Infection

Evonne Fowler Prevention

Evolution to in LTC
Revolution

Ease The
Pain
Special Section
Breaking News FREE CE!
Healthcare Reform

Pressure Ulcer Prevention in Action

 Join the team!
HEALTHY SKIN
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Contact us at healthyskin@medline.com to learn more!
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 HEALTHY SKIN
Improving Quality of Care Based on CMS Guidelines

8 QIS Update
Survey Readiness

Sue MacInnes, RD, LD 51 QAPI for Hospice

Editor

Margaret Falconio-West, BSN, RN, 10 Pressure Ulcer Prevention News from Across the United States
Clinical Editor Prevention

APN/CNS, CWOCN, DAPWCA

29 Best Practices for Blood Glucose Monitoring
33 Education Strategies to Combat CAUTI
Page 20
Alecia Cooper, RN, BS, MBA, CNOR 35 Pressure Ulcer Prevention Program at Rest-Haven York
Managing Editor

38 Pressure Ulcer Prevention Program Statistics

39 Product Spotlight: MARATHON Liquid Skin Protectant
Andy J. Mills, MBA
Contributing Editor

41 Education, Products that Work and Celebration

Lynne Brown, RN, BSN, MBA

Clinical Team

20 C. difficile: Facts and Interventions

Treatment

Clay Collins, RN, BSN, CWOCN, CFCN,

DAPWCA 22 Case Study: Urinary Bladder Matrix Assistance with High Risk
Diabetic Limb Salvage Page 44
Cynthia A. Fleck, RN, BSN, CFCN, CWS,
DAPWCA, MBA, FCCWS 25 Clinical Study of SilvaSorb Gel
Janet L. Jones, RN, BSN, PHN, CWOCN, 44 Reducing Total Pain at the End of Life
DAPWCA 49 The Pain-Relieving Touch of Reiki
Joyce Norman, RN, BSN, CWOCN,
DAPWCA
12 NPUAP and EPUAP Draft New International Pressure
Special Features

Elizabeth OʼConnell-Gifford, RN, BSN,

Ulcer Guidelines
CWOCN, DAPWCA, MBA
14 Evonne Fowler: Revolutionizing Wound Care with Passion
Amin Setoodeh, BSN, RN Page 53
and Commitment
Jackie Todd, RN, BSN, CWCN, DAPWCA
53 Itʼs a Privilege: Caring for U.S. Veterans at Missouri
Veterans Home
57 Point-of-Care Testing: Evolution or Revolution?
Wound Care Advisory Board
Linda Woodward, BSN, RN, OCN, CWOCN
Laurel Wiersema-Bryant, ANP, BC 65 ʻBee Stories: Linda Ellerbee Raises Awareness About
Lynne Grant, MS, RN, CWOCN Breast Cancer
Diane Krasner, PhD, RN, CWCN, CWS,
BCLNC, FAAN
5 Breaking News
Regular Features
Page 57
Evonne Fowler, MSN, RN, CNS, CWON 6 Two Important National Initiatives for Improving Quality of Care
Linda Neiswender, BSN, RN, CPN
Lynne Whitney-Caglia, MSN, RN, CNS,
60 Keep Your Job During Tough Times
Caring for Yourself

CWOCN
72 Healthy Eating: Bangers and Mash with Golden Onions
Patricia Coutts, RN
Dea J. Kent, MSN, RN, NP-C, CWOCN
74 Transdisciplinary Pain Flow Sheet
Forms & Tools
Zemira M. Cerny, BS, RN, CWS
76 Pain Assessment Cards Page 60
78 Hospice Patient and Family Education: Control of Pain
80 Pain Algorithm
84 Taking Care of Type 2 Diabetes - English
Special Insert
1 CE Credit
86 Taking Care of Type 2 Diabetes - Spanish
Following
Page 50

Improving Quality of Care Based on CMS Guidelines 3

 Healthy Skin Letter from the Editor

Dear Reader,

This year my husband and I both turned 50. We used
this milestone as an excuse to celebrate by going on a
long weekend to Cancun. It was February, so leaving the
bitter cold and snow in Chicago was not a problem. It
felt so good to get away, and for the first time in a long
time, I actually sat still for a couple of minutes and let
“work” related issues slip from my mind. I mean it is pretty
hard to think about projects and deadlines when you are
sitting on a pristine beach, soaking in the sun and gaz-
ing at the bluest water you have ever seen. So there I
was on the beach, my husband was reading People
magazine and I was curled up with What We Can Do
About the Health-Care Crisis by Sentator Tom Daschle.
And, I was really happy.
It’s interesting. Everything I read about in this book, like
an emphasis on information technology, aggressively
promoting prevention, greater emphasis on treating
chronic conditions, concentrating our efforts more on the
value of the care we are giving, etc. It is all happening. I
have to tell you it felt better tackling these things with my
eyes wide open. So, get involved, know the potential
problems and start looking into how you can impact the
future. (See the next page for more information on
Daschle’s book.) There are so many creative ideas and
strategies out there and many of the best ones come
from you and the people you are working with.

I know what you are thinking … what in the world

prompted me to read about healthcare reform wile sitting
on a beach? Couldn’t I find anything more interesting,
like a good romance novel or the latest James Patterson
release? But no, I finally had a block of time where no
one would bother me, and I wanted to read about the
proposed future of health care and gain some insight into
whether we were on the right track with the programs,
This edition of Healthy Skin continues to report updates
in the industry. But just as important as knowing the cur-
rent events and trends is knowing how to apply strate-
“
So, get involved,
know the potential
gies that actually work. You can read about real success problems and start
stories, people and facilities that have tried new things,
looking into how
worked together and were able to report positive out-
comes that changed the lives of their staff, their families you can impact
and their patients.

And, for the first time we have decided to put one of

”
the future.

product innovations and research projects we had in the
works. There had been so many changes going on in
our nation not only a change in administration in the
White House, but also the unsettling issues with the
economy. How was this affecting healthcare? Would
the direction we had been following also have to
change? I had my highlighter and my reading glasses
and attacked the book enthusiastically.
those special people who contributed her life to the
wound care profession and the improvement of patient
care, Evonne Fowler, on the cover of Healthy Skin. We
felt it was only appropriate. Evonne was gracious enough
to allow us to interview her, so that we could share her re-
markable story with all of you (pages xx-xx).
Thank you for all you do, everyday!

A couple months later I was interviewing the CEO of a

nearby hospital. As we were about to start the interview,
and quite by coincidence, I noticed the same book by Sue MacInnes, RD, LD
Daschle that I had read in Cancun, on his desk. I asked Editor
him why he was reading it and he said because he also
wanted to see where things were going with health care
and felt it would help him have greater insight into the
future of his hospital.

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
The Quality Summit
July 20-21, Washington DC
On July 20-21 in Washington, DC a conference of
distinguished healthcare leaders in long-term care will be held
called The Quality Summit: Partnering to Improve Care in
Our Nation’s Nursing Homes. Led by Andy Kramer, MD,
Professor of Medicine, University of Colorado at Denver, and
lead developer of the Quality Indicator Survey for CMS, the
conference will address new approaches to quality assur-
ance, as well as the use of health information technology for
quality management.
Former Senator and architect of President Obama’s healthcare
plan, Tom Daschle will discuss healthcare reform and its
impact on the quality of care in nursing homes. The primary
purpose of the conference is to discuss ways in which the
federal and state governments and providers can work
together to improve the quality of care given to the residents
of our nation’s nursing homes.
Critical: What We Can Do About
the Health-Care Crisis, authored
by former Senator Tom Daschle, out-
lines the healthcare reform strategies
that are the foundation of President
Obama’s healthcare plan. Evaluating
where previous attempts at national
healthcare coverage have succeeded
and where they have gone wrong,
Daschle explains the complex social,
economic, and medical issues
involved in reform and sets forth his vision for change. The
book can be purchased at any leading retail bookstore or
online store.
Swine Flu - Residents Are at Risk
The CDC and WHO are currently developing recommenda-
tions on control measures for this outbreak. Clinical presen-
tation is similar to other strains of flu: fever, cough, sore
throat, myalgias, headache, chills and fatigue. Some patients
may have nausea, vomiting, and diarrhea.
WHO Pandemic Levels
• Phase 1: A virus in animals has caused no known
infections in humans.
• Phase 2: An animal flu virus has caused infection
in humans.
• Phase 3: Sporadic cases or small clusters of disease
occur in humans. Human-to-human transmission, if any,
is insufficient to cause community-level outbreaks.
• Phase 4: The risk for a pandemic is greatly increased but
not certain. The disease-causing virus is able to cause
community-level outbreaks.
• Phase 5: Spread of disease between humans is
occurring in more than one country of one WHO region.
• Phase 6: Pandemic level. Community-level
outbreaks are in at least one additional country in a
different WHO region from phase 5.
Interim Guidance
Duration: Infected persons should be assumed to be
contagious up to 7 days from illness onset and residents
should be isolated when symptomatic.
Testing - Preferred respiratory specimens: Collect as
soon as possible after illness onset: nasopharyngeal
swab/aspirate or nasal wash/aspirate. If specimens cannot
be collected, a combined nasal swab with an oropharyngeal
swab is acceptable.
Swabs - Ideally, swab specimens should be collected
using swabs with a synthetic tip (e.g., polyester) and an
aluminum or plastic shaft.
Storing clinical specimens: All respiratory specimens
should be kept at 4°C until they can be placed at -70°C. If a
-70°C freezer is not available, specimens should be kept at
4°C, preferably no longer than 1 week.
Shipping clinical specimens: Clinical specimens should be
shipped on dry ice in appropriate packaging.
 Two Important National Initiatives
for Improving Quality of Care
Achieving better outcomes starts with an understanding of current quality
of care initiatives. Hereʼs what you need to know about national projects and
policies that are driving changes in nursing home and home health care.

QIO Utilization and Quality Control Peer Review Organization

1 9th Round Statement of Work

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:

Purpose: To carry out statutorily mandated review activities, such as:

• Reviewing the quality of care provided to beneficiaries;
• Reviewing beneficiary appeals of certain provider notices;
• Reviewing potential anti-dumping cases; and
• Implementing quality improvement activities as a result of case review activities.
In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The
content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities,
Goal:

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

2 Advancing Excellence in America’s Nursing Homes

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:

additional 2 years (until September 26, 2010).

Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers,
consumers and government that developed a grassroots campaign to build on and complement the work of existing
quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.
To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition
has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction
Goal:

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

1. Improving immunizations as a clinical goal

2. Including target setting in all goals
3. Changes to the order in which the goals are presented

6 Healthy Skin
The 9th Scope of Work Content Themes

1. Recruiting participating practices

Theme #1: Beneficiary Protection Activities will focus on Theme #4: Prevention Activities will focus on nine Tasks:

1. Case reviews 2. Identifying the pool of non-participating practices

nine Tasks:

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
2. Reducing rates of pressure ulcers in nursing homes and hospitals
3. Reducing rates of physical restraints in nursing homes
4. Improving inpatient surgical safety and heart failure treatment
in hospitals
5. Improving drug safety
based on the most recent data available to CMS. The performance
results of the evaluation at both time periods will be used to determine
the performance on the overall contract.
– 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

Clinical and Operational/Process Goals

Goal 1: Reducing high-risk pressure ulcers < 10% 11.4% Goal 5: Establishing individual targets for > 90% 36.4%
Clinical Goals: Goal Actual Operational/Process Goals: Goal Actual

Goal 2: Reducing the use of daily < 5% 4.3% improving quality

physical restraints Goal 6: Assessing resident and family 21.5%
Goal 3: Improving pain management for < 4% 3.9% satisfaction with quality of care
longer-term nursing home residents Goal 7: Increasing staff retention 12.9%
Goal 4: Improving pain management for < 15% 20.4% Goal 8: Improving consistent assignment 25.4%
short-stay, post-acute nursing of nursing home staff so that
home residents residents receive care from the
same caregivers

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.

Participating nursing homes: 7,366

Goal 1: 70.6% Goal 5: 32%
Percentage of participating nursing homes:* 46.8%
Goal 2: 45.0% Goal 6: 62.7% Participating consumers: 2,186
Goal 3: 54.2% Goal 7: 41.1% Average number of goals per
Goal 4: 39.3% Goal 8: 31.3% nursing home: 3.8

Visit this Web site to view progress by state!

www.nhqualitycampaign.org/star_index.aspx?controls=states_map
Represents a 7.4% increase in
*Based on the latest available count of Medicare/Medicaid nursing homes
participation since January 2008.

Improving Quality of Care Based on CMS Guidelines 7


QIS
Update by Andrew Kramer, MD
With training of state surveyors underway in Washington and Maryland, 11 states will be rolling out QIS
by this summer. As of early April 2009, more than 1,700 QIS surveys have been conducted, and the
numbers are growing fast in all QIS states.
New training approach for small states
The Centers for Medicare & Medicaid Services (CMS) have
begun a new training approach for surveyors in small states
so that the entire state can transition to QIS over a short
period of time. The approach was conducted in West
Virginia, where all surveyors will soon be registered QIS
surveyors and they will be conducting only QIS sur-
veys statewide.
Improved QIS software coming in 2010
CMS has begun to discuss their approach to full national
implementation of the QIS with more detail available this sum-
mer about how states will be scheduled. In addition, several
major developments are underway to the QIS process. First,
under contract CMS is programming new QIS software
for the state surveyors to use. The original software was
programmed about eight years ago and is now outdated and
inefficient with all the new developments in QIS. This will not
change any of the QIS questions and logic, but the improved
software will enable more efficient national implementation.
The surveyors will be trained on their new software in early
2010. This will not require changes to the abaqis quality
assurance system.
More enhancements
Several other development activities are underway. One is an
adaptation of the QIS process so that surveys of small facil-
ities can be conducted more efficiently. Another is the devel-
8 Healthy Skin
Survey Readiness
opment of a QIS process for complaint investigations that are
not conducted during the standard annual survey. And a third
is further refinement and automation of the QIS revisit
process. All of these investments by CMS provide evidence
of their commitment to roll out QIS nationwide, ultimately as
the only survey process in use.
Nursing homes are beginning to see the benefits of a more
objective, consistent, and resident-centered survey process.
Those that are taking advantage of these benefits are the
providers that are most proactive about using the QIS forms
and tools like abaqis for ongoing quality assurance and qual-
ity improvement.
About the author
Andrew Kramer, MD is Head of the
Department of Medicine’s Health Care
Policy and Research Division at the Uni-
versity of Colorado and the first recip-
ient of the Peter W. Shaughnessy Endowed Chair in Health
Care Policy. His research interests focus on strategies for im-
proving care provided to frail older adults across the healthcare
continuum. He has authored more than 90 publications and
policy reports, is a frequent advisor to the Centers for
Medicare & Medicaid Services, Office of the Assistant Secre-
tary for Planning and Evaluation, Senate Committee on
Aging and the Institute of Medicine.
“ There are no
surprises anymore
when the nursing home
surveyor comes to our
facilities. And when he
wants to talk to our
residents, we know exactly
what he is going to ask.

How?
We’re an abaqis user.”
Suzanne Giangrasso
Administrator
Lorien Mt. Airy
Mt. Airy, MD

The new Quality Indicator Survey (QIS) for nursing homes
is more resident-centered, with more information obtained
from direct questioning of residents and families. In fact,
60 percent of facilities have had more deficiencies in QIS
than in the prior traditional survey, often in regulatory areas
such as quality of life that were not as fully investigated in
the traditional process.
That gives you a unique advantage in preparing for your
survey – and in meeting your resident’s needs.
abaqis® is sold exclusively through Medline.
Learn more by signing up for a free webinar
demo at www.medline.com/abaqisdemo.

®
abaqis is the only quality assessment and reporting
system for nursing homes that is tied directly to the QIS,
and its quality assessment modules reproduce the same
forms, analysis and thresholds used by State Agency
surveyors. Rich reporting capabilities on 26 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.

New Jersey passes
law mandating nursing
home use of pressure
redistribution mattresses
The New Jersey legislature unanimously
passed a bill in February 2009 to require
nursing homes to replace regular mattresses with pressure redis-
tribution mattresses within three years. Nursing homes will have
to buy the upgraded mattresses when replacing older ones, be-
ginning one year from the bill’s enactment.1
Sponsors of the bill acknowledge that pressure redistribution mat-
tresses may cost more initially than standard spring mattresses,
however, they said they cannot put a price on the continued
health and wellness of the state’s most vulnerable senior citizens.1
This new law is especially significant, considering the positive
results achieved by the New Jersey Pressure Ulcer Collaborative,
a pressure ulcer prevention program sponsored by the New Jersey
Hospital Association.
After nearly two years of applying best practices and preventive
techniques, 150 hospitals, nursing homes and home care agencies
in New Jersey tracked a 70 percent reduction in the incidence
of new pressure ulcers in their patients. Data was tracked from
September 2005 through May 2007.2
Of the organizations taking part in Pressure Ulcer Collaborative,
48 reported achieving results of no new pressure ulcers for a period
10 Healthy Skin
Prevention
of at least three months. In addition, data showed that the preva-
lence of existing pressure ulcers as patients moved from one care
setting to another was reduced by 30 percent.2
The organizations involved in the project were given a review
of various positioning and support surface devices to help
understand the principles behind each type of device and how
they may be used with different patient populations.2
Improvement techniques used by staff across care settings
included:2
• an evaluation of the risk of skin breakdown
• implementation of preventive strategies, such as proper
positioning and use of assistive devices
• ongoing observation of the condition of patients’ skin,
particularly for those identified as being at high risk for
developing a pressure ulcer
Indiana Pressure Ulcer Quality
Improvement Initiative Selects
Medline’s Wound Care Handbook
as Standard Resource Guide
Medline donates 200 handbooks
to help standardize pressure
ulcer education
The Indiana Pressure Ulcer Quality Improvement Initiative has
selected Medline’s wound care handbook as a resource guide for
information and treatment regarding pressure ulcers and wounds.
The comprehensive guide provides information on the basics of
wound care and how various treatments are applied by practi-
tioners in the field. Medline will donate more than 200 copies of
the manual, enough for each healthcare facility (including hospi-
tals, nursing homes and home care agencies) participating in the
collaborative.
“Not every facility has a wound care expert,” said Dea Kent, MSN,
RN, NP-C, CWOCN, a clinical faculty member for the Indiana
Pressure Ulcer Quality Improvement Initiative. “Medline’s wound
care handbook contains all the basic information on skin and
treating pressure ulcers and explains it in an easy-to-understand
format that any clinician can follow.”
Spearheaded by the Indiana State Department of Health and the
University of Indianapolis Center for Aging and Community (CAC),
the initiative is a collaboration of healthcare organizations across
the spectrum of care to develop a program of education, training
and technical assistance to reduce the incidence of pressure
ulcers in healthcare settings across the state of Indiana.3
Wisconsin Forms Pressure
Ulcer Coalition
Healthcare leaders from across
Wisconsin have formed the Wisconsin
Pressure Ulcer Coalition to help reduce
pressure ulcers in the state’s nursing
homes and hospitals.
According to coalition leadership, the coalition is intended to
address pressure ulcer prevention across the continuum of care
by bringing together all players to help facilitate communication
and problem-solving at many levels.4
The goals of the Wisconsin Pressure Ulcer Coalition are to:4
• Decrease the incidence of pressure ulcers in
healthcare settings
• Continue to educate caregivers and leaders about
effective preventive measures
• Improve assessment when an individual is admitted
to a healthcare facility, as well as continue to
monitor appropriately.
• Develop appropriate prevention strategies within 24 hours
if an individual is identified to be at risk of developing
pressure ulcers
• Improve communication between providers to provide
better continuity of care
Improving Quality of Care Based on CMS Guidelines 11
Pennsylvania Launches Pressure
Ulcer Partnership
The Pennsylvania Pressure
Ulcer Partnership is a statewide
collaborative to provide a compre-
hensive approach to the identifica-
tion, prevention and treatment of
pressure ulcers within the state.
The program launched October 21, 2008, with a series of regional
education sessions for healthcare professionals from acute care
hospitals, long-term care facilities and home health organizations.
Participants received the latest evidence in pressure ulcer pre-
vention and treatment from national experts, learned practical and
effective prevention strategies and planned next steps for their
own organizations in reducing the incidence and severity of pres-
sure ulcers.5
In order to measure and demonstrate improvement across the
state and within their own organizations, program participants are
encouraged to commit to monthly data collection and submis-
sion based on metrics selected by the Partnership. These data
measure evidence of risk assessment and reassessment, skin
inspection, prevention strategies and presence of pressure ulcers
and their stages.5
References
1 New state law to mandate nursing homes use pressure-relief mattresses to fight pressure
ulcers. McKnight’s Long Term Care News & Assisted Living Web site. February 9, 2009.
Available at http://www.mcknights.com/New-state-law-to-mandate-nursing-homes-use-
pressure-relief-mattresses-to-fight-pressure-ulcers/article/12706. Accessed February
10, 2009.
2 Tom, P. The sleeper of the season? Home Care magazine Web site. October 1, 2007.
Available at http://homecaremag.com/mag/bed_sales_increase. Accessed April 3, 2009.
3 Indiana State Department of Health Long Term Care Newsletter: Pressure Ulcer Initiative
Update Issue 08-31. December 5, 2008. Available at www.in.gov/isdh/files/ltcnews083.pdf.
Accessed April 24, 2009.
4 Wisconsin a Leader in Pressure Ulcer Initiatives. Medical News Today Web site. Posted
November 30, 2008. Available at www.medicalnewstoday.com/articles/131120.php.
Accessed March 13, 2009.
5 Current Activities of the Pennsylvania Pressure Ulcer Partnership. The Health Care
Improvement Foundation Web site. Available at http://www.hcifonline.org/section/
programs/pennsylvania_pressure_ulcer_partnership.
 Special Feature
NPUAP and EPUAP Draft New
International Pressure Ulcer Guidelines
By Jackie Todd RN, CWCN, DAPWCA
The National Pressure Ulcer Advisory Panel (NPUAP) and
the European Pressure Ulcer Advisory Panel (EPUAP)
presented their newly drafted joint guidelines on pressure
ulcer prevention and care at the 11th Biennial NPUAP Con-
ference February 27-28, 2009, in Washington, DC.
The guidelines will be available for widespread use in early
summer 2009, according to NPUAP member Joyce Black,
PhD, RN, CWCN, CPSN, Associate Professor, College of Nurs-
ing, University of Nebraska Medical Center.
Both the prevention and treatment of pressure ulcers are ad-
dressed in the new guidelines. Prevention areas include eti-
ology, risk assessment, nutrition, skin assessment, positioning
and support surfaces.1 Treatment areas include pressure
ulcer classification, assessment and monitoring of healing,
nutrition, pain assessment and management, support sur-
faces, infection assessment, cleansing, debridement, dress-
ings, biophysical agents, negative pressure wound therapy,
growth factors and biological dressings, operative care and
palliative care.2
An urgent need for up-to-date guidelines3
NPUAP and EPUAP recognized an urgent need for
revised pressure ulcer guidelines and began collaborative
development plans in 2005.
Other groups, including the Wound, Ostomy and Continence
Nurses Society (WOCN), the Wound Healing Society (WHS),
Registered Nurses’ Association of Ontario (RNAO), and even
EPUAP, had also produced guidelines on pressure ulcers,
but each set had its own viewpoint, and there were many
gaps to be filled.
In addition, a thorough literature review for guidelines had
not been done in more than a decade, and considerable
advances in pressure ulcer prevention and care had taken
place during that time. Advances include new techniques
for reducing pressure, adjunctive therapies (such as nega-
tive-pressure wound therapy), new dressings and additional
topical and systematic medications including wound
growth factors.
Also, because pressure ulcers are a significant global issue,
NPUAP and EPUAP determined the need to address the
problem from an international perspective. Pressure ulcer
prevalence rates are more than 25 percent in Canada,
12 Healthy Skin
Germany, Italy and the Netherlands,
according to Scope Document 3.0,
developed by the EPUAP and NPUAP
Collaboration to Produce a Clinical Prac-
tice Guideline.3
The document also states that costs of
treating pressure ulcers consume one
percent of healthcare expenditures in the
Netherlands and four percent in the
United Kingdom. Annual pressure ulcer
treatment costs in the United States
range from $9.1 to 11.6 billion.3
The development process
An official NPUAP/EPUAP planning meeting took place in
early 2007 to set the ground rules for inclusion of literature,
review processes and writing style. The development
process began with a review of existing guidelines and ev-
idence tables, looking for trends, themes and gaps in infor-
mation. Literature was compiled and further reviewed by
small working groups with expertise in specific sub-
areas, such as nutrition, pain assessment and wound
dressings.3
As the working groups began developing guidelines within
their specialty areas, they presented their drafts to the
guideline development committee for editing and critiquing.
When all the guidelines were complete, the draft documents
were posted on the NPUAP and EPUAP Web sites in early
2009 for review by the professional public.
For more information and updates,
visit www.pressureulcerguidelines.org.
References
1 European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure
Ulcer Advisory Panel (NPUAP) Pressure Ulcer Guidelines Web site.
Available at www.pressureulcerguidelines.org/prevention. Accessed
on April 13, 2009.
2 European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure
Ulcer Advisory Panel (NPUAP) Pressure Ulcer Guidelines Web site.
Available at www.pressureulcerguidelines.org/therapy. Accessed on
April 13, 2009.
3 European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure
Ulcer Advisory Panel (NPUAP) Pressure Ulcer Guidelines Web site.
Scope Document 3.0 – Pressure Ulcer Prevention: A European Pressure
Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel
Collaboration to Produce a Clinical Practice Guideline. Available at
http://www.pressureulcerguidelines.org/prevention/page12817.html.
Accessed on April 13, 2009.
 The beauty is in its effectiveness.

