in Washington, DC were polled on the
opportunity is before us today new QIS process and steps their facilities take to prepare
to take charge of quality.
for annual state surveys. Following are some of the poll
questions and responses:
And her definition of quality
involves far more than keeping
What are the top three things that keep you
track of QIs and QMs in note-
up at night?
books, and then analyzing the
data each month. She believes
16% Patient/resident satisfaction
quality is best achieved by integrating a quality mindset 16% State survey
into everything you do at your facility. 13% Documentation
13% Financial stability
“[Quality] is the way you run your business. It is 11% Census
embedded every single day. It is a philosophy of manage- 8% Lawsuits
ment that keeps your facility running,” Ousley said. “It is a 8% Nursing shortage
business model that takes into consideration your business 6% Education & training
systems, your clinical systems, your human resources 6% Turnover
systems. And if you run it any other way, then you won’t
really have a quality management system.” Are your survey preparation activities aligned
with your quality assurance initiatives?
“Quality management – exactly as it should work 80% Yes
– is about moving an organization forward.” 20% No
After beginning her nursing career in acute care, Ousley What do you do to prepare for the survey?
reluctantly switched to long-term care when her husband 60% Mock survey
asked her to serve as administrator for one of their family- 24% Chart review
owned nursing homes in Kentucky. 16% Attempt to predict sample
14 Healthy Skin
Special Feature
2009 Prevention Above All interventions aimed at reducing medical risks and harms
Discoveries Grants awarded associated with hospital-acquired conditions (identified by the
Dr. Andrew Kramer, professor of medicine at Centers for Medicare & Medicaid Services 2008 IPPS final rule).
the University of Colorado, and chair of the
Prevention Above All (PAA) Discoveries Grant All grant applications and proposals were independently
Review Committee, announced the names of reviewed and approved by healthcare professionals who served
the 2009 grant recipients. on the grant committee. Grant recipients will be paired with a
research mentor/consultant to develop methods and guide the
The objective of the PAA Discoveries Grant conduct of the study, ensuring that a rigorous research process
program is to stimulate research that will is followed.
lead to the development of new targeted Continued on Page 17
Pilot Grants (funding up to $25,000 each) Empirical Grants (funding up to $100,000 each)
Title: Surgical Time Out Assurance Program Title: Cost Effectiveness of a Liquid Skin Protectant in the Prevention of
Institution: Carilion Clinic, Roanoke, Virginia Heel Pressure Ulcers
Principal Investigator: Deb Copening Institution: New York Methodist Hospital, Brooklyn, New York
Target: Surgical site infection and errors Principal Investigator: Judy A LaJoie
Target: Heel pressure ulcers
Title: Descriptive Study of OR Nursing Data Elements (Perioperative
Clinical Processes, and Patient Outcomes) Title: Pressure Ulcer Prevention via Early Detection and Documentation
Institution: AORN (Association of PeriOperative Registered Nurses), (both pediatric and adult)
Denver, CO Institution: Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
Principal Investigator: AkkeNeel Talsma Principal Investigator: Marty O. Vischer
Target: Errors obtained in the perioperative area (OR processing errors Target: Pressure ulcers
and surgical patient complications)
Title: Perioperative Positioning Injuries Program
Title: Multi-institutional trial to test the validity of newly created HAI Institution: Massachusetts General Hospital/Harvard Medical School
definitions and criteria designed especially for behavioral hospital and Principal Investigator: Jesse M. Ehrenfeld
health care settings Target: Perioperative positioning-related injuries
Institution: Acadia Hospital, Bangor, Maine
Principal Investigator: Thomas Shandera Title: Family Centered Pressure Ulcer Prevention Program
Target: Healthcare-acquired infections Institution: Grady Health System, Atlanta, Georgia
Principal Investigator: Rhonda Scott
Title: Pressure Ulcer Assessment Among Ethnically Diverse Patients Target: Pressure ulcers
Institution: Kaiser Permanente, San Jose Medical Center, San Jose, Calif.
Principal Investigator: Katherine Ricossa Title: Hand Hygiene Intervention Study
Target: Pressure ulcers Institution: Englewood Hospital and Medical Center, Englewood,
New Jersey
Title: Statewide Maine Infection Prevention Collaborative (MIPC) Principal Investigator: Maryelena Vargas
Institution: Eastern Maine HealthCare System, Brewer, Maine Target: Hospital acquired infections
Principal Investigator: Erik Steele
Target: Healthcare-acquired infections Title: A Comprehensive Pressure Ulcer Prevention Program in a
Multi-System Health Care Network
Title: Progressive Mobility Among Critically Ill and Critically Injured Patients: Institution: St. Luke’s Hospital and Health Network, Bethlehem, Penn.
An Examination of Clinical Outcomes Prior to the Implementation of Principal Investigator: Joanne Labiak
Standardized Guidelines Target: Pressure ulcers
Institution: East Tennessee State University College of Nursing, Johnson
City, Tenn.
Principal Investigator: Mona Baharestani
Target: VAP, Pressure ulcers, falls, DVT, PE, catheter-associated
urinary tract infections
2. Hospital-Acquired Infections
Hand Hygiene Compliance Program
3. Pressure Ulcers
Preventing HACs is one of the most important issues in
Pressure Ulcer Prevention program
health care today. Simply put, the CMS reimbursement
changes that took effect last October 1 mean healthcare 4. Harm Avoidance and Patient Satisfaction
professionals must eliminate HACs and improve patient Educational Packaging
safety — or risk losing Medicare reimbursement dollars.
5. Objects Retained After Surgery
RF Surgical® Detection System
The good news is that almost all HACs are preventable, and
with Medline’s Prevention Above All, you will have 6. Catheter-Associated Urinary Tract Infection (CAUTI)
the knowledge and products to prevent six of the most ERASE CAUTI™ Foley Catheter Management System
common HACs. The program’s multi-layered approach
provides you with targeted evidence-based interventions that
will not only save lives but also improve your bottom line.
18 Healthy Skin
Special Feature
TN NC
AZ NM OK
AR SC
MS FL GA
TX LA
No HAI reporting required
FL
HAI reporting required
AK
HI
Mandatory HAI
Reporting in
Long-Term Care
Only four states currently require long-term care
facilities to report the incidence of healthcare- Copyright 2008 – Association for Professionals in Infection Control and
Epidemiology, Inc.
acquired infections (HAIs). The states are Oregon, Please contact communications@apic.org for reprint permission and
California, Pennsylvania and Florida, as shown on the update requests. Reprinted with permission.
map above.
WA
VT ME
MT
OR MN NH
MA
ID SD WI
NY
RI
WY MI
CT
IA PA NJ
NE
NV DE
IN OH MD
UT
WV
CO
KS VA DC
KY
TN NC
AZ NM OK
SC
MS FL GA
TX LA
AK
No public data
Voluntary reporting
HI
No reporting
State Reporting of
System pending
Adverse Events
With no national mandatory event reporting system in
place, the United States is blanketed by a patchwork
of state reporting systems collecting a variety of data
Reprinted with permission from Hearst Newspapers. Hearst research by
in different ways. The amount of information available Olivia Andrzejczak. Graphic by Kyla Calvert. Template by Alberto Cuadra.
Available at http://www.chron.com/deadbymistake/hospitals.
to the public also differs from state to state.
Patient-centered research
Therefore, the healthcare research conducted under this
initiative will be patient-centered and apply to the “real
world” in order to help patients, clinicians and other deci-
sion makers assess the relative benefits and harms of
strategies to prevent, diagnose, treat, manage or monitor
health conditions.1
20 Healthy Skin
Special Feature
The Council will oversee the $1.1 billion in funding, of which • Compare the long-term effectiveness of weight-bearing
$300 million is allocated to the Agency for Healthcare exercise and biphosphonates in preventing hip and
Research and Quality (AHRQ), $400 million to the National vertebral fractures in older women with osteopenia
Institutes of Health (NIH) and $400 million to the Office of and/or osteoporosis.
the Secretary.1
• Compare the effectiveness of diverse models of
High-Priority Topics for Federally Funded transition support services for adults with complex
Comparative Effectiveness Research3 health care needs (e.g., the elderly, homeless, mentally
The American Recovery and Reinvestment Act of 2009 challenged) after hospital discharge.
called on the Institute of Medicine to recommend a list of
priority topics to be the initial focus of a new national • Compare the effectiveness of different residential
investment in comparative effectiveness research. settings (e.g., home care, nursing home, group home)
in caring for elderly patients with functional impairments.
The complete list contains 100 topics, prioritized into four
groups of 25 each. The following is a sampling of topics that
relate to healthcare professional who care for older adults. References
1. U.S. Department of Health and Human Services. Federal Coordinating Council
They are listed in order from highest to lowest priority, for Comparative Effectiveness Research: Report to the President and Congress,
as indicated by the Institute of Medicine: June 30, 2009. Available at http://www.hhs.gov/recovery/programs/cer/cerannu-
alrpt.pdf. Accessed August 3, 2009.
2. Zigmond, J. Healthy choices: industry wonders how $1.1 billion for comparative-
• Compare the effectiveness of the different treatments effectiveness research will be applied. Modern Healthcare. March 30, 2009:
for hearing loss in children and adults, especially 6-7,16.
individuals with diverse cultural, language, medical 3. Institute of Medicine. 100 Initial Priority Topics for Comparative Effectiveness
Research. Available at http://www.iom.edu/?id=71032. Accessed August 3, 2009.
and developmental backgrounds.
22 Healthy Skin
Special Feature
I remember a television advertisement not too long ago for an My mother was widowed at 74 and continued to live an incredi-
Alzheimer’s drug that has a middle-aged woman narrating about bly active life for the next nine years or so. But then she lost her
her fear that she would have had to put her father into a nursing ability to drive. And her friends lost their ability to drive, or, in some
home if it weren’t for this medication that has allowed him to con- cases, they passed away. She then lost her ability to walk unaided
tinue living with her and her family. It was a warm-hearted ad that and began to experience urinary incontinence. Finally, she was
ended with the family having dinner together and laughing. diagnosed with early stage Alzheimer’s.
The main message of the ad was that this medication Her world, always so rich with outings, friendship, travel,
works, but the not-so-subtle underlying message is that and interest in a wide variety of activities, became
we need to do all we can to make sure that our aged smaller and smaller. It happened quickly and seemingly
parents do not have to live in the dreaded world known all at once. She was left with just two regular activities:
as “the nursing home.” If we are truly loving children, the a weekly trip to the “beauty shop” where she would get
message goes, we will do all we can to make sure our her hair done and a weekly trip to mass.
parents avoid such a hellish existence.
One of my two brothers lived with her in the house where we grew
Though the ad is effective, I became bothered by the message up, but it became clear about three years ago that she needed
that nursing homes are, without question, negative places in more assistance than he was able to give. My husband and I
which to live. I am bothered by this because I know it isn’t true: My teach English at a small college in Vermont and we, along with
88-year-old mother has been living in a nursing home for two-and- our two teenaged children, sincerely offered to have my mom
a-half years, and her time there has not only been “not negative,” move in with us. She’d always loved visiting us several times a
it has been extremely positive. In fact, it has served to bring her year since we moved here in 1989, first with my dad and then,
back to us, her three children and two grandchildren. after he passed away in 1994, on her own. But to our offer she
Continued on Page 25
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“
She moved into the nursing home in the summer
of 2005 and almost immediately we knew it was
the right choice.
”
replied, “Well, I love all of you with all my heart, but honey, what
would I do there?” And although she wasn’t “doing” much in
Michigan anymore, she did have a point. Although her world had
grown small, it was still a world with which she was familiar, in a
town where she’d lived her entire life. She wanted that familiar-
ity and the comfort it provided her.
So there we were. She couldn’t live alone, and she needed more
dinners that are always a treat, the regular concerts given by
people from throughout the community and, of course, the reg-
ular visits from family and friends, and Mom has a richer life than
we would have imagined possible before she moved there.
What is
Palliative
Care?
Palliative care (pronounced
pal-lee-uh-tiv) is the medical
specialty focused on relief
of the pain, stress and other
debilitating symptoms of
serious illness.
26 Healthy Skin
We encourage you to access the Center to Advance
Palliative Care at www.getpalliativecare.org/home where you will
find much more in-depth information, resources, videos and tools
to help you understand and discuss palliative care.
Palliative care is not dependent on prognosis and can be Different from hospice
delivered at the same time as treatment that is meant to cure. Palliative care is NOT the same as hospice care. Palliative care
The goal is to relieve suffering and provide the best possible may be provided at any time during a person`s illness, even
quality of life for patients and residents and their families. from the time of diagnosis. And, it may be given at the same
time as curative treatment.
To date, there have been few resources to assist caregivers in
learning about and explaining palliative care. Healthy Skin Hospice care always provides palliative care. However, it is
would like to introduce you to an excellent, Internet-based focused on terminally ill patients – people who no longer seek
resource from the Center to Advance Palliative Care (CAPC). treatments to cure them and who are expected to live for
This article contains excerpts from the Get Palliative Care Web about six months or less.
site. Let’s look at what they have to offer.
Provided by a team
Ensures quality of life Usually a team of experts, including palliative care doctors,
Palliative care is not a one-size-fits-all approach. Patients have nurses and social workers, provides this type of care. Chap-
a range of diseases and respond differently to treatment lains, massage therapists, pharmacists, nutritionists and oth-
options. A key benefit of palliative care is that it customizes ers might also be part of the team. Typically, you get
treatment to meet the individual needs of each patient. non-hospice palliative care in the hospital through a palliative
care program. Working in partnership with your primary doc-
Palliative care relieves symptoms such as pain, shortness of tor, the palliative care team provides:
breath, fatigue, constipation, nausea, loss of appetite and dif- • Expert treatment of pain and other symptoms
ficulty sleeping. It helps patients gain the strength to carry on • Close, clear communication
with daily life. It improves their ability to tolerate medical treat- • Help navigating the healthcare system
ments. And it helps them better understand their choices for • Guidance with difficult and complex treatment choices
care. Overall, palliative care offers patients the best possible • Detailed practical information and assistance
quality of life during their illness. • Emotional and spiritual support for you and your family
Palliative care benefits both patients and their families. Along How to get pallative care
with symptom management, communication and support for There is a three step process provided by the Center to
the family are the main goals. The team helps patients and Advance Pallative Care to access pallative care. Step 1
families make medical decisions and choose treatments that recommends talking with the doctor. Most of the time,
are in line with their goals. you have to ask a doctor for a palliative care referral to get
palliative care services. Whether you are in the hospital or at
home, a palliative care team can help you. They provide a list
of some tips to help you talk to the doctor.
www.medline.com
Reprinted with permission from the Center to Advance Palliative Care.
www.getpalliativecare.org. Getpallativecare.org is an Internet-based site
sponsored by the Center to Advance Palliative Care (CAPC) and provided for
general educational and informational purposes only. ©2009 Medline Industries, Inc. Medline is a registered trademark
of Medline Industries, Inc.