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 Special Feature

14 Healthy Skin
 EVONNE
FOWLER
Evonne Fowler
Revolutionizing Wound Care
with Passion and Commitment
By Healthy Skin Staff Writer

Whether she’s caring for patients at the bedside or planning a

wound care symposium, Evonne Fowler fuels her career with
steadfast passion and commitment.

One of the first graduates of The Cleveland Clinic enterostomal ther-

apy program – birthplace of the wound care field, Fowler is also
founder of the Symposium on Advanced Wound Care (SAWC) and the
founding president of the Association for the Advancement of Wound
Care (AAWC).

She’s helped forge the way for today’s professionals as one of the
great pioneers in wound care.

The creation of the SAWC

“I would say the SAWC (Symposium on Advanced Wound Care) is my
claim to fame,” Fowler said. As co-chair of the event every year since
it began 21 years ago, she does everything she can to make sure the
SAWC is brimming with “passion and enthusiasm to get people
excited about what they’re doing.”

The first SAWC took place in 1988 in Long Beach, Calif. With about
450 participants, it was so well-attended that they ran out of seats
and people were sitting in the aisles. The symposium has continued to
grow over the years, and today, more than 2,000 participants attend.

The symposium came to fruition when Fowler began a casual

conversation with the head of HMP Communications at a nursing

Improving Quality of Care Based on CMS Guidelines 15

“ We need people from all
walks of life, and we really
are a family”

conference in Las Vegas in the mid 1980s. He asked

Fowler for ideas on new communication and educa-
tion mechanisms for wound care nurses, “and a few
years later we held our first symposium,” Fowler
shared, in her usual matter-of-fact manner.
Collaborating with
a co-worker.
The SAWC has grown more interdisciplinary over the
years. Physicians, who in the past would defer to
“whatever the nurse recommends,” are becoming
more actively involved in wound care. Podiatrists,
vascular specialists and physical therapists also
participate.

The AAWC is the “voice for wound care”

The SAWC had clearly become a success, but the
symposia were held only once a year. What could
Fowler do to keep enthusiasm up during the rest of
the year? The answer was to form the Association for
Advanced Wound Care (AAWC). The organization
officially made its debut in 1995 and now claims more
than 1,600 members.

Fowler encourages all wound care professionals to

consider joining AAWC because it is “the voice for
wound care and has the viability to be agents
to change.”
She also points out that joining the AAWC is a great
way to meet people from different disciplines. The
AAWC’s motto reflects its openness to anyone pas-
sionate about wound care: “One mission, many
faces, one family.”
“We need people from all walks of life, and we really
are a family,” she added.
Making a difference every step of the way
Fowler believes there is a place for everyone in wound
care and recommends making the most of wherever
you are in your career. “No matter who you are or
Reviewing a patient’s chart.
where you are, someone needs you,” Fowler said.
“Be passionate and persistent as you offer your best.”
Today Fowler offers her best to her husband, who is
the one who needs her most right now. Two years
ago, when advancing Alzheimer’s led to incontinence
and other difficulties with the activities of daily living,
Fowler left an exciting 20-year post at the helm of the
busy Chronic Wound Care Clinic 80 miles away at
Kaiser Permanente in Bellflower, Calif., to spend more
time caring for him.
“It was a tough decision, but you do what you have to
do,” Fowler said. “I never thought I would have my

16 Healthy Skin
 Caring for a
patient at
San Gorgonio
Hospital.

own patient right at home, but all of the skills I’ve had
and all of the compassion I’ve had – I’m now using
to care for him.”

At that time, advanced wound care focused primarily

With her humble, take-it-in-stride attitude, she added,
on patients who had wounds associated with
“I’m not unusual. I’m usual. I’m ordinary. This is what
ostomies, such as periostomal denuding of the skin.
people do.”

“Our mission was to keep the patient clean, dry and

She also works part-time close to home at 76-bed
comfortable – and free from pain – while we figured
San Gorgonio Hospital caring for patients with pres-
out what else was going on,” she said.
sure ulcers and incontinence dermatitis. “I often say
I’ve gone from the bedside, to the boardroom, and
Although they were a small group at first, Fowler
now back to the bedside. This is where I am at right
noticed a common trait that united wound care
now, so I am doing my best for these patients.”
nurses. “They had passion and commitment for what
they were doing,” she said. “Patients knew we really
Reflecting on the early days
cared. That passion and commitment kept me going,
Early in her nursing career, Fowler was working as an
and I haven’t lost it yet.”
assistant head nurse at a county hospital. “We had
all the train wrecks – the people who had all the skin
problems,” she recalls. Fowler saw an opportunity
Improvising and experimenting
Back in the ‘70s and ‘80s, the wound care nurse’s
to make a positive impact on the care those patients
toolbox was largely limited to ostomy care products,
received. And then, when she was approached about
and nurses would experiment with products to
becoming head of enterostomal therapy, she said to
c re ate what they needed. Fowler recalls using
herself, I can do something here.
a stoma adhesive as an occlusive dressing over pres-
sure ulcers and stomas.
Entering the advanced wound care field wasn’t some-
thing a lot of nurses were clamoring to do at that time.
“The wound products sales reps would go on patient
“When I started in wound care, nobody else wanted
rounds with us, and then we would tell them what we
to do it. You have to have passion and compassion.”

What’s on the horizon in wound care?

Fowler believes the current emphasis on biomolecular
approaches to wound care will continue into the future.
Stem cell gene therapy, biological dressings, systemic
therapies, improvements in vascular techniques and
regenerative medicine are all on the SAWC’s radar.
The SAWC is also pushing for a physician specialty in
wound care – something that would bring the organi-
zation closer to its goal of being an “umbrella organi-
zation” that represents multiple disciplines.
“We want to create a stronger voice because there is
strength in numbers,” said Evonne. “That would be my
dream.”
As the AAWC eyes the future, they see a changing
landscape in health care – and they’re ready for it. As
CMS revamps its reimbursement policies, the AAWC
will continue to be an advocate for wound care. Evonne
expressed an interest in leading AAWC in the direction
of becoming a political action group.

Improving Quality of Care Based on CMS Guidelines 17

 Assessing a
quality improve-
ment project.

needed. They would develop new products based on

our input, and come back with items that did what we
needed. When I think back on it now, we really were
Pearls of Career Wisdom
pioneers.”
from a Wound Care Pioneer

Make the most of where

The product selection might not have been the best,
you are right now
but the goals of wound care back then are still in line
Whether you are a nursing
with what is happening today. “We’re still doing a lot
assistant or a director of
of things 30 years later that we did then,” Fowler said.
nursing, Fowler advises
“As I age, I can see there’s room for everything in
doing your very best every
terms of product use.”
step along the way. The
rewards will follow. “You
A long and winding career
give, you get. You give, you
Fowler has held myriad positions across the contin-
get. That’s what I believe.”
uum of care. Along the way, she also earned bache-
lor’s and master’s degrees in nursing and became
Learn all you can
licensed as a clinical nurse specialist. She is founder
First, there is formal education with various
and president of Dynamic New Directions, an educa-
degrees and certifications. “But that only gets us
tional and research company that provides education
so far,” Fowler shared. Throughout your career,
to healthcare professionals on skin-related concerns.
continue to learn from mentors, by attending pro-
She also continues as co-chairperson of the SAWC.
fessional conferences and keeping up with the
latest research, studies and trends, while also
In the past she shared her talents as an assistant clin-
drawing on your personal bank of experience.
ical professor at the UCLA School of Nursing and as
co-chair of the multidisciplinary advisory board for the
Keep your passion and commitment
USC ET program.
This is the fuel that feeds the wound care nurse.
“It’s what’s kept me going all these years. And I
Coping with CMS haven’t lost my passion yet,” Fowler said.
Reimbursement changes
The recent changes to the Centers for Medicare &
Medicaid Services (CMS) reimbursement policy for
a select group of “never events” have health care To learn more about the AAWC and SAWC, check out
buzzing. Fowler says preventing the never events their Web sites!
is especially challenging because, “half the patients www.aawconline.org
we see have three or four or five of those condi- www.sawc.net
tions, and they snowball,” she said. Still, she thinks
“this change is really going to help both patients
and providers once we get over the shock!”

18 Healthy Skin
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 Treatment

The geriatric population is especially susceptible to

Clostridium difficile (C. difficile) infection due to risk
factors such as intense antibiotic exposure, prolonged
length of stay, multiple underlying diseases and poor host
immune responses. C. difficile is a spore-forming, bacterial
pathogen that can cause a wide spectrum of infection in
the elderly. Intense use of antibiotic therapy disrupts the
normal flora in the bowel, allowing for overgrowth and

C. difficile: toxin production of the C. difficile bacteria.

Facts and Interventions

for Long-Term Care
C. difficile is frequently found in healthcare facilities and is
responsible for approximately 20 percent of all inci-
By Deb Tenge MS, RNC
dences of antibiotic-associated diarrhea. Colonization of
C. difficile has been noted to be 10 to 25 percent in the
acute care setting and four to 50 percent in the long-term
care setting.

20 Healthy Skin

Differences Between C. difficile Colonization
and C. difficile-associated Disease
C. difficile Colonization
1. Patient/resident exhibits no clinical symptoms
2. Patient/resident tests positive for C. difficile organism
and/or its toxin
3. More common than C. difficile-associated disease
C. difficile-associated Disease
1. Patient/resident exhibits clinical symptoms
2. Patient/resident tests positive for C. difficile organism
and/or its toxin
Current studies indicate that residents who exhibit C. difficile
colonization may have protective qualities against the devel-
opment of C. difficile-associated disease. However, these
residents also have a significantly higher rate of skin and
environmental contamination than non-colonized residents.
They may even contribute to the spread of C. difficile within
the facility.
Epidemiology changes for C. difficile have noted an
increase in the overall incidence. Hospital discharges with
C. difficile have gone from 82,000 in 1996 to 178,000 in
2003. The severity has increased as well, with life-threatening
symptoms going from 1.6 to 3.2 percent. Complications
increase with age (19 percent for age 65 and older; six
percent for age 18-64).
Checklist for Preventing C. Difficile
✓ Use antibiotics judiciously
✓ Use Contact Precautions for residents/patients with
known or suspected C. difficile-associated disease
✓ Perform hand hygiene
✓ Use gloves during patient/resident care or when
handling contaminated clothing and linens
✓ Use gowns if soiling of clothes is likely
✓ Implement an environmental cleaning and
disinfection strategy (refer to the CDC’s “Guidelines
for Environmental Infection Control in Health-Care
Facilities”)
Improving Quality of Care Based on CMS Guidelines 21
ANY SURFACE,
device or material (commodes,
bathing tubs, rectal thermometers)
that becomes contaminated
with feces may serve as a
reservoir for C. difficile spores.
Risk factors for C. Difficile
• Watery Diarrhea
• Fever
• Loss of appetite
• Abdominal pain
• Nausea
• History of antibiotic use (cephalosporins,
fluoroquinolones and clindamycin have been
linked to C. difficile)
• History of C. difficile (Approximately 20% of residents
will experience a single recurrence and 45 to 65
percent will go on to develop additional recurrence)
• History of gastrointestinal procedure
• Lengthy hospital stay
• Hospital discharge within the last 60 to 90 days
Tests for Diagnosing C. Difficile
• Stool culture is the most sensitive test
• Antigen detection for C. difficile. This is a rapid test
(less than one hour) that detects the presence of
C. difficile antigen
• Toxin testing for C. difficile, which detects toxin A,
toxin B, or both A and B. (Same-day results)
Note: C. Difficile toxin is very unstable. The toxin degrades at room
temperature and may be undetectable within two hours after collection
of a stool specimen. False-negative results occur when specimens are
not promptly tested or kept refrigerated until testing can be done.
Sources
1. Centers for Disease Control and Prevention Web site. CDC Frequently
Asked Questions-Information for Healthcare Providers. Available at
http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html.
Accessed February 19, 2009.
2. Clostridium Difficile Infections-Best Strategies for Care of Older Adults.
CE presentation by Erik. R Dubberke, MD and Suzanne F. Bradley.
 The case studies shown here are excerpted from:
Regenerative Medicine: Urinary Bladder Matrix* Assistance
with High Risk Diabetic Limb Salvage
Presented at the Symposium on Advanced Wound Care (SAWC)
and Wound Healing Society, Dallas, TX, April 2009
Joseph Gonzalez, DPM
The Foot Wound Institute
Capital Foot & Ankle Centers
Okemos, Michigan
Case 1
32 year-old male with a past medical history for poorly controlled type II
diabetes with peripheral neuropathy presented with a 1 week history of
an abscess at the lateral aspect of his right heel. He could not recall any
trauma to the area or any other inciting events. He stated that he recently
noticed a red, swollen blister with pus draining. Upon presentation, his
vascular status was intact and he had a deep, tunneling abscess, just an-
terior to the Achilles tendon on the lateral aspect of his heel. The wound
Case 2
A 43 year-old female with a past medical history of type II diabetes with
neuropathy was involved in a motor vehicle accident, causing displaced
fracture of her right calcaneus. She underwent open reduction with
internal fixation with plate and screws two days later. At her two-month
follow-up appointment, it was noted that the incision had not healed,
and she visited the wound center for treatment. Upon initial presenta-
tion, her vascular status was intact and the corner of the wound had de-
hisced and was completely fibrotic at the plantar lateral heel with a small
corner of the plate exposed. Sharp debridement was performed to
remove the fibrotic tissue. The wound was covered with Basement
Membrane/ECM Wound Matrix, covered with oil emulsion, and negative
22 Healthy Skin
measured 0.5cm x 0.7 cm with 1.5 cm of depth. The abscess was ini-
tially drained and debrided. ECM/Basement Membrane material was
packed into the deep tunnel and covered with oil emulsion, negative
pressure wound therapy and a mildly compressive dressing. The patient
was given a post-op shoe to wear. He returned weekly for serial
debridements. The ECM/Basement Membrane was packed into the
wound at each visit. At 4.5 weeks, the wound had epithelialized completely.
pressure wound therapy was implemented. The patient was already
prescribed a six-week course of IV antibiotics and was seen weekly for
serial debridements and local wound care with the Basement Mem-
brane/ECM Wound Matrix was applied every 7 days. Within three weeks,
the wound had granulated completely over the exposed plate. Weekly
debridements and Basement Membrane/ECM Wound Matrix applica-
tion was continued, however edema control was difficult to achieve due
to poor patient compliance. Appropriate compression therapy was uti-
lized with the Basement Membrane/ECM Wound Matrix and the wound
healed after 20 weeks without the need for hardware removal or
aggressive surgical intervention.

Case 3
A poorly controlled, type II diabetic female presented with an abscess in
her left hallux which had been present for at least one week. She had
peripheral neuropathy and her vascular status was noted to be intact.
She had a red, hot, swollen, deep, tunneling ulceration at the left hallux
distal phalanx which measured 0.6cm x 1.0cm x 1.0cm deep. It did
probe to bone and she was placed on antibiotic driven IV antibiotics for
six-weeks. The wound was debrided down to healthy bleeding tissue
Case 4
A 63 year-old female with a past medical history significant for type
II diabetes with neuropathy, rheumatoid arthritis, Charcot neu-
roarthropathy right ankle and left below-knee-amputations was
seen in the hospital for a septic right ankle joint, present for one
week. The infection source was noted to be from a staple in the
talonavicular joint and was surgically removed. The patient was
offered a right below-knee-amputation and subsequently refused,
as she still was not ambulating from the previous left below-knee
amputation three months earlier. Wound Center consultations
were sought for limb salvage options. The initial medial wound
over the talonavicular joint measured approximately 5.0cm x
5.0cm and tunneled to the ankle joint, causing a lateral blow out
of the ankle and a second wound measuring 3.0cm x 1.5cm.
There was a significant amount of purulent drainage, as well as
erythema and edema. A thorough bedside debridement was per-
formed and dilute betadine irrigation was utilized for three days.
Improving Quality of Care Based on CMS Guidelines 23
CASE STUDY
and then packed with Basement Membrane/ECM Wound Matrix and
covered with oil emulsion, negative pressure wound therapy and mildly
compressive dressing. She was placed in an accommodated surgical
shoe. She returned weekly for serial debridements and Basement Mem-
brane/ECM Wound Matrix was packed into the wound at each visit.
Within four weeks, the wound had granulated to the surface. Basement
Membrane/ECM was continued until wound closure at twelve weeks.
Once the purulent drainage was reduced to a minimum, Base-
ment Membrane/ECM Wound Matrix was packed into the tun-
neling wounds and negative pressure wound therapy was utilized.
The patient was discharged on an 8-week course of culture spe-
cific antibiotics and followed up weekly at the Wound Center.
Serial debridements were utilized with continued use of Basement
Membrane/ECM Wound Matrix and negative pressure wound
therapy. Compression therapy was utilized following negative
pressure wound therapy, and the wounds subsequently healed
after three months of treatment. The patient was able to utilize her
prosthetic on the left below-knee amputation and is currently
increasing her ambulation in physical therapy. We continue to use
compression therapy to control the edema, but the medial wound
continues to open and close periodically due the excessive shoe
pressure on this prominent area of her Charcot foot.
 2 little inches of gel
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Forever.