28 Healthy Skin
Some Methods Are Better Than
Others for Getting The Job Done
Use the right tool for the job. A continuous rinsing effect
Sure, it’s possible to cut your lawn using scissors, TenderWet debrides necrotic wounds by
but it’s not the best tool for the job. Using the attracting the large molecule proteins found in
right tools help you get the job done more dead tissue and bacteria. At the same time,
effectively and efficiently. TenderWet cleans by releasing Ringer’s solution
into the wound. This creates a rinsing effect that
That’s why you should consider Skintegrity® lasts for 24 hours, requiring less dressing
Wound Cleanser for cleaning wounds or changes compared to wet-to-dry.
TenderWet® for cleansing and debriding wounds.
Two great options
A gentle, yet thorough cleansing Skintegrity Wound Cleanser and TenderWet offer
Skintegrity Wound Cleanser facilitates the very effective options for cleansing and
removal of debris and proteinaceous material debriding wounds.
from the wound using a non-cytotoxic formula.
“TenderWet is an excellent choice for debriding wounds,
And, it’s within the recommended guidelines for especially compared with wet-to-dry dressings. In our
experience with TenderWet, wounds debride quickly and
proper wound irrigation pressure.
nursing visits are greatly reduced.”
Connie Parsons,
BS, RN, CWCN, CWS
SKINTEGRITY WOUND
CLEANSER & TENDERWET
Better options for cleansing and debriding wounds
FAQs
1. How do I know if palliative care is right for me?
It may be right for you if you suffer from pain and other symp-
toms due to a serious illness. A coordinated clinical team can
provide care to meet your needs and wishes and your family's
during your illness.
Care
under control, you and your doctor can discuss outpatient
palliative care.
30 Healthy Skin
Treatment
6. What does palliative care involve? 7. Does treatment meant to cure me stop when
• Pain and symptom control: Your palliative care team palliative care begins?
will identify your sources of pain and discomfort. No. You can get palliative care at any stage of illness, no matter
These may include problems with breathing, fatigue, what your diagnosis or prognosis.
depression, insomnia, or bowel or bladder. Then the
team will provide treatments that can offer relief. 8. Who provides palliative care?
These might include medication, along with Usually a team of experts, including palliative care doctors,
massage therapy or relaxation techniques. nurses and social workers, provides this type of care. Chap-
• Communication and coordination: Palliative care teams lains, massage therapists, pharmacists, nutritionists and oth-
are extremely good communicators. They put great ers might also be part of the team. Generally, each hospital
emphasis on communication between you, your family has its own type of team.
and your doctors in order to ensure that your needs
are fully met. These include establishing goals for 9. What role does my doctor play?
your care, aid in decision-making and seamless The hallmark of palliative care is a team approach to patient
coordination of care. care. Your primary doctor will continue to direct your care and
• Emotional support: Palliative care focuses on the entire play an active part in your treatment. The palliative care team
person, not just his or her illness. The team members provides support for and works in partnership with your pri-
caring for you will address any social, psychological, mary doctor.
emotional or spiritual needs you may have.
• Family/caregiver support: Caregivers bear a great deal 10. What is hospice care?
of stress too, so the palliative care team supports them Hospice care is for a patient who has a terminal diagnosis and
as well. This focused attention helps ease some of the is usually no longer seeking curative treatment. It focuses on
strain and can help you with your decision-making. relieving symptoms and supporting patients who are expected
to live for months, not years. Hospice care is provided in the
6. What can I expect from palliative care? home, in a residential setting or in the hospital.
You can expect a comfortable and supportive atmosphere
that reduces anxiety and stress. Your specialized plan of care 11. Is palliative care the same as hospice care?
is reviewed each day by the palliative care team and dis- No. Hospice care provides palliative care for those approach-
cussed with you to make sure your needs and wishes are ing the last stages of life.
being met.
Palliative care is appropriate for anyone, at any point of a se-
You can expect relief from symptoms such as pain, shortness rious illness. It can be provided at the same time as treatment
of breath, fatigue, constipation, nausea, loss of appetite and that is meant to prolong your life.
difficulty sleeping. Palliative care addresses the whole person.
It helps you carry on with your daily life. It improves your abil- 12. How do I start getting palliative care?
ity to go through medical treatments. And it helps you better Ask for it! Start by talking with your doctor or nurse. Tell your
understand your condition and your choices for medical care. family, friends and caregivers that you want palliative care.
In short, you can expect the best possible quality of life. Then ask your doctor for a referral.
AquaShield film
– traps moisture, providing better
leakage protection
Innovative backsheet
– air permeability means better skin comfort
To learn more about Ultrasorbs® AP and Medline's Pressure Ulcer Prevention Program,
contact your Medline representative, call 1-800-MEDLINE or visit us at
www.medline.com/incocare
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
A SYSTEMATIC APPROACH TO PRESSURE
ULCER PREVENTION IMPROVES
PATIENT CARE, REDUCES COSTS
By Zemira M. Cerny, BS, RN, CWS
Our Hospital:
Chesapeake Regional Medical Center, Chesapeake, VA, was founded in 1976 with
the goal of providing the highest quality health care available to meet the needs of
southeastern Virginia and northeastern North Carolina. The hospital established
several affiliates over the years, and in 1998 they all combined under the same name,
Chesapeake Regional Medical Center. The Medical Center includes:
• A 310-bed inpatient facility
• A 24-hour emergency room
• Rehabilitation services
• Two intensive care units – one is neurological, one is medical
• Sleep Center
Hospital:
• Lifestyle Center
Chesapeake Regional
• Obstetrics
Medical Center
• Center for Wound Care and Hyperbaric Medicine
Location:
The hospital is a local, independent, community-focused organization offering area
Chesapeake, VA
residents what they want: high-quality health care delivered by people who openly
display their concern and compassion.
Size:
311-bed inpatient facility
Our Challenge
Challenge: When I joined the hospital in April 2008 as the facility’s Wound Care Coordinator,
Develop a systematic program I learned we had an increasing level of hospital-acquired pressure ulcers. Pressure
to reduce prevalence level of ulcers (sometimes referred to as “bed sores”) affect millions of people each year.
hospital-acquired pressure ulcers
Results:
A pressure ulcer is an injury to the skin that is caused by pressure. Sitting or lying in
34 Healthy Skin
books covered CMS policy, risk factors, pressure ulcers in high-risk patients.
assessment, skin care, turning, inconti-
nence care, nutrition and documentation. The program also offers adult briefs and
low air loss mattresses, but we have not
As a further incentive, everyone who employed those products as of yet.
successfully completes the course and
achieves at least an 80 percent on the
post-test will be presented with a reward The Results
pin to display on their uniform and a By the middle of October 2008 – about
certificate of completion. six weeks into the trial – ICU2’s pressure
ulcer incidence was reduced to 23.1
The Medline representatives worked percent, a reduction of more than half
closely with our staff on the education from where we started. At the end of the
assistants to assess their baseline level of aspect of the program by reviewing the trial, ICU2’s incidence rate was down
treating pressure ulcers. A post-test was format outlined in the workbooks. But to 0 percent. This was in the beginning of
then given about four to six weeks later the staff really took it upon themselves January. A few weeks later, they were still
to reassess the staff’s knowledge. The to learn the material through self-training. at 0 percent with February’s facility-wide
goal of the program is to pass the test prevalence study. The facility’s incidence
with a score of 90 percent or higher. Medline conducted intensive inservicing rate was 7.5 percent. As of May 13, 2009,
on the products with our staff – covering the facility’s rate was down to 2.5 percent,
The Medline representatives implemented their benefits and how and when to use which is below the national benchmark
an incentive program with small awards them. Product education was a crucial of 3.3 percent. What this means in real
to encourage staff members to review the step in the success of the program. The numbers is that at the end of the trial we
materials and complete the tests within main products utilized in the program are: had virtually no facility-acquired pressure
the specified time frame. This system ulcers, compared to the 25 we had at
worked well, and all nursing staff in • Remedy advanced skin care
the beginning of the trial. This trend
ICU2 completed their tests on time. system, Medline’s exclusive line of
has continued as we report incidence
skin care products. The compre-
levels well below the national average.
The staff’s initial test scores were actually hensive program includes cleanser
pretty high – the average CNA score was foams, barrier ointments, and
The staff’s post-test scores also reflect
85 percent and the nurse’s was 83 percent. skin repair creams (moisturizers).
these outstanding results. Both the CNA
(See figure 1 on back page.) The staff also likes the products’
and nurse’s scores averaged 98 percent!
scent and feel, which further
Moreover, whatever little resistance we
Medline also supplied and reviewed the motivates them to use the products
did have from our staff to this new sys-
education and training materials with and follow the protocols.
tem has completely disappeared and has
our staff. The unit manager received a • Ultrasorbs Dry Pads, a superab- been replaced by enthusiasm and a great
comprehensive training manual including sorbent underpad that wicks amount of self-satisfaction for doing an
a CMS presentation, workbooks, moisture away from the skin for excellent job. To have your staff believe
instructor’s guide, forms and tools and increased dignity and better skin care. in the benefits of the program and see
pre- and post-tests. their efforts result in improved patient
We also are using more pressure relief care are essential to the long-term success
The nursing assistant’s workbook devices for highly vulnerable areas such of this or any patient care initiative.
included basic information covering as heels and elbows. These devices,
skin care, patient turning, incontinence when used properly in conjunction with Most importantly, senior administration
care and nutrition. The nurse’s work- the products cited above, help prevent and materials management have fully
36 Healthy Skin
Join the program
to reduce pressure ulcers.
We’ve Made Pressure Ulcer Prevention Easy Pressure Ulcer Prevention Program
Systematic efforts at education, heightened awareness, and specific The Pressure Ulcer Prevention Program from Medline will help
interventions by interdisciplinary healthcare teams have demon- you in your efforts to reduce pressure ulcers in your facility.
strated that a high incidence of pressure ulcers can be reduced.1
The program includes:
The main challenges to having an effective pressure ulcer prevention • Education for RNs, LPNs, CNAs and MDs
program are: lack of resources; lack of staff education; behavioral • Teaching materials for you to help train your staff
challenges; and lack of patient and family education.2 • Practical tools to help reduce the incidence of pressure ulcers
• Innovative products supported by evidence-based information
Medline’s comprehensive Pressure Ulcer Prevention Program offers that results in better patient care
solutions to these challenges.
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.
“
To join the fight against pressure ulcers and for more
This has been a great learning experience for our staff information on the Pressure Ulcer Prevention Program,
and for our facility as a whole. I am thankful Medline please contact your Medline sales representative or call
had this program and that we were able to access it. 1-800-MEDLINE.
I can’t imagine recreating this wheel!”
Katrina “Kitty” Strowbridge, RN
Quality Improvement Coordinator
St. Luke Community Healthcare Network
Ronan, Montana
www.medline.com
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Under Pressure?
Alternating-pressure, low-air-loss therapy mattresses are a critical component
in your battle to help prevent pressure ulcers. Medline® Supra DPS mattresses
are affordable, state-of-the-art and virtually maintenance free.
They feature a digital pump and advanced technology.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. www.medline.com
Hotline Hot Topic
Support Surfaces
by Jackie Todd, RN, CWCN, DAPWCA
ate support surface, you must become familiar with the follow-
Many factors go into appropriately choosing a support surface.
ing terms:
Developing product selection guidelines specific to a particular
• Capillary closing pressure
facility and based on patient characteristics may reduce exces-
sive and inappropriate use of specialty support surfaces.1 • Internal cushion pressure
• Interface pressure
Minimizing the risk for pressure ulcers These terms may sound confusing, but think about an item you
Many patients are considered to be at high-risk for pressure already know, such as a tire. The surface of the tire, where the
ulcer development due to their injuries, disease processes rubber meets the road, is the interface pressure, the air inside
and/or the presence of risk factors such as malnutrition and the tire corresponds to the internal cushion pressure, and if there
immobility Although many factors are involved, the primary happened to be a cat in the road, and you accidentally rode
cause of pressure ulcers is sustained over its tail, there would be capillary
compression of the cutaneous and “Pressure causes closing pressure in the tail.
subcutaneous tissue between a bony pressure ulcers,” and the Now, if that same cat were not on the
prominence and a surface. When
external pressure is greater than capil- only variable you have road, but on a soft marsh when the tire
lary blood-flow pressure, diminished complete control of rode over its tail, the tail would sink into
and impaired blood flow leads to the the soft surface and be protected from
death of the tissues.1
is the support surface. the pressure of the tire.
“Pressure causes pressure ulcers,” and the only variable you You can use the same theory when thinking of a support surface
have complete control of is the support surface. Therefore, it is for your patient or resident. This would equate to the “immer-
important to understand the performance characteristics deliv- sion” property of the surface, which is the ability to let the pa-
ered by various support surfaces. Each redistributes pressure in tient’s body sink into the surface. Along with the envelopment
a different way and to a different degree. Let’s start with how to that occurs around the patient’s body as he is immersed into
evaluate a support surface’s ability to redistribute pressure. the surface, the redistribution of weight is maximized across the
surface. This, in turn, minimizes pressure over any given point
Pressure redistribution and reduces the risk of capillary closure and subsequent
It would be nice if we had a tool that could predict when tissue tissue death that results in pressure ulcer formation.
is in danger of dying from pressure. Unfortunately, there are no
tissue viability measurement tools currently available. So, to help Another key component to remember is that a small amount of
make an informed decision when selecting the most appropri- pressure (even while sitting or lying on a surface that provides
maximum pressure redistribution) over a long period of time can In addition to keeping these contributing factors in mind, as well
do as much damage at the capillary level as a large amount of as whether the patient already has existing pressure ulcers and
pressure over a short period of time. their anatomical locations, we also must consider pain control
when we decide which support surface the patient requires.
What does all of this mean? It means that no surface is a magic
potion or silver bullet. Regardless of the support surface used, Whether a prevention or treatment surface is needed and
patients/residents still need to be turned a minimum of every chosen, the need for pain control must be included in the choice
two hours or more frequently if tissue tolerance requires it. criteria. Turning and repositioning, as well as pressure redistrib-
ution, are key components in pain control for immobile patients.