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At the same time, SilvaSorb Gel helps wounds

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makes SilvaSorb Gel ideal, for cavity wounds…
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CLINICAL STUDY

Randomized Clinical Study of SilvaSorb®

Gel in Comparison to Silvadene® Silver
Sulfadiazine Cream in the Management
of Partial-Thickness Burns

Paul M. Glat, MD, This prospective, randomized study

Wade D. Kubat, DO, assessed the clinical, microbiological,
John F. Hsu, DO,
and patient comfort characteristics of
Tarek Copty, MD,
two silver-based topical agents in the
Brooke A. Burkey, MD,
Wellington Davis, MD, management of partial-thickness burn
Isak Goodwin, MD wounds. Pediatric patients were ran-
domly assigned to treatment with
®
either Silva-Sorb Gel (Medline Industries, Mundelein, IL) or
Perioperative Pressure
Silvadene® silver sulfadiazine cream (King Pharmaceuticals, Ulcer Education.
Bristol, TN) for up to 21 days or to the point of full reepithelializa-
tion of the wound. Inclusion criteria were patients ranging in age
More important
from 2 months to 18 years with TBSA ranging from 1 up to 40%. than ever before
A total of 24 patients were enrolled and completed the study.
Findings demonstrated that the use of SilvaSorb Gel was asso-
ciated with less pain and greater patient satisfaction when com-
pared with Silvadene. No statistically significant differences

“I have seen an increase in the number of legal issues

were found when assessing the rate of infection, time to

linking facility-acquired pressure ulcers to post-surgical

reepithelialization, or the number of dressings changes

patients. A pressure ulcer program for the OR is more

required during treatment. The reduction of pain and improved

critical than ever.”

overall patient satisfaction with the use of SilvaSorb Gel

Diane Krasner, PhD, RN, CWCN,

compared with Silvadene indicates an important role for

CWS, BCLNC, FAAN

SilvaSorb Gel in treatment of partial-thickness burns in a
pediatric population.
Medlineʼs Pressure Ulcer Prevention Program
now has a component designed specifically for the
Reprinted with permission. © 2009. Journal of Burn Care Research.

perioperative services. The easy-to-use interactive

2009;30(2):262–267

CD addresses the following:

• Hospital-acquired conditions
• CMS reimbursement changes
• Best practices for pressure ulcer prevention
• Perioperative assessment tools
• Critical patient and equipment
risk factors

Contact your Medline sales representative for more

details. You can also learn more about Medlineʼs
Pressure Ulcer Prevention Programs for long-term
care, acute care and perioperative services by visiting
www.medline.com/pressureulcerprevention.

Improving Quality of Care Based on CMS Guidelines 25

Think green with environmentally conscious
products for all areas of your facility.
These Medline products are either:
Recycled, recyclable, biodegradable or made from easily
renewable materials
Reduced in size to take up less space when shipped,
saving fuel and reducing carbon monoxide emissions
Free from environmentally harmful chemicals or pollutants
Reusable, to reduce waste in landfills
Water-conserving
Minimally packaged
 Environmentally conscious Medline products
Apparel Food Service Miscellaneous
Enviro ISO gown Biodegradable paper cups Connecting tubes
Reusable surgical gowns Recyclable plastic cups and straws Drain bags
Reusable ISO gowns Patient utensils Eco-friendly foam positioners
Reusable briefs and underpads Med-Pack
Scrubs Infection Control Oxygen concentrator
Advanced Bowie Dick test Peak flow units
Diagnostic Equipment Bio-zolve pre-soak instrument spray Reusable nebulizer cups
Blood pressure cuffs (reusable) Sterilization containers Safesorb
Sphygmomanometers Silver Foley catheters
Stethoscopes Latex-Free Surgical Products Suction catheters
Thermometers Aneroids
Anesthesia breathing bags More Ways to Go Green
Environmental Services Anesthesia circuits • Make it a habit to turn off the
Disinfectant products Anesthesia masks lights when leaving any room
Eco floor mats Anti-fog solution for 15 minutes or more.
Eco floor mops Band bags and equipment covers
General cleaners Bone wax • Think before you print. Could
Hard surface germicidals Disposable safety scalpels this document be read or stored
Microfiber cleaning cloths Electrosurgical disposables online instead?
Microfiber mops (tips, ground pads, pencils • Make it a policy to purchase
Pillows and tip cleaner) supplies made from recycled
Recycling sorting containers Esmark bandages materials.
Reusable hamper bags Insufflation tubing and needles • Bring your own mug instead
Super-concentrated detergents Light handle covers of using paper cups at work.
and lubricants Sharps safety products (magnetic
• Brighten up your workplace
Touchless sensor faucets drapes, transfer trays, scalpel
with live plants, which absorb
and flushers holders)
indoor pollution.
Tile, grout and bathroom Skin markers
cleaner/deodorizer Stockinettes
Source: The Sierra Club, www.sierraclub.com
Toilet paper, facial tissue Suture boots
and hand towels Thermoform molded trays
Trash liners Tube holders (amnio hook, Ask your Medline rep for details
Upholstery cleaner umbilical cord clamp, umbilical on ordering these products.
Urinals cord clamp cutter)
Vessel loops 1-800-MEDLINE
(1-800-633-5463)
©2009 Medline Industries, inc. Medline is a registered trademark of Medline Industries, Inc.
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• Simple 3-button navigation your Medline sales representative or
• Test starts only when enough blood is applied– call 1-800-MEDLINE.
designed to minimize errors, repeat tests and
wasted test strips

©2009 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.
TrueMeasure is a registered trademark and Advanced Technology Made www.medline.com
Simple is a trademark of the Abbott Group of Companies.
 Prevention

Best Practices for

Blood Glucose Monitoring
Glucose testing plays an important role in treating diabetes.
Your residents, whether they have Type 1 or Type 2 diabetes,
should be tested routinely, per physician’s orders, and care
should be provided based on the results obtained.

Testing blood glucose in a long-term care facility follows

Occupational Safety and Healthy Administration (OSHA),
Joint Commission and Centers for Disease Control (CDC)
guidelines to promote safety and best standards of care. The
glucose monitor, proper finger stick site location and type
of lancets used play an important role in obtaining accu-
rate results.

Resident Blood Glucose Testing Procedure

• Explain the procedure to the resident.
• Check the expiration date on the test strips.
• Calibrate the monitor (if necessary) according to the
manufacturer’s instructions.
• Ensure the displayed calibration code matches
the code on the calibration bar and the code
on the test strip package insert.
• The calibration bar is stored in the carrying case until
all of the test strips in that box have been used.

Improving Quality of Care Based on CMS Guidelines 29

 KEEP IN MIND
that one lancet type may not serve the needs
of all of your residents.
• Ensure that the monitor and test strips are at room
temperature. If there is a temperature change,
the monitor and test strips should sit at room temperature
for 10 to 12 minutes.
• Insert a test strip in the monitor according to the
manufacturer’s instructions.
• Lance the resident’s finger, obtain a sample of blood.
• Apply the blood sample to the test strip when prompted
by the monitor.
• If your monitor allows for the addition of a second drop
of blood, please refer to the user’s manual for
detailed instructions.
• Dispose of the used lancets and test strips
immediately according to the facility’s policies or the
state mandates.
• Record the result in the resident’s record
and follow physician orders for notification and
providing care.
• Document all interventions in the resident’s
medical record.
Fingerstick Testing Using a Safety Lancet
This section addresses best practices regarding how to
prepare for and perform a fingerstick test while protecting
the nursing staff from infectious cross-contamination.
When to conduct a fingerstick test
Always follow physician orders. Some recommendations for
scheduled fingerstick tests are:
• Before a meal
• 1 to 2 hours after a meal
• Before bed
30 Healthy Skin
Choosing the correct lancet
Using the correct lancet is as important as using proper
technique. Blood sample size varies depending on the
glucose monitoring system you choose. A higher gauge
(thinner) lancet can be used for smaller sample sizes and
may result in less discomfort for the resident. However, keep
in mind that one lancet type may not serve the needs of all
of your residents.
Although there are a variety of safety lancet brands on the
market, there are only two lancet designs:
Pressure Activated – the lancet is activated by applying
pressure to a person’s fingertip.
Non-Pressure Activated – the lancet is activated by press-
ing a button, or a firing pad, on the device.
Test site recommendations
Here are some guidelines regarding preferred test site
locations:
• The puncture should occur on the side or the top
of the finger.
• It is better to test either the side or tip (not the center)
of the finger because tissue is about half as thick
there and a finer gauge (thinner needle) can be used.
• Never lance directly on a resident’s fingerprint, as
the nerve endings there could cause a great deal
of discomfort.
• Preferred puncture sites are the middle and ring fingers.
 C O M PA S S
Fit Right Program
Survey Readiness
Ta g F 3 1 5 & Q I S
Preparing the finger Be survey ready at all times with Medline’s
1. For optimal blood flow, it is recommended that you Compass Fit Right Program— an inconti-
warm the test site prior to lancing. Place a warm, nence reference for front-line caregivers.
moist towel on the area for three to five minutes; at
Compass Fit Right Program – Survey
a temperature no higher than 107 degrees F, or 41.7 Readiness Tag F315 & QIS includes
degrees Celsius (this increases arterial blood flow and quality improvement forms and tools,
will not burn the skin). Alternately, you can warm the plus the following:
skin by massaging the hand, beginning from the palm • Program Manual Binder provides an
and slowly working toward the fingertips. overview to implementing a thorough
2. Next, cleanse the site using a 70 percent isopropyl incontinence program and compiles
alcohol solution. program manager guidance on how
3. Allow the area to air-dry so that the alcohol’s antiseptic to use the various components of
the program.
action can take effect (if skin isn’t dry, test results can
be inaccurate). • Practical Guide to Understanding
F315 & QIS
Performing the test • CNA & RN Workbooks
After you have prepped and cleaned the finger, it is time to • DVD Education (with CE hours)
perform the test. Puncture the site, and then use a gauze
• Continuous Pressure Ulcer
pad to wipe away the first drop of blood. Apply the blood to
Prevention Tablets
the testing strip, being sure to follow the manufacturer’s
instructions. Once the test is over, use a 2'' x 2'' gauze pad • Measuring Tapes
to wipe away any excess blood, and then apply slight pres-
sure (or follow your facility’s policy and procedure).

Test site rotation

Some residents have their blood sugar tested daily, while
others might be tested as often as four to six times a day.
The more frequent the testing, the greater the chance of
fingertip soreness. That is why it is important to rotate the
puncture site with each fingerstick. Additionally, site rotation
helps to minimize callous formation. Avoid “milking” a finger,
since it can cause tissue fluid contamination of a specimen
and result in a false low reading.