Tissue tolerance is the skin’s ability to resist injury due to pres- Comfort and the ability to rest are very important pieces in the
sure. Capillary closing pressure for every person is as individual healing process as well, so choosing the surface that meets
as a fingerprint. So everyone’s skin can tolerate different all these needs is imperative to positive outcomes.
amounts of pressure for different lengths of time before injury
takes place. The right support surface dramatically contributes to the pre-
vention and treatment of pressure ulcers. Combining good skin
Capillary closing pressure is the measurement of pressure on care, adequate nutrition, appropriate interventions for all con-
capillaries (in mmHg) that will cause their collapse or closure. tributing factors and co-morbid conditions makes attaining pos-
Capillary closing pressure is the only measurement that has real itive outcomes a more realizable goal. Positive outcomes result
value because it reflects intracapillary pressure in the tissues from “managing the whole patient, not just the hole in the
themselves, not surface pressures outside the body. Capillary patient” and getting positive outcomes shows the high quality of
closing pressure can only be measured by invasive techniques care given, which results in improved quality of life.
and has been found to be around 32 mmHg2 but will be differ-
References
ent for each patient. The pressure can range from as low as 1. Warren JB, Yoder LH, Young-McCaughan S. Development of a decision tree for support
12 to as high as 40 mmHg.3 This information supports the indi- surfaces: a tool for nursing. MedSurg Nursing. 1999; 8(4):239-245, 248. Available at http://
findarticles.com/p/articles/mi_m0FSS/is_4_8/ai_n18608862. Accessed August 28, 2009.
vidualization of turning schedules to prevent skin breakdown. 2. Viney C. Mobility Needs In: Nursing the Critically Ill. 1999. Harcourt Publishers Limited:
Edinborough, Scotland. Available at: http://books.google.com/books?id=kEe9tvW5kSs
C&pg=PA288&lpg=PA288&dq=Capillary+closing+pressure+has+been+found+to+be+
How to choose the right support surface around+32+mmHg&source=bl&ots=5b-jyYQAw8&sig=spSd2AATO3jF1YtczogkAQvv
Specialty support surfaces are frequently rented, and those fees P24&hl=en&ei=cxWhSob-K4u_lAfBpo2TDQ&sa=X&oi=book_result&ct=result&
resnum=1#v=onepage&q=Capillary%20closing%20pressure%20has %20been%20
can dramatically add to yearly expenditures for treatment of found%20to%20be%20around%2032%20mmHg&f=false. Accessed September 4, 2009.
pressure ulcers, depending on the sophistication of the tech- 3. Le KM, Madsen BL, Barth PW, Ksander GA, Angell JB, Vistnes LM. An in-depth look
at pressure sores using monolithic silicone pressure sensors. Plastic & Reconstructive
nology used. That’s why capital purchases of surfaces have Surgery 1984; 74(6):745-754.
become a more appealing choice. Plus, having the right surface
About the author
readily available means quicker intervention, which results in bet-
Jackie Todd RN, CWCN, DAPWCA is the
ter outcomes. Clinical Education Specialist for the Atlantic
Region of Medline Industries. She is a member
So how do you choose the right support surface for your patient of the Wound Ostomy and Continence Nurses
or resident? This is not a “one size fits all” world, and one prod- Society; a Diplomat in the American Profes-
uct cannot meet the needs of everyone. When selecting a sup- sional Wound Care Association; and a member
of the Association for the Advancement of
port surface, it is best to begin by determining the depth of
Wound Care. Jackie is a Corporate Advisory
tissue destruction and/ or by determining the patient’s level of Council member of the National Pressure Ulcer Advisory Panel, serving
risk. You’ll also want to review the support surface features that on both the Support Surface Standards Initiative and the Deep Tissue
can reduce or eliminate shear, friction, moisture and other Injury Task Force, and Public Policy Committee. She has served as a
factors that contribute to pressure ulcer development. Corporate Advisory Council member to the European Pressure Ulcer
Advisory Panel, a corporate liaison to board members of the Japanese
Pressure Ulcer Society and the Australian Wound Management
Association.
40 Healthy Skin
Bringing it home to you
More than 1 million Americans receive home health care For your free cost-savings analysis, contact your
services every year.1 Just as every patient is unique, so is sales representative or call 1-800-678-7852.
every home health care agency.
Reference
1 The Centers for Disease Control and Prevention. Home Health Care Patients:
www.medline.com
Data from the 2000 National Home and Hospice Care Survey. Available at:
www.cdc.gov/nchs/pressroom/04facts/patients.htm. Accessed April 12, 2008.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Prevention
References
1. Voss AC, Bender SA, Ferguson ML, et al. Long-term care liability for pressure
ulcers. J Am Geriatric Soc. 2005;53:1587-1592.
2. Ayello EA, Capitulo KL, Fife CE, Fowler E, Krasner DL, Mulder G, et al. Legal
is sues in the care of pressure ulcer patients: key concepts for healthcare
providers. White paper. June 2009.
3. Aronovitch SA. Intraoperatively acquired pressure ulcers: are there common
risk factors? Ostomy Wound Management. 2007;53(2):57-69. Available at
http://www.o-wm.com/article/6776. Accessed July 29, 2009.
42 Healthy Skin
IJJJJJJJJJJJJI
Deposed: A Personal Perspective
By Evonne Fowler, MSN, RN, CWOCN
The unthinkable happened to me. of bruising or wounds. She developed sepsis, had
an altered mental status with bouts of confusion,
In my 46 years of nursing, I have always felt uncooperative behavior, lethargy, difficulty
that I was a patient advocate. In fact, I have told awakening and agitation; she was verbally abusive
many a patient, “If I were you, I would want me to the staff. Her hospitalization was fraught with
to take care of you.” I was shocked when I opened complications, including pneumonia with subsequent
the door one evening and was handed a subpoena need for intubation. Her behavior became combative.
to report for a deposition. She pulled out the nasogastric tube and intravenous
lines and had to be placed in restraints.
One of the patients I had cared for a few years
ago had brought a lawsuit against the hospital and Eight days after admission, two pressure ulcers
I was implicated as one of the wound care specialists (Stage I and Stage II) were noted in the sacral area.
who had rendered service. As per our protocol, photographs were taken. On post
op day 12, the orthopedic surgeon requested a wound
I was devastated. I have always done my best care consultation for recommendations regarding the
to keep patients in my charge clean, dry, comfortable management of the open fasciotomy incision. During
and safe. So how did this happen and what does it the skin assessment, the wound care nurse document-
mean for me? What would happen next? ed a 9 x 20 centimeter unstageable pressure ulcer
on the sacral area, 75% black, 20% yellow, 5% red.
I remembered the patient quite well. She was a The patient was on the bariatric air support surface.
very complex and difficult patient. Here’s what my
review of her medical record revealed. She was a The post-op leg wound continued to heal;
54-year-old morbidly obese (425 lbs.) female who however, the sacral pressure ulcer needed multiple
was admitted to the Emergency Department after surgical debridements. At the base of the pressure
three days of being febrile, unable to eat, experienc- ulcer, an abscessed area was found. Once the sacral
ing liquid stools and being lethargic. The paramed- area was clean, a negative pressure wound therapy
ics had been called to the home earlier, but she had closure device was applied over the wound.
refused to be taken to the hospital. Later that night,
her daughter was able to persuade her to go to the Upon discharge, she spent an additional six
Emergency Department. Her admitting diagnosis months in a skilled nursing facility for pressure ulcer
was right leg cellulitis. She had a history of multiple management. Eventually, she returned home with
co-morbidities including venous disease, diabe- a small open wound. Her lower leg cellulitis had
tes, morbid obesity, hypertension, chronic anemia, extended into an eight-month saga due to the com-
chronic kidney disease, asthma, and of non-adherent plication from the hospital-acquired pressure ulcer.
behavior. She had called the membership services
over 100 times during her years of coverage, Now what?
reporting various incidents regarding her care.
I was a fact witness (required to help relate the
A few hours after admission, she was taken specific facts of this one case) rather than expert
to the operating room, where she had a soft tissue witness (who is usually called in to offer an opinion).
incision and fasciotomy for compartment syndrome The hospital’s attorney represented me for the
of the right leg. On post-op admission to the inten- deposition. I was called by the defense and counseled
sive care unit, her initial skin assessment was clear not to give any opinions.
IJJJJJJJJJJJJI
Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers
Improving
21 Quality of Care Based on CMS Guidelines 43
IJJJJJJJJJJJJI
My attorney sent a file box filled with medical records Lessons Learned
for me to review. I was frustrated as I reviewed these Some of the common complaints registered against
records. Notes were handwritten, difficult to read and nurses in a lawsuit are failure to follow a standard
fragmented with different disciplines writing in various of care, failure to communicate, failure to assess and
sections. Very few notes were made in the comment monitor appropriately, failure to report significant
section of the nursing notes. Flow sheets were not com- findings, failure to act as a patient advocate and
pleted. It was challenging to determine if the patient failure to document. That certainly applies in this
actually had been turned, cleansed and repositioned case. Documentation is essential! Here are the main
consistently. Although the patient was incontinent of lessons I learned from this experience:
stool, there were very few episodes of incontinence
s /N ADMISSION IT IS IMPORTANT FOR THE wound
noted. Even though I remembered that she was placed
care specialist to assess the patient’s skin and
on a special mattress for pressure redistribution, I was
wound and write a detailed, initial, focused
unable to determine this fact from the chart, despite
assessment. If a wound is present on admission,
the fact that a special bed was ordered on day eight.
document the wound profile.
The Deposition s $OCUMENT THE TYPE OF SUPPORT SURFACE the
The attorney for the plaintiff handed me the nurses’ patient is on or whenever a support system
notes for the first seven days of the patient’s change is ordered.
hospitalization and asked me to read the Braden
s 4AKE A CLEAR PHOTOGRAPH OF THE WOUND according
Score, the integumentary, neuromuscular section,
to your organization’s guidelines. For me, that
turning/repositioning section of the flow sheet and
would mean using a measurement label and a
the nurses’ comment section. There was very little
black marking pen to clearly identify the patient’s
charted in any of the sections. The Braden Score
name or initials, medical record number, date
showed the patient to be at high risk for pressure
and location of the wound on the photo.
ulcer development. I was unable to find a plan of
care in any of the files. Although the hospital had s 2EVIEW AND FOLLOW THE GUIDELINES RELATED
just implemented a new pressure ulcer program, to skin and wound care.
none of the new forms or the pressure ulcer trending
s ,ABEL AND PLACE THE PREVENTION PROTOCOL
were filled out. The attorney had me go through
standing orders and, if a wound is present,
the chart looking for documentation of instances
the wound and skin care treatment standing
of patient non-adherence. I was stunned at the lack
orders. Complete the required sections and sign.
of documentation by both physicians and nurses
about her behavior, the skin and the pressure ulcer s .OTIFY THE PHYSICIAN REGARDING THE SKIN
throughout her hospitalization. wound condition. Based on your findings,
document if the wound is healable or
The opposing counsel had me read my own charting non-healable and document the interventions
for the times I had interacted with the patient and for prevention and treatment of the skin/wound.
asked if the doctor had been informed consistently
s -AKE SURE YOU DO A FOLLOW
UP NOTE
regarding the skin changes and wound management
of the pressure ulcer. I was embarrassed with my s 2ECORD IN THE DISCHARGE NOTE THE SKIN
own charting and lack of information charted. The and wound status.
photographs taken throughout her hospitalization
s 2EMEMBER THE POWER OF WORDS 0AY
were not labeled properly and were out of sequence.
attention to “words not to use.”
There were no follow-up notes to indicate the patient
or family received education about pressure ulcer
prevention or treatment. There also was no discharge
note detailing the pressure ulcer other than the order
to continue negative therapy.
After a few months, the case was settled out of court in favor of the patient.
I hope by my sharing my own story of doing a deposition, you will gain from my pain!
IJJJJJJJJJJJJI
Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers
44 Healthy Skin 22
Are Your
What to Do Physicians
If This Happens Making
to You 2
the Grade?
Although finding out you are being sued can be shocking and A recent survey graded physiciansʼ abilities to
upsetting, it is crucial to stay calm and take some simple recognize, assess and document Stage III and
steps to allow for the best possible results. IV pressure ulcers at a “D” level. Medlineʼs new
Pressure Ulcer Prevention Program MD Education
• Notify your institution and malpractice carrier CD contains everything physicians need to brush
immediately for the name of your attorney (counsel). up on their skills and comply with the new CMS
Inpatient Prospective Payment System (IPPS).
• DO NOT create notes on your own – separate and apart
from a meeting with your lawyer. These notes could “The new MD Education component of Medlineʼs
easily be discoverable in litigation. Pressure Ulcer Prevention Program is critical for
acute-care facilities to ensure that physicians
• Avoid the temptation to talk to anyone about the case understand their role in recognizing and accurately
until you have discussed it with your attorney. Your documenting POA pressure ulcers.”
attorney will likely advise you to avoid talking to Michael Raymond, MD, Associate Chief Medical
colleagues about the case; this is important advice. Quality Officer, NorthShore University HealthSystem,
Skokie Hospital, Skokie, IL
• Your attorneys or legal department are your resources,
so ask them about terminology or procedures that are
unfamiliar to you.
Up to 80 percent of leg ulcers are the result of chronic venous hyperten- Introduction and Background
sion, most commonly caused by valvular incompetence.Various prod- Relatively recently, and in parallel with the understanding of the key role
ucts have been proven to be effective for treatment under compression of ECM in wound healing, biomaterial science has evolved allowing the
therapy, including extracellular matrix technology. harvesting and processing of biological tissue into high quality biomate-
rials suitable for regular clinical use. For example, the acellular ECM
Naturally derived, non-crosslinked extracellular matrix, such as those isolated from the porcine bladder, or other similar materials isolated from
derived from Urinary Bladder Materials (UBM), are unique among scaffold the intestinal submucosa, are complex multicomponent biomaterials that
technologies that fundamentally change healing through the have potential for making transformational changes in the practice of
deployment of significant biomolecules. These biomolecules have wound healing.
the capacity to engage cells involved in natural wound healing, including
progenitor cells that differentiate to fully functional adult cells in site- The Wound Center is developing a protocol of using this UBM-derived
specific tissues. Specifically, preclinical research shows that the base- Basement Membrane/ECM associated biomolecules to “fill” a tissue
ment membrane component of the product described here allows defect, hypothesizing that the complex interplay of the Basement Mem-
increased activity from a wound healing perspective, as it contains mul- brane components will provide the ability to recruit progenitor cells that
tiple collagen types, proteoglycans, multiple growth factors, glycoproteins may progress on to differentiate into a number of tissue types that fill the
and anti-infective peptides.1,2 During the healing process, the Basement wound as nature intended.
Membrane containing Wound Matrix* – the product studied in this case
series – is known to be resorbed and replaced with new tissue where In this study we used the Basement Membrane/ECM material on a
scar tissue normally would be expected. series of venous insufficiency-associated wounds that had resisted all
efforts in healing. Each patient had significant co-morbidities and associ-
The experience at a busy wound center using this novel biomaterial are ated problems. The objective of the study was to note if the Basement
presented in a case study series on four patients with chronic venous Membrane/ECM material would change the dynamics of a wound that is
ulcers with varying degrees of complexity. stalled in a pernicious state of equilibrium with no healing observed using
other advanced treatment methods.
Case 1
In the context of wound healing, of particular significance is the use of the dressings. After two months of weekly treatment and minimal healing,
Basement Membrane layer in the ECM material.* One of the best sources he was treated with the Basement Membrane/ECM Wound Matrix
of an easily harvestable and reliable acellular Basement Membrane/ECM fixated in place with Steri-strips™ and covered with foam and a four-
is the porcine urinary bladder material or UBM. layer compression dressing. The wound was debrided weekly. In the last
two weeks of healing, the patient was treated with the Basement
A 58-year-old male with a past medical history significant for chronic Membrane/ECM Wound Matrix and covered with a silver impregnated
venous insufficiency presented to the Wound Center with a large venous foam dressing under the compression wrap. The wound healed in seven
wound on the medial aspect of his right heel. Initially, he was treated with weeks following the initiation of the Basement Membrane/ECM Wound
silver and collagen products and covered with four-layer compression Matrix
Case 2
A 41-year-old male presented to the Wound Center three months status patient had significant venous edema in the right lower extremity with a
post ORIF right tibial plateau fracture, ORIF right ankle fracture, and large anterior ankle wound and a small venous wound laterally. Both were
decompression of compartment syndrome, following a traumatic snow- granular, with no signs of infection, yet remained open for three months.
mobile accident. The patient’s past medical history is significant for Therefore, Basement Membrane/ECM Wound Matrix was applied, fix-
chronic venous insufficiency as well as hypertension. The surgeons had ated with Steri-strips™ and covered with oil emulsion and a four-layer
attempted skin grafting on the wounds at the same time as the leg skin compression wrap. The patient returned weekly for dressing changes
grafting with continued areas of non-healing. Upon initial evaluation, the and serial debridements, including a debulking of the hypergranular tis-
46 Healthy Skin
CASE STUDY
sue laterally. Each week, a new piece of Basement Membrane/ECM was completely healed after seven weeks; the patient was placed in a custom-
applied and four-layer compression was continued. The wounds were made knee-high compression stocking and discharged.
Case 3
A 66-year-old female presented to the Wound Center 16 weeks status appeared to be intact with no sign of infection or loosening. Therefore,
post ORIF of a right fibula fracture. The initial incision had yet to heal due Basement Membrane/ECM Wound Matrix was applied, fixated with Steri-
to the patient’s chronic venous insufficiency. Her significant past medical strips™ and covered with oil emulsion and a four-layer compression wrap.
history includes COPD and hypertension. Upon initial presentation the The patient returned weekly for serial debridements and continued appli-
proximal one-third of her incision remained open with no exposed hard- cation of the Basement Membrane/ECM Wound Matrix and com-
ware. X-rays revealed adequate fixation across the fracture with a semi- pression wrap. The wound healed in three weeks. She was placed in
tubular plate and screws. The fracture was well-healed and the screws custom-made knee-high compression stockings and discharged.
Case 4
An 87-year-old male presented to the Wound Center with a new venous Membrane/ECM Wound Matrix and covered with oil emulsion and a two-
ulceration at the lateral aspect of his left ankle. His past medical history layer compression wrap. The patient returned weekly for serial debride-
included recurrent slow-healing, venous wounds as well hypertension. ments and treatment with Basement Membrane/ECM Wound Matrix
For the initial two months, he was treated for the ulceration with silver covered with compression wraps. Six weeks after the initial application of
dressings, collagen and Apligraf® with minimal improvement. Two months Basement Membrane/ECM Wound Matrix, the wound was completely
following the application of Apligraf®, he was treated with the Basement healed.
Medline’s Educational Packaging offers all the information you need, step by step,
short and sweet, to help the Medline dressing do its job of healing.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Special Feature
C. diff
ESBL
VRE
E. coli
Choosing from the “bugs” shown above, indicate your answers below.
1______ In one study, 65 percent of nurses who cared for patients with this type of bacteria
also contaminated their uniforms with it.
2______ Bleach is the only known cleaner proven to kill this “bad bug.”
4______ This is one of the many types of bacteria found in human and animal feces.
Raw beef is sometimes infected with it, causing illness in humans.
50 Healthy Skin
Prevention
DISPATCH ®
In one study, 65 percent of nurses who cared for worn by health care workers, that becomes contami-
patients with MRSA contaminated their uniforms with nated with blood or other potentially infectious body
MRSA.6 Staphylococci and Enterococci were found to fluids, regardless of who owns the scrubs.”9
survive for days to months after drying on commonly
used hospital fabrics, such as scrubs made from 100 The CDC supports home laundering of scrub uniforms
percent cotton or 60 percent cotton and 40 percent in its Guideline for Isolation Precautions (2007), which
polyester, as shown in a study conducted by the states, “In the home, textiles and laundry from patients
Shriners Hospital for Children and the Department of with potentially transmissible infectious pathogens do
Surgery at the University of Cincinnati.6
Continued on Page 55
Your shield
against
bacteria.
www.medline.com
54 Healthy Skin
mark of Medline Industries, Inc.
home-laundered scrub clothing can be worn safely in scrubs, turn those dials to hot, and of course – keep
13
labor and delivery units. What about other areas of washing your hands. Pass the word along to colleagues,
a hospital? and you may be surprised to see your facility’s HAI rates
go down.
The other study tested the left front shoulders only of 30
home-laundered scrubs and 20 hospital-laundered
References
scrubs. No pathogenic growth was found on either the 1 Estimates of Healthcare-Associated Infections. Centers for Disease Control
and Prevention Web site. Available at
home- or hospital-laundered fabrics.14 It could be argued, http://www.cdc.gov/ncidod/dhqp/hai.html. Accessed May 13, 2009.
2 Lecat P, Cropp E, McCord G, et al. Ethanol-based cleanser versus isopropyl
however, that the front shoulder of a scrub uniform is one alcohol to decontaminate stethoscopes. American Journal of Infection
of the least likely areas to be touched or contaminated. Control. 2009;37(3):241-243.
3 Merlin MA, Wong ML, Pryor PW, et al. Prevalence of methicillin-resistant
Staphylococcus aureus on the stethoscopes of emergency medical
services providers. Prehosp Emerg Care. 2009;13(1):71-74.
Fewer bacteria = fewer HAIs 4 Marinella MA, Pierson C, Chenoweth C. The stethoscope. A potential
source of nosocomial infection? Archives of Internal Medicine.
When it comes to preventing HAIs, it’s better to be safe 1997;157(7):786-790.
5 McCaughey, B. Hospital scrubs are a germy, deadly mess. The Wall Street
than sorry. If there’s even a small chance you could be Journal. January 8, 2009:A13.
transferring bacteria to patients, why not take a little extra 6 LeTexier, R. Coming clean on home laundered scrubs. Infection Control
Today Web site. Posted October 1, 2001. Available at http://www.infection-
time and a small amount of effort to clean up your act? controltoday.com/articles/407/407_1a1feat4.html. Accessed May 11, 2009.
7 Recommended Practices for Surgical Attire in: 2008 Perioperative
Standards and Recommended Practices. Association of PeriOperative
Registered Nurses: Denver, CO.
Hand rub dispensers are conveniently located through- 8 Dix K. Apparel in the hospital: what to wear, where? Infection Control Today
Web site. Posted March 1, 2005. Available at http://www.infectioncontrolto-
out most facilities, so go ahead and disinfect your day.com/articles/407/407_531inside.html. Accessed May 11, 2009.
9 Belkin NL. Use of scrubs and related apparel in health care facilities.
stethoscope between patients. When you wash your American Journal of Infection Control. 1997;25(5):401-404.
10 Siegel JD, Rhinehart E, Jackson M, et al. Centers for Disease Control and
Infection. 2007 Guideline for Isolation Precautions: Preventing Transmission
of Infectious Agents in Healthcare Settings. Available at
http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf. Accessed May
Change your habits for infection prevention 11, 2009.
• Keep isopropyl alcohol wipes or ethanol-based 11 Recommendations on Children with Methicillin-Resistant Staphylococcus
aureus (MRSA) in School Settings. Pennsylvania Department of Health Web
hand cleaner available and wipe down your site. Available at http://www.stlouisco.com/doh/CDC/MRSA.pdf. Accessed
stethoscope after each patient encounter. May 11, 2009.
12 Helpful Reminders About MRSA Infection. Massachusetts Department of
• Wear street clothes to work, and then change Public Health Web site. Available at:
http://www.mass.gov/Eeohhs2/docs/dph/cdc/antibiotic/mrsa_helpful_re-
into clean scrubs every day. Keep an extra set minders.pdf. Accessed May 11, 2009.
on hand and change mid shift if your scrubs 13 Kiehl E, Wallace R, Warren C. Tracking perinatal infection: is it safe to launder
your scrubs at home? MCN Am J Matern Child Nurs. 1997;22(4):195-197.
get visibly dirty or notably splattered with any 14 Jurkovich P. Home- versus hospital-laundered scrubs: a pilot study.
substance possibly containing bacteria. Change MCN Am J Matern Child Nurs. 2004;29(2):106-110.
15 Diarrhea-causing bacteria common in hospitals. Health News. Available at
back into street clothes before leaving the facility www.redorbit.com/news/health/1599632/diarrheacausing_bacteria_com-
to avoid carrying bacteria into your car, public mon_in_ us_hospitals. Accessed May 13, 2009.
16 Denny D. Monroe Hospital’s low infection rates draw national interest.
places and your home. If you wear a lab coat, January 19, 2009. Bloomington Herald Times. Available at http://www.hear-
aldtimesonline.com/stories/2009/01/19/news.qp-7992582.sto?1242057521
keep a clean supply at your facility and change 17 Wenzel R, Edmond MB. The impact of hospital-acquired blood stream
into a new one each day. infections. Emerg Inf Dis. 2001;7(2):174-177.
A cost-effective alternative
to urinary catheterization
ia
Californ
sp ita l
Ho
cr ea s e s
De
it Use
h
CAUTI w nence
ti
of Incon s
Brief
Knowing catheter-related urinary tract infections (UTIs) According to Rothfeld’s findings, catheters are needed in only
are the most common of all hospital-acquired infec- about half the cases in which they are used.
tions, Alan F. Rothfeld, MD, was looking for alternatives to
catheterizing patients at Hollywood Presbyterian Medical Before beginning the study, Rothfeld developed the
Center (HPMC), a 434-bed hospital in Los Angeles. following indications for the use of urinary catheters:
1. Written orders for hourly urinary output
Rothfeld noted that new incontinence management products 2. Inability to void spontaneously (usually due
offer less costly and more effective alternatives to catheteri- to obstruction)
zation. Restore ultra-absorbent disposable briefs, manufac- 3. Active urinary tract infection with Stage 3 or 4
tured by Medline, stay dry and hold significantly more urine pressure ulcer
per day.
If a patient had none of these indications, no catheter was
In order to document whether using disposable briefs in place requested. If a patient had a catheter already, a request to the
of urinary catheters would decrease UTIs, Rothfeld led a six- physician for discontinuance was initiated.
month study, from January to October 2008, at HPMC’s ICU
step-down units. The study observed the use of Restore An anonymous questionnaire conducted at the end of the
briefs during two three-month periods in two separate units of study revealed the disposable briefs were a welcome alter-
the hospital with a total of 60 beds, averaging 83 percent native among physicians and nurses. “In fact, no patient
occupancy. reported decreased comfort and most of the staff was sup-
portive of this program, indicating it increased overall satis-
50 Percent Reduction in UTIs faction among nursing personnel,” Rothfeld said.
There were five hospital-acquired UTIs during the three-month
control period, indicating an infection rate of 3.2 per 1,000
catheter days. During the three-month intervention period,
there were only two hospital-acquired UTIs, with an infection
rate of 2.4 per 1,000 catheter days.
References
Ditch the foleys, adopt diapers to address UTIs. Infection Control Today Web
Infections during the intervention period fell from an average of site. Posted March 10, 2009. Available at http://www.vpico.com/articleman-
1.06 per 1,000 patient days to 0.45. “The reduction in ager/printerfriendly.aspx?article=23711. Accessed May 22, 2009.
infections was mainly due to the decrease in catheter use Rothfeld AF & Stickley A. A Program to Reduce Nosocomial Urinary Catheter
rather than other changes in patient care,” Rothfeld Infections at an Acute Care Hospital [manuscript]. Hollywood Presbyterian
Medical Center; 2009.
explained, noting that catheter use during the intervention
period fell from 330 to 190 per 1,000 patient days. Restore is a registered trademark of Medline Industries, Inc.
56 Healthy Skin
Prevention
2. I follow strict aseptic technique when 5. Before placing a catheter, I assess whether
inserting a catheter. the patient really needs it, and I document
a. Always the assessment in the medical record.
b. Sometimes a. Always
c. Never b. Sometimes
c. Never
3. At my facility, we educate catheterized What’s your score?
residents about urinary tract infections.
a. Always a _____ x 5 = _______
b. Sometimes b _____ x 3 = _______
c. Never c _____ x 0 = _______
TOTAL _______
How do you rate?
25 Perfect score! Keep up the great work and educate others.
17 – 23 Great job. Read below for more helpful tips.
8 – 14 You’re doing OK. Read “Tell Me Again Why This Resident Needs a Catheter?”
to find out more about CAUTI prevention AND earn a free CE!
0 – 5 Lots of opportunity to improve practices at your facility. Medline can help! Also review the strategies below.
We invite you to join the Race to ERASE CAUTI! With 100,000 nurses working together, we can do it!
References
1. Expert discusses strategies to prevent CAUTIs. Infection Control Today Web site. June 1, 2005. Available at http://www.infectionacontroltoday.com/articles/402/402_561feat2.html.
Accessed July 10, 2009.
2. Catheter-related UTIs: a disconnect in preventive strategies. Physician’s Weekly. 25(6), February 11, 2008.
3. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute
care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41–S50.
4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008. Draft. Centers for Disease Control
and Prevention. Available at http://www.cdc.gov/ncidod/dhqp/pdf/pc/cauti_GuidelineApx_June09.pdf. Accessed July 10, 2009.
5. Gokula RM, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004;32:196-199.
6. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at
http://www.medscape.com/viewarticle/587464_4. Accessed July 6, 2009.
58 Healthy Skin
MAJOR BARRIERS TO CAUTI PREVENTION
Too many indwelling urinary catheters are inserted
It has been estimated at up to 50 percent of the
indwelling urinary catheters are unnecessarily placed.7
healthcare-associated infection (HAI) that can reasonably additional statistics. Did you know that the hospital emer-
be prevented through the application of evidence-based gency department (ED) has the highest percentage of
practice. CMS reported in the 2008 Federal Register catheter placements?3 In the ED, documentation of the rea-
that in 2007 there were 12,185 CAUTIs, costing $44,043 son for catheter placement is poor, and a written physician
per hospital stay. CAUTI is one of 10 hospital-acquired order is frequently lacking. Without a physician order, physi-
conditions (HACs) for which CMS will no longer provide cians are unaware that the patient has a catheter.7 When
reimbursement if it occurs during hospitalization. physicians do not know that a catheter has been inserted,
it is no wonder that an order for timely removal is lack-
Brand-new CAUTI prevention guidelines ing, and catheters stay in longer than medically necessary.