Source
D.O.N. Instruction Manual. A Diabetes Resource for Long-Term Care.
Medline Industries, Inc., Mundelein, IL. 2009.

Improving Quality of Care Based on CMS Guidelines 31

 Don’t gamble with patient safety.
Catheter-associated urinary tract infections (CAUTI) represent
approximately 40 percent of all healthcare-acquired infections.1
Silvertouch® Foley catheters from Medline can help you stack
the odds in your favor.

Every Silvertouch catheter is lined inside and out with ionic silver,
well recognized as a broad-spectrum antimicrobial effective
against gram-positive and gram-negative bacteria, including
resistant strains such as MRSA and VRE.*

Silvertouch catheters also remain comfortable for a longer period

of time, thanks to a hydrophilic coating that hydrates quickly and
maintains its lubricity for at least a week. All Silvertouch catheters
are latex-free and 100 percent silicone, so both caregivers and
patients are kept safe.

References
1. http://cdc.gov/ncidod/dhqp_uti.html

* In-vitro test data on file.

To learn more about Silvertouch catheters, contact

your Medline representative or call 1-800-MEDLINE.

www.medline.com
©2008 Medline Industries, Inc. Medline and Silvertouch are registered trademarks of Medline Industries, Inc.
Prevention

Resident and Family Education

Strategies to Combat CAUTI

By Janet Nau Franck, MBA, RN, CIC

Have you ever wondered what it must be like to have an

indwelling foley catheter? Do your residents really understand
what a urinary catheter is and how it works? Do they know how
to prevent an infection and how to care for their catheter when
they go home? Surveyors are certain to ask for documentation that
verifies that residents and their families receive education.1

Urinary tract infections account for up to 40 percent of all hospital-

acquired infections (HAIs), and the majority of these infections are
associated with urinary catheters.1 The increasing numbers of these
infections can create a tremendous clinical and financial burden for
the healthcare facility. This has made education to prevent infection
an even greater priority.

Providing residents with guidelines for urinary catheter care and

infection prevention helps include the resident in their care plan and
can assist caregivers to provide better care. Turn the page for a
guideline for residents and their families that you may find useful.

Improving Quality of Care Based on CMS Guidelines 33

 Caring for Your Urinary Catheter
Infection Prevention Guidelines for Residents

What is a urinary catheter?
A urinary catheter is a thin tube placed in the bladder to drain
urine. Urine drains through the tube and empties into a collec-
tion or indwelling “foley” bag.
A urinary catheter may be used:
• If you are unable to urinate on your own.
• To measure the amount of urine produced.
• During and after certain types of surgery or tests.
What should you know about your catheter?
• Catheters are inserted by a trained individual and should
be removed as soon as possible.
• Caregivers clean their hands by washing them with soap
and water OR by using an alcohol-based hand rub before
and after touching your catheter.
• If you do not see your caregivers cleaning their hands,
please ask them to do so.
How can I reduce my chances of getting an infection?
• Clean your hands with soap and water or use hand sanitizer
before and after coming in contact with your catheter.
• Keep the catheter secured to your leg to avoid pulling on
the tubing whenever possible.
• Always keep your urine bag below the level of your bladder.
• Do not twist or kink the catheter connection tubing.
• Tell your caregiver if you notice that the bag is more than
half full.
• Keep the drainage spout from touching anything while
emptying the bag.
• Do not disconnect the catheter or drainage tube.
• Ask your caregiver every day if you still need the catheter.
How do you know if you have a urinary tract infection?
Some of the common symptoms of a urinary tract infection are:
• Burning or pain in the area below the stomach
• Fever
• Bloody urine
• Urinating more frequently or more urgently than normal
after the catheter is removed
• If you have questions, be sure to contact your doctor.
An antibiotic may be prescribed.
What do you need to do when you go home?
• If you will be going home with a catheter, your doctor or nurse
should explain everything you need to know about taking care
of the catheter.
• Make sure you understand how to care for your catheter
before you leave the facility.
• Before you leave the facility, make sure you know who to
contact if you have questions after you get home.
My doctor’s name and office phone number is
Adapted from: Frequently Asked Questions (FAQs) about Catheter
Associated-Urinary Tract Infections (collaborative fact sheet),
co- sponsored by several organizations, including the Centers for Dis-
ease Control and Prevention (CDC), http://www.cdc.gov/ncidod/dhqp/
pdf/ guidelines/CA-UTI_tagged.pdf, 2008.
For additional copies of patient education materials, visit Medline
University at www.medline.com/CAUTI.

What is a “catheter-associated urinary tract infection”?

A urinary tract infection (UTI) is caused by germs that do not
normally live in the urinary tract. If germs are introduced while a
urinary catheter has been inserted, they can travel along the
catheter and cause an infection called a catheter-associated
urinary tract infection (or “CAUTI”). Germs can enter the urinary tract
when the catheter is being put in or while the catheter remains in the
bladder. For this reason, patients with urinary catheters have a
greater chance of getting a urinary tract infection.
About the author
Janet Nau Franck, RN, MBA, CIC has more than 30 years
Reference of experience as an infection preventionist and consultant. As an
1. Beaver M. CMS reimbursement changes put spotlight on prevention international leader, she has served as past president of the
of catheter-related infections. Infection Control Today Web site. Association for Professionals in Infection Control (APIC), adjunct
Available at http://www.infectioncontroltoday.com/articles/cms-regulations-
faculty at Loyola University-Chicago, and has received numerous
catheter-infections.html. Accessed April 22, 2009.
awards for having lectured and published worldwide. She can
be reached at jnauf@aol.com.

34 Healthy Skin
 Prevention

Tom Clopp and Lisa LeBeau of Medline

present CE certificates to Rest Haven
staff. In the foreground is nursing assis-
How sweet it is! Chastity Williams, LPN; Jan Daley, tant Missy Strayer.
RN - Nursing Supervisor and Sue Hoch, LPN.

Implementing Medline’s Pressure Ulcer

Prevention (PUP) Program at Rest Haven-York
Tom Clopp, MSEd
Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

Rest Haven-York is a 180-bed independently owned

nursing home in York, Pennsylvania, that employs
Q What sold you on the need for the PUP program
at Rest Haven York?
75 registered nurses and 115 nursing assistants. Staff
members completed Medline’s Pressure Ulcer Prevention
Diane Krasner:
(PUP) program this spring and celebrated their newfound
The wound team at Rest Haven-York has been offering
knowledge with the awarding of certificates and pins.
continuing education on pressure ulcers for many years. But
there was never any good way to measure patient outcomes
The Pressure Ulcer Prevention Program is a strategic product
or demonstrate staff competencies. The PUP program
bundle consisting of skin care products and incontinence
pre-test/post-test format and its ability to measure outcomes
garments to assist in reducing or preventing pressure ulcers
are what really sold me. After completing the program, our
and incontinence-associated skin conditions.
RNs, LPNs and nursing assistants appreciated seeing on
paper how much they had learned. We placed a copy of
The program also packages together education and training
everyone’s CE certificate in their human resources file. We now
tools so a healthcare team can implement an effective pressure
have demonstrated and recorded competencies for our
ulcer prevention program and immediately begin reducing the
nursing staff.
incidence of healthcare-acquired pressure ulcers. Included are
workbooks, patient and family education brochures, a CD with
printable electronic forms and tools, and a staff rewards program. Rest Haven-York PUP Program Test Scores
In addition, the new MD Education DVD includes everything Compared to National Averages
Nursing assistants and nurses at Rest Haven-York scored
the physician needs to recognize, assess and document
higher than the national averages on the PUP program pre- and
present–on–admission (POA) indicators for stage III and IV
post-tests.1
pressure ulcers. PUP
Pre-test % Post-test %
Nursing Assistant (NA) Average 58 80
Rest Haven-York NA Average 67 96

Nurse Average 78 88
Rest-Haven York Nurse Average 80 99

Improving Quality of Care Based on CMS Guidelines 35

 Q Why was the focus on prevention important Q You have introduced this program at many
for your facility? long-term care facilities and hospitals across
Pennsylvania. Why do you think it works so
Diane Krasner: well across the continuum of care?
Prevention is where the rubber meets the road. Our wound
team oversees the plan of care for our residents with pressure Tom Clopp:
ulcers, but prevention is the responsibility of the nursing staff The key elements apply to every care setting. Pressure ulcer
at the bedside. The PUP program reinforces the importance of prevention has been instilled in long-term care staff for years, yet
their eyes and ears as our first line of defense in pressure ulcer a refresher course on best practices is extremely beneficial.
prevention. Hospitals are now bound by the new Centers for Medicare
& Medicaid Services (CMS) guidelines and will risk loss of
reimbursement if pressure ulcers develop during patient stays.
WHEN PREVENTION BUNDLES
(toolkits) are employed, pressure Similarly, long-term care facilities are bound by F-tag 314, which
ulcers are reduced.2 states that “A resident who enters the facility without pressure
sores does not develop them unless the individual’s clinical
condition demonstrates that they were unavoidable.”3 Above
and beyond that, patient care is at the top of every healthcare
Q What was the best part of the facility’s list.
program for you?

Diane Krasner: CLOSE TO 40 PERCENT

Our staff members were so thrilled to have accomplished their of the facilities participating in the PUP
first self-paced learning activity. Tom Clopp arrived from Med- program are nursing homes or LTCs.1
line with pins, certificates and cookies, and we all celebrated!

Q What were the biggest successes and challenges

in implementing the PUP program at Rest
Haven-York?

Tom Clopp:
The biggest challenge was getting buy-in from staff to
complete a program on a topic that they felt they were already
up-to-date on. The successes were much greater. After com-
pletion, many of the staff realized that there were things they
did not know or had forgotten about. They really enjoyed
receiving the CE certificates and pins and participating in our
awards ceremony. Beyond that, the success of the program
was shown in the measurable decrease in pressure ulcers and
Rest Haven-York nurses display their PUP continuing education (CE)
skin tears facility-wide.
certificates. (Left to right): Rosie Grow, LPN; Lois Brunson, NA;
Laura Rivera, NA and Brandi Hollerbush, LPN.
CONTINUOUS PROFESSIONAL
development trains staff members on
an ongoing basis in their work setting
and results in confirming current practice,
changing current practice or causing
the learner to seek more information.2

36 Healthy Skin
 CLINICIAN TRAINING AND
education is an ideal opportunity for the
wound care community to partner with
associations or industry to develop
appropriate programs and materials
that can be implemented quickly.2

Q Why are value-added services, like the PUP

program, so appreciated by the clinicians you
call on?
Tom Clopp:
Value-added services help clinicians in a lot of ways. Number
one is a program, like PUP, that is already built – because it
saves facilities both time and money. Nurses are busy enough
with their daily tasks. Building a program like PUP from scratch
would take months. It realistically could be a full-time project
for a wound care nurse who is already needed for consults,
treatments and education.
Medline’s Tom Clopp presents a PUPP continuing education (CE)
certificate to Wound Team Manager Wendy McKinney, LPN, CWCA.
References
1 Medline Industries Inc. Pressure Ulcer Prevention (PUP) program. Data on file.
2 Armstrong DG, Ayello EA, Capitulo KL, et al. Opportunities to improve pressure
ulcer prevention and treatment: implications of the CMS inpatient hospital care
present on admission (POA) indicators/hospital acquired conditions (HAC)
policy. Adv Skin Wound Care. 2008;21(10):469-78.
3 Thomas DR. The new F-tag 314: prevention and management of pressure
ulcers. Clinical Practice in Long-Term Care. 2006;7(8):523-531.

Although PUP is an out-of-the-box program, it can be

customized for each facility. The accompanying CD features
a variety of forms and tools in different formats, so clinicians
can choose the format that fits in best at their facility. The
facility logo also can be added to the printable forms.

It was an exciting and educational experience Tom Clopp, MSEd is an advanced wound
for all the nursing staff. It broadened everyone’s and skin care product specialist for Medline
knowledge base and awareness of prevention in Industries, Inc.

a fun way!
Chrissy Leppo, RN
Director of Nursing
Rest Haven-York
Diane Krasner, PhD, RN, CWCN, CWS,
BCLNC, FAAN, WOCN is a special projects nurse
The PUP program was presented in an easy, at Rest Haven-York.
interesting format. The nursing assistants were
For more information on pressure ulcer prevention efforts at Rest
really receptive and they appreciated being
Haven-York, visit http://www.medline.com/special/PAA/pup.asp.
included - it gave them a sense of being part
of the team.
Sandy Augustine, LPN
Wound Team
Rest Haven-York

Improving Quality of Care Based on CMS Guidelines 37

 1
Celebrating 1 Year
Medline’s Pressure Ulcer
Prevention Program!

The results are in the numbers. Be a part of out national

benchmark scorecard to measure your progress and reduce
facility-acquired pressure ulcers
Are Your
Physicians
Making
Hospitals currently enrolled 232
the Grade?
Nursing homes currently enrolled 83

A recent survey graded physiciansʼ abilities to

recognize, assess and document Stage III and
IV pressure ulcers at a “D” level. Medlineʼs new
Average test scores Pre-test Post-test

Pressure Ulcer Prevention Program MD Education

Nursing Assistant 58 87

CD contains everything physicians need to brush

LPN/RN – Core 77 95

up on their skills and comply with the new CMS

LPN/RN – Advanced 80 91

Inpatient Prospective Payment System (IPPS).

Pressure Ulcers

“The new MD Education component of Medlineʼs

Average Facility-acquired Incidence

Pressure Ulcer Prevention Program is critical for

Before implementing 6 pressure ulcers (16%)

acute-care facilities to ensure that physicians

Medline PUP program

understand their role in recognizing and accurately

documenting POA pressure ulcers.”
After implementing 3 pressure ulcers (3%)
Medline PUP program -Michael Raymond, MD, Associate Chief Medical
Quality Officer, NorthShore University HealthSystem,
Skokie Hospital, Skokie, IL

Contact your Medline sales representative for more

Source: Data on file. Medline Industries, Inc.

details. You can also learn more about Medlineʼs

Pressure Ulcer Prevention Programs for long-term
care, acute care and perioperative services by visiting
www.medline.com/pressureulcerprevention.

38 Healthy Skin
Product
Spotlight
MARATHON Liquid Skin Protectant
By Janet Jones, BSN, RN, PHN, CWOCN, DAPWCA
Skin Breakdown is a national health concern whether your
practice setting is acute care, long-term care, long-term
acute care or home care. Most care settings are affected
by monetary fines related to skin breakdown, which will
ultimately change the care of those residents with skin and
wound issues.
Early treatment and protection against wounds are keys to
success in minimizing in-house acquired wounds. The
most vulnerable areas are over bony prominences where
friction is an issue or areas that remain moist.
MARATHON Liquid Skin Protectant is a non-stinging,
cyanoacrylate based monomer that forms a fully con-
formable, flexible and remarkably strong protective layer
over intact or damaged skin. MARATHON bonds to the
skin surface and integrates with the epidermis as the
cyanoacrylate polymerizes at the molecular level while
supporting the natural integrity of the skin.1 It provides
higher strength1,4 and higher resistance to wash off than
other thin film barriers.2 MARATHON Liquid Skin Protec-
tant is resistant to external moisture, yet it allows the skin
to breathe.
MARATHON Liquid Skin Protectant is designed to protect
intact or damaged skin from breakdown caused by friction
or moisture.
Improving Quality of Care Based on CMS Guidelines 39
MARATHON:
Minimizes friction and reduces the risk of developing
skin tears.
- Creates a strong physical barrier against
abrasive forces.
- Also recommended for damaged skin to protect
against further breakdown.
- Can be applied to pressure points to avoid the
risk of skin breakdown.
Protects skin from prolonged exposure to moisture,
which weakens and damages the skin surface and
makes it more susceptible to breakdown.3
- Incontinence: MARATHON should be used on at-risk
areas such as the sacrum, buttocks and groin.
- Stomas and drain sites: Helps protect the area around
stomas and drain sites from breakdown caused by
body fluids, exudate and the effect of adhesives.
Maintains skin integrity.
- Applying MARATHON to the skin once it has closed
should help protect it and maintain integrity.
MARATHON can be applied to pressure points to
avoid friction and reduce the risk of skin breakdown.
Examples include toes, soles of the feet, heels,
ankles, ears, shoulders, scapulas, spine, elbows,
coccyx, trochanters and ischium.
 How should MARATHON be used?
MARATHON Liquid Skin Protectant comes in a single-use Is This
sterile applicator. Each 0.5 gram applicator can cover a
4-inch x 4-inch (10 cm x 10 cm) area. The product should a Four-Star Hotel?
be applied in a very thin layer, without covering the site
more than once.

MARATHON can be used when the epidermis is broken or Nope – it’s a nursing home!
damaged. However, it should not be applied directly to
deep, open, chronic or bleeding wounds. It adheres to the
Medline, the company that knows health care,
skin and dries in less than a minute. It can remain on the
brings you luxury you can depend on.
skin for several days. It will wear off naturally as the skin re-
generates. Reapplication is usually every one to three days Our Feels Like Home™ line of textiles includes everything from
depending upon location and contact with caustic effluent soft and cozy towels to 100 percent terry robes and 310 thread
such as urine, stool, or moisture from a wound or gas- count reverse sateen sheeting. All of Medline’s Feels Like Home
trostomy sites. products provide the same comfort and quality that your residents
expect in their own homes.
Incorporating MARATHON Liquid Skin Protectant into
your “wound care tool chest” will give you a more durable Feels Like Home products don’t stop at luxury – they’re practical,
liquid barrier product. Upon initial application it should be
too. All of these products were designed with nursing input to
clear that the product is much more durable in protecting
ensure that they meet the needs of patient-centered care. They’re
high-risk areas than a skin barrier wipe.
also incredibly durable and have been tested to withstand the
References wear and tear of commercial laundering.
1 Bond P. Scanning Electron Microscope Examination and Assessment of SUPERSKIN
(Liquashield [REGISTERED SYMBOL]). 2001. University of Plymouth, UK. Data held on file at
MedLogic Global Limited. To learn more about the
2 CyberDERM Clinical Studies. Study to Compare the Wash-off Resistance of Two Barrier
Films Exposed to Synthetic Urine. Data on file.
Feels Like Home line,
3 The Merck Manuals Online Medical Library. Pressure Sores. Available at please call 1-800-MEDLINE,
http://www.merck.com/mmhe/sec18/ch205/ch205a.html?qt=moisture%20skin%20dam-
age&alt=sh#sec18-ch205-ch205a-262. Accessed on April 9, 2009. visit www.medline.com or
4 CyberDERM Clinical Studies. Abrasion Test. Data on file. speak to your Medline
sales representative

About the author

Janet Jones, BSN, RN, PHN, CWOCN, DAPWCA is a
board-certified wound, ostomy and continence nurse. She
has extensive experience in long-term and home care and
has developed wound prevention and treatment programs
for many national healthcare groups. She’s also ready to

www.medline.com
take your call on Medline’s Educare Hotline!

©2009 Medline Industries, Inc. Medline is a registered trademark

40 Healthy Skin
of Medline Industries, Inc.

Education, Products that Work
and Celebration
The secret ingredients for a successful
skin care program
By Lisa Bogle, RN
When I became the director of nursing at Liberty Village of
Clinton four years ago, we were a new facility, and it was clear
we had inherited a problem with skin and wound care. We had
multiple wounds of varying stages. Our physicians were prescribing
different products and protocols. We might have three or four ways
to treat a skin tear and certainly dozens of wound care products on
the shelf. This was a project I had to tackle right away, but I knew it
would take a multifaceted approach.
Educating all levels
Our first step was to give the staff some solid education. Nurses,
CNAs and even our families learned the importance of moisturiz-
ing the skin, protecting with barriers when necessary and using
proper positioning techniques. The direct care staff was an impor-
tant part of the solution. They had to know that they could truly
make an impact and that they were the eyes and ears of the unit
nurse. We utilized our infection/skin report more effectively and also
implemented regular skin checks on every resident.
Improving Quality of Care Based on CMS Guidelines 41
Prevention
We even changed our admission process to include a swallowing eval-
uation and weekly weighing of residents so that we could catch and
treat the nutritional aspects so important for skin health.
Products that work
Our direct care staff was given the task to test skin care products and
evaluate which ones made a difference. We targeted a group of resi-
dents with extremely fragile skin and a history of skin tears. At that
time, our 134-bed facility typically had four or five skin tears per week.
After years of using inexpensive and random lotions, we decided to
test a high-quality skin protectant with some science behind it and to
use it consistently. After 30 days of using Remedy® Skin Repair Cream
twice a day, we only had two residents experience a superficial skin
tear. We are now expanding the use of this product to include all res-
idents unless contraindicated.
We looked for other residents who could benefit from a therapeutic
skin care plan. An example was a newly admitted resident with a long,
chronic history of lower extremity venous stasis ulcers. She had been
very uncomfortable with this condition for many years. We imple-
mented the Remedy Skin Repair Cream and over the course of two
 months, her ulcerated, fragile skin showed exceptional improve- Lisa Boyle, RN,
ment. inspires her
residents through
When new residents were admitted with purple-tinged legs, com- personal touch.
mon to vascular disease, within days of our new skin care plan,
their families were surprised to see the visible improvements; lighter,
plumper, healthier-looking skin.