As a result of this data, leading industry experts, including
the Association for Professionals in Infection Control and Automatic stop orders and nurse-driven protocols, which
Epidemiology (APIC), the Society for Healthcare Epidemiol- allow nurses to remove catheters without a physician order
ogy (SHEA), the Centers for Disease Control and Prevention when the patient no longer meets established criteria, can
(CDC), the Joint Commission and many others have joined help with the timely removal of catheters.
together to outline strategies and guidelines to prevent
catheter-associated urinary tract infections in acute care Common catheter practices in healthcare settings
hospitals.5 The CDC’s Draft Guideline for Prevention of Adding to the problem, inappropriately placed catheters are
Catheter-Associated Urinary Tract Infections 2008 (released more often forgotten about.7 In 56 percent of hospitals there
in June 2009) identifies new guidelines and recommenda- is no system to keep track of which patients have catheters,
tions to prevent CAUTI.6 and 74 percent of hospitals do not keep track of how long
the catheter is in place.8 Shocking as this may be, let’s
Barriers to CAUTI prevention see if any of these common situations occur at your facility.
Three distinct barriers to the prevention of CAUTI become 1. Do you assess patients to determine if the standing
evident when analyzing the problem. In the long-term care order to insert an indwelling catheter is medically
environment the presence of a catheter predisposes the indicated?
resident to symptomatic and asymptomatic bacteriuria. 2. When a patient comes to your facility with an
Now, compound this problem with the fact that many nurses indwelling urinary catheter or when you insert one,
do not routinely perform aseptic technique and may not be do you regularly evaluate the need to keep the
aware when contamination occurs. In fact, during most catheter in place?
observations of nurses, we have seen inconsistent practice 3. Do you date and time when the catheter was
in setting up a sterile field and inserting indwelling inserted? This critical step helps clinicians remove
catheters aseptically. It is perfectly clear that in many health- catheters in a timely manner.
care settings, three barriers to CAUTI prevention occur
routinely – too many catheters are inserted, catheters stay Nurses are positioned to significantly impact the reduction
in too long and contamination occurs upon insertion. and elimination of catheter-associated urinary tract infec-
tions by removing catheters when patients do not meet the
CAUTI reduction strategies approved indications. Take a peek at Table 1, which lists
To help you further realize the magnitude and role when indwelling urinary catheters should and should not
nurses play in preventing CAUTI, let’s look at some be used.
60 Healthy Skin
MAJOR BARRIERS TO CAUTI PREVENTION
Contamination occurs during insertion
Most nurses are aware of the importance of aseptic technique but it can take extra time.
Heavier nursing workloads contribute to poor compliance with aseptic technique.3
GO!
technique and remove catheters in a timely manner.
62 Healthy Skin
Clinical Infectious Diseases. 2008; 46(2):243-250.
CE Questions
3. Usage of indwelling urinary catheters can be 12. It has been estimated that up to ____ percent of
expected to result in higher CAUTI rates. T F indwelling urinary catheters are unnecessarily placed.
a. 85
4. Assistance in pressure ulcer healing for incontinent b. 10
patients is an approved indication for urinary c. 50
catheterization. T F d. None of the above
5. Allowing only trained healthcare providers to insert 13. Which of the following is a successful strategy
catheters is one method for preventing catheter- implemented by healthcare organizations to
associated urinary tract infections (CAUTI). T F reduce CAUTI?
a. Redesign patient care areas
6. A recent survey of U.S. hospital practices identified b. Utilize multidisciplinary teams to put
that no strategy is consistently or universally used to evidence-based changes in practice
prevent CAUTI. T F c. Serve cranberry juice to patients
d. Deploy rapid response teams (RRTs)
7. CAUTI is one of 10 hospital-acquired conditions for
which the Centers for Medicare & Medicaid Services 14. Which of the following organizations did not
(CMS) will no longer provide reimbursement if it participate in outlining strategies and guidelines
occurs during hospitalization. T F to prevent CAUTI?
a. American Medical Association (AMA)
8. Nurses rarely request to place a urinary catheter for b. Centers for Disease Control and Prevention (CDC)
nursing convenience. T F c. Association for Professionals in Infection Control
and Epidemiology (APIC)
Multiple Choice d. The Joint Commission
9. Which of the following is not an approved indication
for urinary catheterization? 15. What percent of hospitals do not keep track of how
a. To improve comfort during end-of-life care. long the catheter is in place?
b. Management of acute urinary retention and a. 25%
urinary obstruction. b. 10%
c. The patient requires prolonged immobilization. c. 36%
d. The patient is incontinent and requires two or d. 74%
three linen changes per shift.
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:
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.
www.medline.com
ww
w.
m
ed
l in
e.
co
m
/e
ra
se
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.
Prevention
A L
F LS in Nursing Homes
Those who experience non-
fatal falls can suffer injuries,
have difficulty getting around
and have a reduced quality
of life.2
66 Healthy Skin
How big is the problem? Each year, a
• In 2003, 1.5 million people 65 and older lived in typical nursing
nursing homes.3 If current rates continue, by 2030 home with 100
this number will rise to about 3 million.4 beds reports
• About 5% of adults 65 and older live in nursing 100 to 200 falls.
homes, but nursing home residents account for Many falls go
about 20% of deaths from falls in this age group.1 unreported.1
• Each year, a typical nursing home with 100 beds
reports 100 to 200 falls. Many falls go unreported.1
• As many as 3 out of 4 nursing home residents fall
each year.2 That’s twice the rate of falls for older
adults living in the community.
• Patients often fall more than once. The average is
2.6 falls per person per year.5 • Medications can increase the risk of falls and
• About 35% of fall injuries occur among residents fall-related injuries. Drugs that affect the central
who cannot walk.6 nervous system, such as sedatives and anti-anxiety
drugs, are of particular concern.11,12
How serious are these falls? • Other causes of falls include difficulty in moving from
• About 1,800 people living in nursing homes die each one place to another (for example, from the bed to
year from falls.7 a chair), poor foot care, poorly fitting shoes, and
• About 10% to 20% of nursing home falls cause improper or incorrect use of walking aids.10,13
serious injuries; 2% to 6% cause fractures.7
• Falls result in disability, functional decline and reduced How can we prevent falls in nursing homes?
quality of life. Fear of falling can cause further loss of Fall prevention takes a combination of medical treatment,
function, depression, feelings of helplessness, and rehabilitation, and environmental changes. The most
social isolation.2 effective interventions address multiple factors.
Interventions include:
Why do falls occur more often in nursing homes? • Assessing patients after a fall to identify and address
Falling can be a sign of other health problems. People in risk factors and treat the underlying medical
nursing homes are generally more frail than older adults conditions.5
living in the community. They are generally older, have • Educating staff about fall risk factors and prevention
more chronic conditions, and have difficulty walking. They strategies.10
also tend to have problems with thinking or memory, to • Reviewing prescribed medicines to assess their
have difficulty with activities of daily living, and to need potential risks and benefits and to minimize use.14,15
help getting around or taking care of themselves.8 All of • Making changes in the nursing home environment to
these factors are linked to falling.9 make it easier for residents to move around safely.
Such changes include putting in grab bars, adding
What are the most common causes of nursing raised toilet seats, lowering bed heights, and installing
home falls? handrails in the hallways.10
• Muscle weakness and walking or gait problems are • Providing patients with hip pads that may prevent a
the most common causes of falls among nursing hip fracture if a fall occurs.16
home residents. These problems account for about • Using devices such as alarms that go off when
24% of the falls in nursing homes.2 patients try to get out of bed or move without help.2
• Environmental hazards in nursing homes cause 16% Exercise programs can improve balance, strength,
to 27% of falls among residents.7,2 Such hazards walking ability, and physical functioning among nursing
include wet floors, poor lighting, incorrect bed height, home residents. However, it is unclear whether such
and improperly fitted or maintained wheelchairs.2,10 programs can reduce falls.17,18
68 Healthy Skin
• Direct costs do not account for the long-term effects • Fractures were both the most common and most
of these injuries such as disability, dependence on costly type of nonfatal injuries. Just over one third of
others, lost time from work and household duties, nonfatal injuries were fractures, but they accounted
and reduced quality of life. for 61% of costs—or $12 billion.1
• Hip fractures are the most frequent type of fall-related
How costly are fall-related injuries among fractures. The cost of hospitalization for hip fracture
older adults? averaged about $18,000 and accounted for 44% of
• In 2000, the total direct cost of all fall injuries for direct medical costs for hip fractures.8
people 65 and older exceeded $19 billion: $0.2 billion
for fatal falls, and $19 billion for nonfatal falls.1 Reprinted with permission from the Centers for Disease Control,
• By 2020, the annual direct and indirect cost of fall National Center for Injury Prevention and Control, Division of
injuries is expected to reach $54.9 billion (in 2007 Unintentional Injury Prevention
dollars).2
References
• In a study of people age 72 and older, the average 1 Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls
health care cost of a fall injury totaled $19,440, which among older adults. Injury Prevention 2006;12:290–5.
2 Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries.
included hospital, nursing home, emergency room, Journal of Forensic Science 1996;41(5):733–46.
and home health care, but not doctors’ services.6 3 Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community-living
older adults: a 1-year prospective study. Archives of Physical Medicine and
Rehabilitation 2001;82(8):1050–6.
How do these costs break down? 4 Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG.
Preventing falls among community-dwelling older persons: results from a randomized
Age and sex
trial. The Gerontologist 1994;34(1):16–23.
• The costs of fall injuries increase rapidly with age.1 5 Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for
• In 2000, the costs of both fatal and nonfatal falls were fall-related injuries in older adults. American Journal of Public Health 1992;82(7):1020–3.
6 Rizzo JA, Friedkin R, Williams CS, Nabors J, Acampora D, Tinetti ME. Health care
higher for women than for men.7 utilization and costs in a Medicare population by fall status. Medical Care
• Medical costs in 2000 for women, who comprised 1998;36(8):1174–88.
7 Roudsari BS, Ebel BE, Corso PS, Molinari, NM, Koepsell TD. The acute medical care
58% of older adults, were two to three times higher costs of fall-related injuries among the U.S. older adults. Injury, Int J Care Injured
than for men.1 2005;36:1316-22.
8 Barrett-Connor E. The economic and human costs of osteoporotic fracture. American
Journal of Medicine 1995;98(suppl 2A):2A–3S to 2A–8S.
Type of injury and treatment setting
• In 2000, traumatic brain injuries (TBI) and injuries to
the hips, legs, and feet were the most common and
costly fatal fall injuries, and accounted for 78% of
fatalities and 79% of costs.1
• Injuries to internal organs caused 28% of deaths and
accounted for 29% of costs from fatal falls.1
• Hospitalizations accounted for nearly two thirds of
the costs of nonfatal fall injuries, and emergency
department treatment accounted for 20%.1
• On average, the hospitalization cost for a fall injury
was $17,500.7
Falls are a major concern in nursing homes. In fact, about Bath Safety Products
1,800 people living in nursing homes die each year from falls. Medline carries a wide variety of bath safety products, includ-
About ten to 20 percent of nursing home falls cause serious ing grab bars, raised toilet seats and more. Our rugged steel
injuries.1 grab bars are easy to grip and help reduce the risk of acci-
dents. Raised toilet seats consist of a plastic, add-on seat
According to the Centers for Disease Control and Prevention cover that elevates a low toilet by six to seven inches to reduce
(CDC), fall prevention entails a combination of medical treatment, strain on both patients and assisting caregivers.
rehabilitation and environmental changes.
Pressure-Sensing Safety Alarms
Some of the environmental interventions you can put into place When used properly, patient alarms can alert caregivers when
include installing grab bars, adding raised toilet seats, providing a resident at risk for falls is on the move. Medline’s patient
patients with hip pads that may prevent a hip fracture, and alarms come packed with some of the most sought-after tech-
using alarms that go off when patients try to get out of bed or nological features, including auto-sensing without the need for
move without help.1 All of these safety-enhancing products are an on/off switch, as well as nurse call system compatibility.
available from Medline.
Reference
1 Centers for Disease Control and Prevention.
Falls in Nursing Homes. Available at:
http://www.cdc.gov/ncipc/factsheets/nursing.htm.
Accessed September 3, 2009.
www.medline.com
Survey Readiness
Summary of
CMS requirements
for a homelike
environment
The Centers for Medicare & Medicaid Services (CMS) issued a new survey and
certification letter June 12, 2009, that revises and clarifies requirements related
to quality of life and environment.
The new guidelines enhance instructions to surveyors on how to Access and Visitation Rights - F172
evaluate compliance with areas such as resident choices about Facilities must provide 24-hour access to
daily schedule, (including when to get up, go to bed, eat and non-relative visitors who are visiting with the
bathe) visitation issues, homelike environment, food procure- consent of the resident. These other visitors
ment and expand significantly on guidance related to lighting. are subject to “reasonable restrictions,” such
as those imposed by the facility to protect
The following is a summary of the new guidelines. Beginning the security of all the facility’s residents:
June 18, 2009 surveys are being conducted with a sharpened • Keeping facility locked at night
focus on elements of quality of life. • Denying access or providing limited and supervised
access to a visitor if that individual has been found to be
Because some of the changes require significant facility remod- abusing, exploiting or coercing a resident
eling and capital expenditures, CMS realizes these modifications • Denying access to a visitor who has been found to have
are not feasible immediately. CMS recommends that facilities been committing criminal acts such as theft
view those changes as goals to strive toward. • Denying access to visitors who are inebriated
and disruptive
Continued on Page 74
72 Healthy Skin
Control
odors while
you control
costs
No special laundering
What’s more, there are no laundering restrictions, no
need for special laundering additives and no changes to
staff protocol required.
www.medline.com
©2009 Medline Industries, Inc. Medline and Silvertouch are registered trademarks of Medline Industries, Inc.
Accommodation of Needs – F246 Safe, Clean, Comfortable and
The facility is responsible for evaluating Homelike Environment – F252
each resident’s unique needs and prefer- For the purpose of this requirement,
ences and ensuring that the environment “environment” refers to any area in the
accommodates the resident to the extent facility that is frequented by residents,
reasonable and does not endanger the including (but not limited to) the residents’
health or safety of individuals, including rooms, bathrooms, hallways, dining
other residents. This includes adapting areas, lobby, outdoor patios, therapy
the resident’s bedroom and bathroom furniture and fixtures areas and activity areas. A determination of “homelike” should
as necessary to ensure that the resident can (if able): include the resident’s opinion of the living environment.
• Open and close drawers and turn faucets on and off
• See himself or herself in the mirror and have toiletry The intent of the word “homelike” is to provide an environment
articles within reach at the sink as close to that of a private home as possible. The concept of
• Open and close bedroom and bathroom doors and creating a home setting includes eliminating institutional odors
operate room lighting and practices to the extent possible. The following practices
• Perform other desired tasks, such as turning a table also decrease the institutional character of the environment:
lamp on and off or using the call bell • Eliminating overhead paging and canned music
• Dining room meals served on regular dishes without trays
Additional areas regarding accommodation of needs • Storing medications securely in cabinets or resident rooms
include providing: rather than using medication carts
• Reasonably sufficient electric outlets to accommodate • Limiting the use of audible chair and bed alarms to avoid
resident’s need to safely use his or her electronic startling the resident
personal items • Using less institutional-looking furnishings
• Comfortable seating for residents in their bedroom • Eliminating large, centrally located nurses stations
• Adequate task lighting in resident’s bedroom to
accommodate resident’s chosen activities
• Accommodation of resident’s preference for the
arrangement of furniture to the extent space allows, Kind, Caring Staff
including facilitating resident choice about where to
place his or her bed (with roommate’s consent) + Knowing Me as an Individual
• Varying types and sizes of furniture in common areas
to accommodate individual resident’s preferences
and needs for seat height, depth, firmness and arms
= Quality Care
that assist in arising to a standing position
• Staff interaction in a way that takes into account the Source: “Creating Home: The New Quality of Life Revisions to LTC Surveyor
resident’s physical limitations, assures communication Guidance” Webinar Series. June 10 & 11 and June 17 & 18, 2009. Presented
by Pioneer Network, American Association of Homes and Services for the
and maintains respect, (e.g., getting down to eye level
Aging (AAHSA) and American Health Care Association (AHCA).
to speak with a resident who is sitting)
Syst em
es (DH HS)
CM S M anualOper at ions
Human Ser vic A complete copy of the surveyor guidance summarized in this
edi car e &
Center s for M
at e
Pub. 100-07 St
vices (C M S)
M edi cai d Ser
article is located at: CMS Manual System Pub. 100-07, Provider
tif ication 2009
Pr ovider Cer
NE 12,
Date: JU
Certification. Transmittal 48. June 12, 2009. Revisions to Appendix
Tr ansmi ttal 48 m
or s of L ong Ter
idance to Sur vey
pendix PP, “ Gu
Revisions to Ap
PP, “Guidance to Surveyors of Long Term Care Facilities.”
SUBJECT:
Car e Facilit ies” Guidance to
Appendix PP, “
instruction revises language is unchanged.
ANGES: Thi s
CH ula tory
http://www.cms.hhs.gov/transmittals/downloads/R48SOMA.pdf.
SUM M AR Y OF
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Continued on Page 76
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Bringing You Closer to Home™
www.medline.com
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Quick Ways to Adapt Your Facility to Residents’ Needs
Widespread change to your facility to accommodate new sur-
veyor guidelines can take time, effort and money. But small
changes can begin right away for little cost. Here are some
ways to begin taking smaller steps toward change.
Source: Schoeneman K & Bowman C. Quick fixes for the environment. Pioneer Network Conference, 2008.
Available at http://www.pioneernetwork.net /Data/Documents/Quick_Fixes_for_the_Environment.pdf.
Accessed August 31, 2009.
76 Healthy Skin
Adequate and Comfortable
Lighting – F256 Interiors by Medline
Lighting is important, as residents often
have issues with eyesight. As people age,
the eyes usually change, requiring more
light. Adequate lighting design includes
these features:
• Sufficient lighting with minimal glare
• Even light levels in common areas
and hallways
• Use of daylight as much as possible
• Elimination of glare caused by high-gloss flooring,
waxes and uncovered windows
• Task lighting for reading and other activities
requiring concentration
• Night lights to help residents find their way to the
bathroom at night
• Dimmer switches or the use of pen lights to allow
nurses to care for residents at night without
disturbing roommates
• Floor and baseboard to be in contrasting colors to
enable residents with impaired vision to determine the
horizontal plane of the floor
• Use of contrasting colors for bathroom walls and toilets
Living Spaces Room
so residents with impaired vision can distinguish the toilet Makeover Contest
fixture from the wall.
• Use of dishes that contrast with the table or tablecloth Enter to win a FREE resident
to help residents with impaired vision see their food.
room makeover!
Incontinence Briefs
Today’s adult incontinence products come in many forms and sizes increased pressure over the entire groin and delicate perineal area
to meet individual needs. They are helpful in promoting healthy skin when the wearer is “wrapped” in excess layers of product. Ill-fitting
and maintaining the overall health of individuals who are incontinent. garments do not fit snugly and are not able to quickly wick away
moisture from urine, which can cause skin maceration. Skin mac-
The most frequently used products are briefs and protective eration in turn can lead to further damage and potential infection.
underwear (pull-ups). The level of incontinence, gender, fit and use
are all factors in product selection. Sizing is important for correct fit, Bigger ≠ better
leakage control and to help prevent skin damage. A myth that compounds the sizing problem is that bigger is “better”
or “easier to apply.” Larger products do not hold more urine or
Improper sizing can lead to problems feces. And the risk of damage to skin from an improperly fitted gar-
Frail skin can be damaged in a number of ways by an inappropri- ment far outweighs the ease of applying an oversized product.
ately fitted brief. A brief that is too small can lead to friction and
pinching, which can result in skin damage. Briefs that are too large Larger sized products are often packed with fewer pieces per pack-
can cause even more problems. Products that are oversized create age, taking up more storage space than smaller products. They are
78 Healthy Skin
Treatment
• Improperly fitting briefs require more frequent changing,
which can be expensive and time-consuming.
• A properly fitting brief is more comfortable for the wearer. Adult brief
• Those who wear briefs are apt to be less sensitive about the
Small: Green backing 20"–32" (51cm – 81cm)
touchy issue of “diapers” if the garment is somewhat discreet
under clothing. Medium: White backing 32"– 42" (81cm – 107cm)
delivers) supplies, and nursing assistants and caregivers actually
apply the products.
Knit pants
All departments need to work as a team to ensure the correct prod-
uct is available and used for a resident when necessary. It might be Medium/Large: 20"– 60" (51cm – 152cm)
more convenient to order only large and extra large products due Blue/Brown waistband
to ease of ordering and storage limitations, however, this practice X-Large: 45"– 70" (114cm – 178cm)
will not meet the Centers for Medicare & Medicaid Services (CMS) Green waistband
guidelines that call for the provision of “individualized interventions.” XX-Large: 50"– 75" (127cm – 191cm)
People come in all shapes and sizes, and appropriate sizing Purple waistband
of product promotes dignity, self-esteem, healthier skin, and
cost-effectiveness.
Disposable mesh pants
Step 1: Measure across the front of the body; from hip bone
to hip bone and over the abdomen. Or measure from thigh
Medium
Large:
X-Large:
XX-Large:
28"– 40"
30"– 45"
32"– 48"
38"– 58"
(72cm – 102cm)
(76cm – 114cm)
(81cm – 122cm)
(97cm – 147cm)
to thigh, if that area appears to be larger.
Step 2: Double the measurement from Step 1 and add Need additional help with sizing? Ask your Medline representative
two inches. to arrange for a nurse to visit your facility for hands-on instruction.
Step 3: Match the final measurement with the manufacturer’s
size chart.
One look and you can see the advantages. The wider hook
tape tabs make it easier to grasp and won’t stick to skin or
gloves, and the compressed packaging is easier to handle.
www.medline.com
Special Feature
Creative
Communication Techniques
Take the stress out of relating to people with Alzheimer’s
by Jo Huey
If you find yourself on the “Absolutely Never” side, don’t despair. Simply
move to the right side of the list and things will improve. For a more
detailed version of this tool, turn to page 102.
TEN ABSOLUTES
Absolutely Never!!!!!!! Instead
1. Argue Agree
2. Reason Divert
3. Shame Distract
4. Lecture Reassure
5. Say “Remember” Reminisce
6. Say “I Told You” Repeat/Regroup
7. Say “You Can’t” Do What They Can
8. Command/Demand Ask/Model
9. Condescend Encourage/Praise
10. Force Reinforce
©Huey 1996
por Jo Huey
DIEZ ABSOLUTOS
Absolutamente Nunca!!!!!!! En vez de ello
1. Discuta Esté de acuerdo
2. Razone Desvíe
3. Avergüence Distraiga
4. Sermonee Tranquilice
5. Diga “Recuerda” Rememore
6. Diga “Te lo dije” Repita/Reagrupe
7. Diga “No puedes” Haga lo que ellos pueden
8. Ordene/Demande Pregunte/Modele
9. Sea condescendiente Estimule/Alabe
10. Fuerce Refuerce
©Huey 1996
Sobre la Autora
Jo Huey es una especialista de renombre mundial en ayudar a cuidadores
de familia a abrirse paso entre el laberinto de emociones y habilidades
necesarios para ayudar a un paciente con Alzheimer. También es autora
de dos libros: Enfermedad de Alzheimer: Ayuda y Esperanza y No Dejes
a Mamá en Casa con el Perro. Para más información,
visite www.alzheimersadvocate.com
82 Healthy Skin
How 4 square inches of Puracol Plus
changed chronic wound care.
Forever.
Continued on Page 86
84 Healthy Skin
OptiumEZ Blood Glucose Monitoring provides
easy,
accurate
&
reliable
results
86 Healthy Skin
to non-GDH-PQQ methodology. Therefore, healthcare
providers (and patients) should refer to device labeling or
consult with test strip manufacturers to confirm the type of
methodology used.
References
1. U.S. Food and Drug Administration. FDA Public Health Notification: Potentially Fatal
Errors with GDH-PQQ* Glucose Monitoring Technology. Available at: http://www.fda.
gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm
176992.htm. Accessed September 9, 2009.
2. Abbott Diabetes Care. Letter to healthcare providers, September 1, 2009.
Perioperative Pressure
Ulcer Education.
More important
than ever before
90 Healthy Skin
Caring for Yourself
How to Communicate More Effectively and Get More of What You Want
To get around this, do a reality test, especially when a shared 2. Get Really Good at Asking Questions
understanding is critical. Here are several examples. When As an executive coach, I’ve learned the benefits of asking
your spouse tells you how much you irritate him, summarize questions. Here is what questions can do:
your conversation: “Sweetheart, let me just make sure that • Put you in control of the conversation. Questions elicit
you and I are on the same page. What I heard you say was . an almost Pavlovian response in the listener to find
. .” At the end of a complicated instruction to one of your pa- an answer.
tients: “Now Miss Eager, we went over a lot of technical in- • Establish rapport. Questions demonstrate interest, which
formation. To make sure you will be able to follow my causes others to like you. And people who like you
instructions, please repeat what you heard me say.” are more likely to comply with your wishes and requests.
• Build trust. Eliciting ideas from others causes them to
feel that you care about them, which helps build trust.
• Achieve deeper understanding. When you ask questions, My consistent advice is deceptively simply but extremely
you will help the other party focus on what you want powerful: If in doubt, check it out.
them to focus on.
• Provide for greater buy-in, higher motivation and 4. Utilize Adult Language
compliance. Questions allow individuals to come up According to Eric Berne and Thomas Harris, of the transac-
with their “solution,” and invariably their level of tional analysis (TA) fame, all of us utilize three different internal
commitment will increase. “recordings” that represent our “ego states”: child, parent
and adult.
3. Avoid Fundamental Attribution Errors
Someone is late for an appointment, and we perceive that The child ego state refers to the behavior pattern, thoughts
they don’t care or they are sloppy, when in fact they may and feelings we learned as children. They include helpless-
have had an accident. In psychology this is referred to as ness, blaming and emotional expressions such as “I can’t
making a fundamental attribution error. I refer to it as “we help it,” “Don’t blame me,” “It’s your fault,” etc. Nonverbal
are very good at running our own movies,” meaning that we cues of the child ego state include whining, whistling, laughing,
attach all kinds of meanings to behavior we observe that has teasing, expressing dejection, pouting, nail biting, moving
nothing whatsoever to do with the person’s actions. restlessly and looking rebellious, nervous or sad.
I see this all the time in my coaching practice. Our parent ego state was developed by observing parents
A manager tells me, “My boss does not care about me.” and other authority figures. When we are in a parent role we
I ask, “How do you know?” tend to be very judgmental, critical, controlling, comforting or
“Well, he never tells me anything.” nurturing, and use such phrases as “You can’t do that,” “You
I ask, “How do you mean?” have to,” “Always,” “Never,” etc. Nonverbal cues include
“Well, most of the time I find out stuff through finger pointing, looking at your watch while communicating,
the grapevine instead of from my boss.” finger tapping, pressing lips tight, grinding teeth, checking
I ask, “Have you ever asked him to keep you in the loop?” up on others, scowling, sneering, patronizing or expressing
“No, but you know, that is a very good idea. sympathy.
I should really do that.”
The third internal recording is that of the adult. An adult is a
fact finder, information seeker, analyzer and logical problem
92 Healthy Skin
“
It is better to remain quiet and be thought a fool
than to speak and remove all doubt,”
— Anonymous
solver. When you use your adult recording, you ask why? 6. Listen Actively
what? when? where? who? how? and say such things as “I Even though it’s been said by the prolific author Anonymous,
made a mistake,” “I changed my mind,” “I don’t know,” “It is better to remain quiet and be thought a fool than to
“I don’t understand,” “It’s my opinion,” “Let me check on speak and remove all doubt,” most of us are very good at re-
that,” and “What can we learn from this?” When you are in moving all doubt. One reason is that most of us are very
this ego state, you tend to be clear, calm and non-judg- good at “talking and telling” instead of “listening and learn-
mental. Your nonverbal expressions include straight but ing.” To become an active listener, remind yourself that there
relaxed posture, comfortable eye contact and a friendly face must be a reason that we were born with only one mouth
that says, “I’m interested in what you have to say. I’m alert, and two ears.
thoughtful and attentive.”
The better you get at listening, the more you’ll find out what
Communication effectiveness is dramatically enhanced the other party really wants. Once you know that, you are
when you express yourself in an adult ego state, especially communicating from a position of strength. Your husband
when both you and the other party are playing the same says: “For our next vacation I want to go to Phoenix.” Un-
recording. Since it is difficult to change other people, fortunately you are tired of Phoenix. Instead of telling him
I strongly urge you to get in the driver’s seat of your trans- why Phoenix is a bad idea, ask questions to find out what he
actions by using adult language whenever you are commu- really wants. “Please tell me what you would like to do in
nicating. If you would like more help with this, read my How Phoenix?” He might say, “I want to play golf where the air is
to Maximize Professional Potential CPE program available warm and dry.” Now you can put your thinking caps on to
from www.easyCPEcredits.com. identify lots of places that will meet both of your needs. Here
are several related strategies:
5. Accept 111 Percent Responsibility • When someone asks a question, keep your mouth shut
for the Entire Communication Process until the other person has finished speaking. Do this even
Most of us are experts at playing the blame game. Have you though you know the answer when the other person
noticed that when there is a breakdown in communication, begins to speak. Remember, when the mouth is
it’s almost always the fault of someone or something else, engaged, the ears are out of gear.
but seldom the person who is making the excuses! To make • Show the person speaking that you are listening actively
this point, ask someone who arrives late for a meeting, by totally focusing all of your mental energy on what the
“Would you have been on time if $1,000 were riding on it?” other person is saying, not only with her words but also
The typical answer is “Of course!” her body. You can achieve that by making strong eye
contact, leaning slightly forward and using your body
To achieve dramatic improvements in your communication language to acknowledge the message and
effectiveness, I strongly recommend that you buy 111 per- the messenger.
cent into the following axiom: If it is to be, it is up to me. (This
one works for all aspects of your life, so do try this at home.)
94 Healthy Skin
results with far less resistance. (For other powerful techniques
read my Win-Win Negotiation CPE program, available at
www.easyCPEcredits.com.)
people use habitually without being aware of their implica- 12. Make Them Glad They Communicated
tions. For example, avoid saying, “Let me be absolutely with You
honest with you.” If you say that to me, I’m thinking: “What are To turbo-charge your communication effectiveness, pretend
you normally?” that all people you communicate with have printed across
their forehead a big bold sign that reads MAKE ME FEEL
10. Strive For Win-Win IMPORTANT! This phrase will remind you to always focus on
When you are communicating be on the lookout for things their needs first, because once they get the feeling you want
that will be beneficial to the other party. For example, if you are to help them, most people will do whatever they can to
talking with a team member, instead of saying “You have to reciprocate, which in the long run will help you get more of
yada, yada, yada,” use: “How can I help you with . . .?” When what you want.
you are talking to patients, instead of saying, “According to
hospital policy you have to . . .,” use, “What options can we
think of that will . . .” This attitude shows that you are inter-
ested in helping the other person get what he wants, which
in turn will make him more receptive to helping you get what
you want.
You’re Not
Alone
More Americans are losing sleep because of finan- high-sugar and high-carbohydrate foods, and they
cial worries. Declining home values, dwindling savings smoked or used tobacco more often than better sleepers.2
and fear of layoffs are forcing more people to seek help for
insomnia and a host of other sleep disorders.1 And we’re more tired than ever. The average adult needs
seven hours and 24 minutes of sleep, but most report
Nearly 30 percent of Americans say they lose sleep at getting just six hours and 40 minutes on a typical week-
least a few nights a week, according to a national “Sleep day, according to the poll. One in five surveyed said they
in America” poll conducted by the National Sleep Foun- get fewer than six hours of sleep on average. The number
dation.1 of Americans who report they get the recommended eight
hours has declined since 2001.2
Sleep specialists say the survey results mirror patient con-
cerns in their medical practices lately. “We’ve been seeing Lack of sleep can have devastating health consequences.
this clinically for months, a very sharp increase in insom- A 1999 study at the University of Chicago showed that
nia due to stress,” said Joseph Ojile, CEO and founder of restricting sleep to just four hours per night for a week left
Clayton Sleep Institute in St. Louis.2 healthy young adults with the glucose and insulin read-
ings of diabetics.1
Losing sleep goes deeper than just feeling tired. People
who slept poorly were also almost twice as likely to eat
96 Healthy Skin
Caring for Yourself
If you’re having trouble sleeping lately, here are some ways to help
get your inner clock back on track.3
• Go to bed and get up at about the same time every day, • Start a relaxing bedtime routine. Do the same things
even on the weekends. Sticking to a schedule helps each night to tell your body it's time to wind down. This
reinforce your body’s sleep-wake cycle. may include taking a warm bath or shower, reading a
• Don’t eat or drink large amounts before bedtime. book, or listening to soothing music.
Eat a light dinner at least two hours before sleeping. • Go to bed when you’re tired and turn out the lights.
• Avoid nicotine, caffeine and alcohol in the evening. If you don’t fall asleep within 15 to 20 minutes, get up and
These are stimulants that can keep you awake. Avoid caffeine do something else. Go back to bed when you’re tired. Don’t
for eight hours before your planned bedtime. And although agonize over falling asleep. The stress will only prevent sleep.
often believed to be a sedative, alcohol actually • Check with your doctor before taking any sleep
disrupts sleep. medications. He or she can make sure the pills won’t
• Exercise regularly. Regular physical activity, especially interact with your other medications or with an existing
aerobic exercise, can help you fall asleep faster and make your medical condition. Your doctor can also help you
sleep more restful. However, for some people, exercising right determine the best dosage.
before bed may make getting to sleep more difficult. • Nearly everyone has occasional sleepless nights.
• Make your bedroom cool, dark, quiet and comfortable. But if you have trouble sleeping on a regular or frequent basis,
Adjust the lighting, temperature, humidity and noise level see your doctor. You could have a sleep disorder, such
to your preferences. Use blackout curtains, eye covers, as obstructive sleep apnea or restless legs syndrome.
earplugs, extra blankets, a fan or white-noise generator,
a humidifier or other devices to create an environment References
1. Layton MJ. More people are seeking help for insomnia and sleep disorders.
that suits your needs. The Ledger. March 29, 2009; p. N25. Available at: http://www.theledger.com/arti-
• Sleep primarily at night. Daytime naps may steal hours cle/20090329/NEWS/903305029?Title=More-People-are-Seeking-Help-for-Insom-
nia-and-Sleep-Disorders. Accessed August 17, 2009.
from nighttime slumber.
2. Marcus MB. Economy doing a number on people’s sleep. USA Today. March 1, 2009.
• Children and pets are often disruptive, so you may need Available at: http://www.usatoday.com/news/health/2009-03-01-sleep-economy_
to set limits on how often they sleep in bed with you. N.htm. Accessed August 17, 2009.
3. Mayo Clinic. 10 tips for better sleep. Available at http://www.mayoclinic.com/
health/sleep/HQ01387. Accessed August 17, 2009.
Support
Breast Cancer
Awareness
Month October 2009
5
Medline Breast Cancer Awareness Campaign
Celebrates Five Years
Breast breast.
2. Before a Mirror
Cancer Inspect your breasts with your
arms raised high overhead. Next,
English ............................................................102
Positive Interactions
Spanish ............................................................104
1. Argue Agree
“You know your mother has been dead for years. You cannot “I haven’t seen your mother today. If I see her, I will tell her you
wait for her to eat dinner” “You have lived in this house for 25 are looking for her. While we are waiting, let’s have a bite to eat.
years, you are home” I want to go home, too. While we are waiting, let’s have a bite
to eat.”
2. Reason Divert
“You did not take a bath today, and you need to take a bath “Please come in here with me. Oh, I know you aren’t going to
because we have an appointment with the doctor. Then we take a bath. Let me help with that shoe. Oh, I know you aren’t
are going to go to lunch with Jane, and then we are going to going to take a bath. Just slide this off over your arm. Oh, I know
get you a new pair of shoes, and why are you walking off you aren’t going to take a bath. How does this water feel? It
when I am talking to you? We have to go in here and get your seems warm enough. Oh, I know you aren’t going to take a
bath and we have to hurry.” bath. Just step right in here.”
3. Shame Distract
“How can you accuse John of stealing after all he has done “John is here to help us find your wallet. Let’s have a cup of
for us?” coffee and get started.”
4. Lecture Reassure
“You have got to go back to bed and get some sleep. You “I can’t sleep either. Let’s go to the bathroom. I need something
have been up half the night and why on earth did you empty to drink.” (Offer a drink.) “Try to lie down again.” (Pat the bed.)
these drawers? Who is supposed to clean up this mess? “No? How about some cookies and milk?” “Try to lie down
I suppose tomorrow you will want to sleep all day and we again.” (Sit beside bed and pat the bed.) “Doesn’t that feel
won’t be able to go to Carol’s house and help with the good?” (Stay until settled or asleep. Rub their hand, forehead
children. I am just too tired to deal with this, so you have to or arm.)
get in bed and go to sleep right now. We can’t continue like
this. No one can live this way. We both have got to get
some sleep.”
8. Command/Demand Ask/Model
“You have got to change your clothes. Sit down right here “This is pretty. Do you want to try it on? Sit with me a minute.”
and stop walking around. This doesn’t belong to you. Now (Pat the chair.) “This is nice. May I see it? Do you want to
give it back. Why would you take those when we didn’t pay buy those? See if you will be warmer with this. How about
for them? You have to leave your clothes on; we’re in a going here?”
public restroom. We are in a hurry. You need to do this
right now.
9. Condescend Encourage/Praise
“Did you have any problem with him today? Be sure he takes “I’m sure you were your sweet, wonderful self today. Dad will
his medicine; he spit it out this morning. I hope you don’t have help you with his medication today; it has been hard to swallow.
trouble today. It took me 20 minutes just to get him into the We are having a challenging day today, and Dad will help you a
car. He has been looking for his mother all morning.” lot. He is especially interested in his mother today.”
© Huey 1996
From: Alzheimer’s Disease: Hope and Help by Jo Huey
Reprinted with permission.
2. Razone Desvíe
"No te bañaste hoy, y necesitas bañarte porque tenemos una "Por favor entra aquí conmigo. Oh, Sé que no te vas a bañar.
cita con el doctor. Luego vamos a almorzar con Jane, y luego Déjame ayudarte con ese zapato. Oh, sé que no te vas a bañar.
vamos a comprarte un nuevo par de zapatos, y ¿por qué te Desliza esto por tu brazo. Oh, sé que no te vas a bañar. ¿Cómo
alejas cuando te estoy hablando? Tenemos que entrar y se siente esta agua? Parece lo suficientemente tibia. Oh, sé que
bañarte, y tenemos que darnos prisa." no te vas a bañar. Pisa justo aquí."
3. Avergüence Distraiga
"¿Cómo puedes acusar a John de robar después de todo "John está aquí para ayudarnos a encontrar tu billetera.
lo que ha hecho por nosotros?" Tomemos un café y empecemos."
4. Sermonee Tranquilice
"Tienes que volver a la cama y dormir un poco. Has estado "Yo tampoco puedo dormir. Vamos al baño. Necesito algo de
despierto la mitad de la noche y ¿por qué vaciaste estos beber." (Ofrezca algo de beber.) "Trata de recostarte de nuevo."
cajones? ¿Quién crees que va a limpiar este lío? Supongo (Palmadas en la cama.) "¿No? ¿Qué te parece unas galletas y
que mañana querrás dormir todo el día y no podremos ir a la leche?" "Trata de recostarte otra vez." (Siéntese al lado de la cama
casa de Carol y ayudar con los niños. Simplemente estoy y dé palmaditas en ésta) "¿No se siente rico?" (Quédese hasta
demasiado cansada para ocuparme de esto, así que tienes que esté tranquilo o dormido. Frote su mano, frente o brazo.)
que ir a la cama y dormirte ahora. No podemos seguir así.
Nadie puede vivir así. Ambos tenemos que dormir un poco."
8. Ordene/Demande Pregunte/Modele
"Tienes que cambiarte de ropa. Siéntate aquí y deja de dar "Esto es bonito. ¿Te lo quieres probar? Siéntate conmigo un
vueltas. Esto no te pertenece. Ahora devuélvelo. ¿Por qué minuto." (Toque la silla.) "Esto está bien. ¿Puedo verlo? ¿Quieres
tomaste esto cuando no lo pagamos? Tienes que dejarte comprarlos? Ve si estás más abrigado con esto. ¿Qué tal si
la ropa puesta, estamos en un baño público. Estamos apura vamos aquí?"
dos. Necesitas hacer esto de inmediato.
© Huey 1996
De: Enfermedad de Alzheimer: Esperanza y Ayuda, por Jo Huey.
Reimpreso con permiso.
Heavy Protective
Moderate volume of urine Liners Briefs Underwear
up to two cups or 500cc
• Urge, overflow or bowel
incontinence
• Bedridden
• Difficulty walking or
standing
Protective
Heavy Plus Underwear
Moderate volume of urine Liners Briefs High Capacity
more than two cups or 500cc
in 4 hours
• Overflow or bowel
Incontinence
• Contracted, bedridden
• Difficulty walking or
standing
• Loose stool
Ultrasorbs® AP Ultrasorbs®
DryPad DryPad
&YƐ
;ĨƌĞƋƵĞŶƚůLJĂƐŬĞĚƋƵĞƐƟŽŶƐͿ
ĂďŽƵƚ
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hƌŝŶĂƌLJdƌĂĐƚ/ŶĨĞĐƟŽŶ͟
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ĂƚŚĞƚĞƌŝŶƐĞƌƟŽŶ
ƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶ;ĂůƐŽĐĂůůĞĚ͞hd/͟ͿŝƐĂŶŝŶĨĞĐƟŽŶŝŶƚŚĞƵƌŝŶĂƌLJ
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ŽƌLJĞĂƐƚƐͿĚŽŶŽƚŶŽƌŵĂůůLJůŝǀĞŝŶƚŚĞƐĞĂƌĞĂƐ͖ďƵƚŝĨŐĞƌŵƐĂƌĞŝŶƚƌŽĚƵĐĞĚ͕ Ž KŶůLJƉƌŽƉĞƌůLJƚƌĂŝŶĞĚƉĞƌƐŽŶƐŝŶƐĞƌƚĐĂƚŚĞƚĞƌƐƵƐŝŶŐƐƚĞƌŝůĞ;͞ĐůĞĂŶ͟Ϳ
ĂŶŝŶĨĞĐƟŽŶĐĂŶŽĐĐƵƌ͘ ƚĞĐŚŶŝƋƵĞ͘
/ĨLJŽƵŚĂǀĞĂƵƌŝŶĂƌLJĐĂƚŚĞƚĞƌ͕ŐĞƌŵƐĐĂŶƚƌĂǀĞůĂůŽŶŐƚŚĞĐĂƚŚĞƚĞƌĂŶĚ Ž dŚĞƐŬŝŶŝŶƚŚĞĂƌĞĂǁŚĞƌĞƚŚĞĐĂƚŚĞƚĞƌǁŝůůďĞŝŶƐĞƌƚĞĚŝƐĐůĞĂŶĞĚ
ĐĂƵƐĞĂŶŝŶĨĞĐƟŽŶŝŶLJŽƵƌďůĂĚĚĞƌŽƌLJŽƵƌŬŝĚŶĞLJ͖ŝŶƚŚĂƚĐĂƐĞŝƚŝƐĐĂůůĞĚĂ ďĞĨŽƌĞŝŶƐĞƌƟŶŐƚŚĞĐĂƚŚĞƚĞƌ͘
ĐĂƚŚĞƚĞƌͲĂƐƐŽĐŝĂƚĞĚƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶ;Žƌ͞Ͳhd/͟Ϳ͘ Ž KƚŚĞƌŵĞƚŚŽĚƐƚŽĚƌĂŝŶƚŚĞƵƌŝŶĞĂƌĞƐŽŵĞƟŵĞƐƵƐĞĚ͕ƐƵĐŚĂƐ
ͻ džƚĞƌŶĂůĐĂƚŚĞƚĞƌƐŝŶŵĞŶ;ƚŚĞƐĞůŽŽŬůŝŬĞĐŽŶĚŽŵƐĂŶĚĂƌĞƉůĂĐĞĚŽǀĞƌ
tŚĂƚŝƐĂƵƌŝŶĂƌLJĐĂƚŚĞƚĞƌ͍ ƚŚĞƉĞŶŝƐƌĂƚŚĞƌƚŚĂŶŝŶƚŽƚŚĞƉĞŶŝƐͿ
ƵƌŝŶĂƌLJĐĂƚŚĞƚĞƌŝƐĂƚŚŝŶƚƵďĞƉůĂĐĞĚŝŶƚŚĞďůĂĚĚĞƌƚŽĚƌĂŝŶƵƌŝŶĞ͘ ͻ WƵƫŶŐĂƚĞŵƉŽƌĂƌLJĐĂƚŚĞƚĞƌŝŶƚŽĚƌĂŝŶƚŚĞƵƌŝŶĞĂŶĚƌĞŵŽǀŝŶŐŝƚƌŝŐŚƚ
hƌŝŶĞĚƌĂŝŶƐƚŚƌŽƵŐŚƚŚĞƚƵďĞŝŶƚŽĂďĂŐƚŚĂƚĐŽůůĞĐƚƐƚŚĞƵƌŝŶĞ͘ƵƌŝŶĂƌLJ ĂǁĂLJ͘dŚŝƐŝƐĐĂůůĞĚŝŶƚĞƌŵŝƩĞŶƚƵƌĞƚŚƌĂůĐĂƚŚĞƚĞƌŝnjĂƟŽŶ͘
ĐĂƚŚĞƚĞƌŵĂLJďĞƵƐĞĚ͗ Catheter care
ͻ /ĨLJŽƵĂƌĞŶŽƚĂďůĞƚŽƵƌŝŶĂƚĞŽŶLJŽƵƌŽǁŶ
Ž ,ĞĂůƚŚĐĂƌĞƉƌŽǀŝĚĞƌƐĐůĞĂŶƚŚĞŝƌŚĂŶĚƐďLJǁĂƐŚŝŶŐƚŚĞŵǁŝƚŚƐŽĂƉ
ͻ dŽŵĞĂƐƵƌĞƚŚĞĂŵŽƵŶƚŽĨƵƌŝŶĞƚŚĂƚLJŽƵŵĂŬĞ͕ĨŽƌĞdžĂŵƉůĞ͕ĚƵƌŝŶŐ ĂŶĚǁĂƚĞƌŽƌƵƐŝŶŐĂŶĂůĐŽŚŽůͲďĂƐĞĚŚĂŶĚƌƵďďĞĨŽƌĞĂŶĚĂŌĞƌ
ŝŶƚĞŶƐŝǀĞĐĂƌĞ ƚŽƵĐŚŝŶŐLJŽƵƌĐĂƚŚĞƚĞƌ͘
ͻ ƵƌŝŶŐĂŶĚĂŌĞƌƐŽŵĞƚLJƉĞƐŽĨƐƵƌŐĞƌLJ
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ƉůĞĂƐĞĂƐŬƚŚĞŵƚŽĚŽƐŽ͘
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ƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶƚŚĂŶƉĞŽƉůĞǁŚŽĚŽŶ͛ƚŚĂǀĞĂĐĂƚŚĞƚĞƌ͘ Ž ǀŽŝĚĚŝƐĐŽŶŶĞĐƟŶŐƚŚĞĐĂƚŚĞƚĞƌĂŶĚĚƌĂŝŶƚƵďĞ͘dŚŝƐŚĞůƉƐƚŽƉƌĞ-
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,ŽǁĚŽ/ŐĞƚĂĐĂƚŚĞƚĞƌͲĂƐƐŽĐŝĂƚĞĚƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶ;Ͳhd/Ϳ͍ Ž dŚĞĐĂƚŚĞƚĞƌŝƐƐĞĐƵƌĞĚƚŽƚŚĞůĞŐƚŽƉƌĞǀĞŶƚƉƵůůŝŶŐŽŶƚŚĞĐĂƚŚĞƚĞƌ͘
/ĨŐĞƌŵƐĞŶƚĞƌƚŚĞƵƌŝŶĂƌLJƚƌĂĐƚ͕ƚŚĞLJŵĂLJĐĂƵƐĞĂŶŝŶĨĞĐƟŽŶ͘ DĂŶLJŽĨƚŚĞ Ž ǀŽŝĚƚǁŝƐƟŶŐŽƌŬŝŶŬŝŶŐƚŚĞĐĂƚŚĞƚĞƌ͘
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tŚĂƚĂƌĞƚŚĞƐLJŵƉƚŽŵƐŽĨĂƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶ͍ tŚĂƚĐĂŶ/ĚŽƚŽŚĞůƉƉƌĞǀĞŶƚĐĂƚŚĞƚĞƌͲĂƐƐŽĐŝĂƚĞĚƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶƐ
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ͻ ƵƌŶŝŶŐŽƌƉĂŝŶŝŶƚŚĞůŽǁĞƌĂďĚŽŵĞŶ;ƚŚĂƚŝƐ͕ďĞůŽǁƚŚĞƐƚŽŵĂĐŚͿ ͻ ůǁĂLJƐĐůĞĂŶLJŽƵƌŚĂŶĚƐďĞĨŽƌĞĂŶĚĂŌĞƌĚŽŝŶŐĐĂƚŚĞƚĞƌĐĂƌĞ͘
ͻ &ĞǀĞƌ ͻ ůǁĂLJƐŬĞĞƉLJŽƵƌƵƌŝŶĞďĂŐďĞůŽǁƚŚĞůĞǀĞůŽĨLJŽƵƌďůĂĚĚĞƌ͘
ͻ ůŽŽĚLJƵƌŝŶĞŵĂLJďĞĂƐŝŐŶŽĨŝŶĨĞĐƟŽŶ͕ďƵƚŝƐĂůƐŽĐĂƵƐĞĚďLJŽƚŚĞƌ ͻ ŽŶŽƚƚƵŐŽƌƉƵůůŽŶƚŚĞƚƵďŝŶŐ͘
ƉƌŽďůĞŵƐ ͻ ŽŶŽƚƚǁŝƐƚŽƌŬŝŶŬƚŚĞĐĂƚŚĞƚĞƌƚƵďŝŶŐ͘
ͻ ƵƌŶŝŶŐĚƵƌŝŶŐƵƌŝŶĂƟŽŶŽƌĂŶŝŶĐƌĞĂƐĞŝŶƚŚĞĨƌĞƋƵĞŶĐLJŽĨƵƌŝŶĂƟŽŶ ͻ ƐŬLJŽƵƌŚĞĂůƚŚĐĂƌĞƉƌŽǀŝĚĞƌĞĂĐŚĚĂLJŝĨLJŽƵƐƟůůŶĞĞĚƚŚĞĐĂƚŚĞƚĞƌ͘
ĂŌĞƌƚŚĞĐĂƚŚĞƚĞƌŝƐƌĞŵŽǀĞĚ͘
^ŽŵĞƟŵĞƐƉĞŽƉůĞǁŝƚŚĐĂƚŚĞƚĞƌͲĂƐƐŽĐŝĂƚĞĚƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶƐĚŽŶŽƚ tŚĂƚĚŽ/ŶĞĞĚƚŽĚŽǁŚĞŶ/ŐŽŚŽŵĞĨƌŽŵƚŚĞŚŽƐƉŝƚĂů͍
ŚĂǀĞƚŚĞƐĞƐLJŵƉƚŽŵƐŽĨŝŶĨĞĐƟŽŶ͘ ͻ /ĨLJŽƵǁŝůůďĞŐŽŝŶŐŚŽŵĞǁŝƚŚĂĐĂƚŚĞƚĞƌ͕LJŽƵƌĚŽĐƚŽƌŽƌŶƵƌƐĞƐŚŽƵůĚ
ĞdžƉůĂŝŶĞǀĞƌLJƚŚŝŶŐLJŽƵŶĞĞĚƚŽŬŶŽǁĂďŽƵƚƚĂŬŝŶŐĐĂƌĞŽĨƚŚĞĐĂƚŚĞƚĞƌ͘
ĂŶĐĂƚŚĞƚĞƌͲĂƐƐŽĐŝĂƚĞĚƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶƐďĞƚƌĞĂƚĞĚ͍ DĂŬĞƐƵƌĞLJŽƵƵŶĚĞƌƐƚĂŶĚŚŽǁƚŽĐĂƌĞĨŽƌŝƚďĞĨŽƌĞLJŽƵůĞĂǀĞƚŚĞ
zĞƐ͕ŵŽƐƚĐĂƚŚĞƚĞƌͲĂƐƐŽĐŝĂƚĞĚƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶƐĐĂŶďĞƚƌĞĂƚĞĚǁŝƚŚ ŚŽƐƉŝƚĂů͘
ĂŶƟďŝŽƟĐƐĂŶĚƌĞŵŽǀĂůŽƌĐŚĂŶŐĞŽĨƚŚĞĐĂƚŚĞƚĞƌ͘zŽƵƌĚŽĐƚŽƌǁŝůůĚĞƚĞƌ- ͻ /ĨLJŽƵĚĞǀĞůŽƉĂŶLJŽĨƚŚĞƐLJŵƉƚŽŵƐŽĨĂƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶ͕ƐƵĐŚ
ŵŝŶĞǁŚŝĐŚĂŶƟďŝŽƟĐŝƐďĞƐƚĨŽƌLJŽƵ͘ ĂƐďƵƌŶŝŶŐŽƌƉĂŝŶŝŶƚŚĞůŽǁĞƌĂďĚŽŵĞŶ͕ĨĞǀĞƌ͕ŽƌĂŶŝŶĐƌĞĂƐĞŝŶƚŚĞ
ĨƌĞƋƵĞŶĐLJŽĨƵƌŝŶĂƟŽŶ͕ĐŽŶƚĂĐƚLJŽƵƌĚŽĐƚŽƌŽƌŶƵƌƐĞŝŵŵĞĚŝĂƚĞůLJ͘
What are some of the things that hospitals are doing to prevent catheter-
ͻ ĞĨŽƌĞLJŽƵŐŽŚŽŵĞ͕ŵĂŬĞƐƵƌĞLJŽƵŬŶŽǁǁŚŽƚŽĐŽŶƚĂĐƚŝĨLJŽƵŚĂǀĞ
ĂƐƐŽĐŝĂƚĞĚƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶƐ͍
ƋƵĞƐƟŽŶƐŽƌƉƌŽďůĞŵƐĂŌĞƌLJŽƵŐĞƚŚŽŵĞ͘
dŽƉƌĞǀĞŶƚƵƌŝŶĂƌLJƚƌĂĐƚŝŶĨĞĐƟŽŶƐ͕ĚŽĐƚŽƌƐĂŶĚŶƵƌƐĞƐƚĂŬĞƚŚĞĨŽůůŽǁŝŶŐ
ĂĐƟŽŶƐ͘ /ĨLJŽƵŚĂǀĞƋƵĞƐƟŽŶƐ͕ƉůĞĂƐĞĂƐŬLJŽƵƌĚŽĐƚŽƌŽƌŶƵƌƐĞ͘
ŽͲƐƉŽŶƐŽƌĞĚďLJ͗
Also available:
Sterillium Rub
for surgical hand
antisepsis
How to Handrub?
RUB HANDS FOR HAND HYGIENE! WASH HANDS WHEN VISIBLY SOILED
Duration of the entire procedure: 20-30 seconds
1a 1b 2
Apply a palmful of the product in a cupped hand, covering all surfaces; Rub hands palm to palm;
3 4 5
Right palm over left dorsum with Palm to palm with fingers interlaced; Backs of fingers to opposing palms
interlaced fingers and vice versa; with fingers interlocked;
6 7 8
Rotational rubbing of left thumb Rotational rubbing, backwards and Once dry, your hands are safe.
clasped in right palm and vice versa; forwards with clasped fingers of right
hand in left palm and vice versa;
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind,
either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.
May 2009
Practice Hospital
Bed Safety
“H
ospital beds are
found in nearly
all patient care
settings or environments,”
says Joan Ferlo Todd, RN, a
senior nurse-consultant at the
Food and Drug Administration’s
(FDA) Center for Devices
and Radiological Health
(CDRH). “They are used not
only in hospitals, but also in
outpatient care centers, long-
term care facilities, and in
private homes.”
CDRH reports that about 2.5 mil- Hospital Bed Entrapment Zones
lion hospital beds are in use in the
United States. The center regulates An FDA guidance characterizes the head, neck, and chest as key
these beds as medical devices. body parts at risk of entrapment, and identifies seven potential
“Many of today’s hospital bed “zones of entrapment” where special care is required:
models are quite complex. Patients
and health care professionals should 1. within the rail
understand how to use them prop-
erly, and manufacturers must provide 2. under the rail, between the rail supports or next to a single rail
adequate instructions for use,” says support
Todd, who works in CDRH’s Office 3. between the rail and the mattress
of Surveillance and Biometrics.
4. between the rail, at the ends of the rail
Beware of Entrapment 5. between split bed rails
The main risk is entrapment, which
occurs when a patient is caught in 6. between the end of the rail and the side edge of the head or
spaces in or around the bed rail, foot board
mattress, or bed frame. Entrapped
individuals can become strangled. 7. between the head or foot board and the mattress end
1 / FDA Consumer Health Information / U.S. Food and Drug Administration JUNE 2009
Additional features:
• Optimal hi-low range of 26” to 7.25”
• Built-in motor stop keeps the bed from applying more
pressure in the event that something gets caught in the
head or foot section
• Interest-free payment plan of 3, 6 or 12 months
Alterra 1232
MAX
height of
26"
LOW
height of
7.25"
www.medline.com
Forms & Tools Practice Hospital Bed Safety
2 / FDA Consumer Health Information / U.S. Food and Drug Administration JUNE 2009
3 / FDA Consumer Health Information / U.S. Food and Drug Administration JUNE 2009
PRESSURE ULCER
POCKET REFERENCE CARD
www.medline.com
MKT209365/LIT186R/20M/HLG5
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.