I am particularly proud of our success with another resident who ex-

perienced discomfort from an extreme case of scleroderma. Her
skin has many areas of tightness and pain. She has expressed
great relief after moisturizing and protecting her skin with Remedy Leslie Taylor,
Skin Repair Cream. CNA, spends
extra time listen-
Celebration ing to a resident’s
No amount of education or miracle product will change behavior if story while she
management does not continue to make skin care a priority. We do applies Remedy
everything we can to celebrate our skin care success. We recog- Skin Repair
Cream to
nize our staff by name in our meetings for their ideas and sugges-
her feet.
tions and tell them, “Great job!” We have a healthy competition
among our four units, and each one wants to be the best. We try
to find the humor in everything. If there is a laugh to be had, we’ll
have it. Lisa Bogle, RN,
compliments a
It may sound cliché, but we try to give ownership of the skin care resident on her
program to the front line employees. We have plenty of the inven- handmade
tory available and allow them the autonomy to choose the skin care necklace.
product (moisturizer, barrier, skin paste) that they think is best for the
situation. We ask their opinions and truly listen to their feedback.
When one CNA shared that she felt good about talking with the
resident while applying the cream, it made all of us remember that
giving residents individualized one-on-one time is so important for
quality of life and our own job satisfaction.
Leslie Taylor,
Keeping the program alive CNA, notices
Therapeutic skin care is a daily part of the care Liberty Village pro- improvement as
vides. We have reduced nursing treatment time and cost by re- she inspects a
ducing the occurrences of skin tears and pressure ulcers. We resident’s skin.
continue to celebrate good skin. In fact, I’d like to give a “shout out”
to our terrific staff that makes all the difference. “Great job!”

Lisa Bogle, RN, is director of nursing at Liberty Village of Clinton in

Clinton, Illinois.

42 Healthy Skin
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 By M. Susan Stanek, RN

Pain is a common symptom of end-stage illness,

affecting between 70 and 90 percent of patients with
advanced cancer and large numbers of patients expe-
riencing other life-threatening illnesses.1 It is a complex
and individual experience, often requiring creative approaches
to identify causes and seek solutions for relief.2

The concept of “total” pain was first described by hospice

founder Dame Cicely Saunders in the late 1960s, following
her extensive work with terminally ill patients in London. Total
pain encompasses physical, social, emotional, spiritual and
psychological aspects, which interact through com-
plex mechanisms, resulting in each person’s unique
pain experience.2

Total pain management is increasingly viewed as the respon-

sibility of the multidisciplinary healthcare team. For hospice,
primary team members include nurses, certified nursing
assistants (CNAs) and/or home health aides, physicians, a
Reducing Total social worker, a chaplain and patient care volunteers.

Pain at the

44 Healthy Skin

Science continues
to demonstrate a
connection between
spirituality and health.
Hospice of the Western Reserve (HWR), a recognized leader in end-
of-life care that serves four counties in northeastern Ohio, developed
a highly effective, multidisciplinary pain management model for palliative
care that addresses total pain.1
Performance improvement mechanisms are a critical component of any
pain management program, especially for hospice organizations, which
now must comply with the new QAPI (Quality Assessment and Per-
formance Improvement) regulation implemented by The Centers for
Medicare & Medicaid Services (CMS). The QAPI requires hospice or-
ganizations to develop a customized quality assessment and perform-
ance improvement program to meet their needs. Hospice organizations
are directed to focus on high-risk, high-volume or problem-prone areas
where quality and patient outcomes could be improved.3 Pain manage-
ment is one possible area for improvement. (See story on page 51 for
more details on QAPI for hospice.)
When first implementing their new pain management model, HWR set a
goal of decreasing patients’ average pain intensity scores to 4 or lower
(out of 10) within 24 hours of admission to hospice. After piloting the new
pain management model, improvements in pain scores were evident at
three and six weeks into the program.1
The HWR pain management program incorporates three
major steps for pain management: screening, assessment
and education.1
Pain screening
Pain screening is an important mechanism that helps identify pain. All
members of the HWR transdisciplinary team screen for pain and docu-
ment the report at every visit on a form called the transdisciplinary pain
flow sheet. A set of four laminated pocket-sized cards guide them
through the screening process. The cards include a pain intensity scale,
a list of analgesics, an opioid reference table and a conversion formula
that gives the accepted doses for different opioid medications.1
An RN or LPN documents screening scores. In addition to screening for
physical pain, nursing, social work, spiritual care, expressive therapy and
bereavement coordinators screen for emotional and/or spiritual pain on
every patient visit.1
Improving Quality of Care Based on CMS Guidelines 45
Treatment
Emotional pain. In addition to addressing physical pain, good pain
management seeks to alleviate the stress caused by the patient’s
emotional issues, such as troubled relationships and the many fears
involved with facing mortality.4
Patients at the end of life can achieve comfort and a sense of completion
in personal relationships by talking with a social worker or counselor and
addressing the following five key points to help work through the
relationship(s) causing distress. These talking points were discovered by
Ira Byock, MD, a longtime palliative care physician and director of pallia-
tive medicine at Dartmouth-Hitchcock Medical Center:8
• “I forgive you.”
• “Forgive me.”
• “Thank you.”
• “I love you.”
• “Goodbye.”
Spiritual pain. Science continues to demonstrate a connection between
spirituality and health. Likewise, consideration of patients’ spirituality is
thought to be vital for providing quality care, especially in patients expe-
riencing critical and life-threatening illness.9
The availability of a planned, formalized assessment tool that facilitates
the gathering of objective information ensures that spiritual information will
be addressed and retained. The spiritual assessment tool should be
easy-to-use, flexible, adaptable and not time-consuming. The style and
language should be clear and simplistic to promote patient participation.9
Key questions to include on a spiritual assessment address the source
of the patient’s meaning and purpose in life, where and how he derives
strength and hope, how the patient feels about being seriously ill and
what the patient thinks will happen as the result of his illness.9
Pain assessment
The gold standard of pain management is pain assessment. Simply ask-
ing patients about their pain is the best way to obtain this information.6
A comprehensive assessment of pain includes all the information from
the screening, in addition to the type of pain, use of pain medications, the
level of sedation, side effects and non-drug interventions. At HWR, this
detailed assessment is completed by nursing whenever pain is present,
 new pain develops, an incremental increase in pain occurs, the pain
level is unacceptable to the patient or caregivers, or there is a per-
ceived change in a non-verbal patient’s pain level.1
Assessing pain in non-verbal patients. Patients are not always able
to verbalize their pain, especially those with dementia. Staff members
must learn how to assess subtle signs of pain such as acting-out
behaviors, facial grimaces or moaning.4 A comprehensive list and
review of currently published tools for assessing pain in nonverbal people
is available at http://prc.coh.org/PAIN-NOA.htm. See also sidebar,
“Principles for Assessing Pain in People with Advanced Dementia.”
At a minimum, an initial pain assessment should include the following:9
• Quality and description of pain (sharp, dull, throbbing, etc.)
• Location (use a drawing of the body and ask the patient to mark
the area(s) of pain)
• Intensity of pain (using a pain scale)
• Frequency of pain
• History of pain (when it started, when it gets worse, when it
gets better)
• Effects of pain (sleep, appetite, relationships, emotions)
• Satisfaction and effectiveness of current/past treatments
46 Healthy Skin
Pain medications. Before pain medications are prescribed, an
assessment is required to determine the nature of the pain, taking into
account the physical, social, emotional, spiritual and psychological
aspects. Analgesics work most effectively when all aspects of total
pain have been explored.6
Opioids are often the medication of choice for end-of-life pain. They are
safe and effective for the treatment of patients with moderate to severe
pain, and they have side effects that can be managed effectively.
Nausea, sedation and pruritus are common temporary side effects of
opioids and usually resolve within three to five days.6
Patients and their families may delay the use of opioids fearing their use
foretells imminent death, and patients may fear that opioid use early in
their care will diminish the effectiveness of such medication. It is
important to counsel patients that this result will not be allowed
to occur.6
Alternative methods for relieving pain. Alternative therapies have
proven beneficial in relieving spiritual, emotional and psychological
pain, which can contribute to physical pain. Although expectancy and
placebo factors undoubtedly contribute to all techniques, subtle

energy factors are often evoked, which explain the demonstrated ef-
fectiveness of techniques such as Reiki/therapeutic touch, acupunc-
ture and homeopathy (the use of extremely dilute preparations of
natural substances) in placebo-controlled studies.7
Reiki masters at the National Institutes of Health Palliative Care Serv-
ice in Bethesda, Maryland, use Reiki (pronounced RAY-KEE) to soothe
patients’ psychosocial-spiritual discomfort. They say Reiki not only ad-
dresses anxiety and pain, but also the spiritual suffering that frequently
presents as anxiety and pain. Preliminary research on biological mark-
ers support Reiki’s ability to precipitate the relaxation response.10 (See
story on page 49 for more information on Reiki.)
Educating patients and families
Inadequate pain relief is often associated with concerns about addic-
tion and side effects of pain medications. Patients and their families
have their own ideas about pain and their own reasons for not want-
ing to talk about it. Some fear that worsening pain means worsening
disease.11 There is also a false, widespread belief that pain at the
end of life cannot be relieved. To address these concerns, HWR
developed a patient education sheet that answers frequently asked
pain-related questions.1
Another way to improve pain relief is to get doctors and nurses to talk
to patients about pain. These conversations help patients realize the
importance of reporting when they are in pain, understanding different
treatments for pain and expecting that pain will be relieved. Clinical
staff can comfort patients, letting them know that their final months or
hours need not be overwhelmed by pain.11
As patients and families begin to understand their right to have
adequate pain management at the end of life and the myths about
pain management are removed, barriers to are easily broken.1
Improving Quality of Care Based on CMS Guidelines 47
Principles for Assessing Pain in
People with Advanced Dementia13
Self-report. Although self-report of pain is often possible in patients
with mild to moderate cognitive impairment, as dementia progresses,
the ability to self report decreases and eventually is no longer possible.
Searches for potential causes of pain and discomfort. Consider
causes of chronic pain common in older persons, such as a history of
arthritis or lower back pain. A recent fall, injury or the end-of-life illness
itself could be causing pain.
Observation of patient behaviors. Observe for recognized indica-
tors of pain, such as facial expressions, vocalizations, body move-
ments, changes in interpersonal interactions, changes in activity and
mental status changes. Some behaviors are common and typically
considered pain-related (e.g., facial grimacing, moaning, groaning, rub-
bing a body part), but others are less obvious (e.g., agitation, rest-
lessness, irritability, confusion, combativeness or changes in appetite).
Reporting of pain by caregivers, family or friends. The certified
nursing assistant (CNA) is a key healthcare provider who has been
shown to be effective in recognizing the presence of pain. Education
on screening for pain should be a component of all CNA training. Fam-
ily members and friends are also likely to have the most familiarity with
typical pain behaviors or other changes that might suggest the pres-
ence of pain.
Attempt an analgesic trial. Estimate the intensity of pain based on
information obtained from prior assessment steps and select an
appropriate analgesic.
Educating staff
In a 2006 study that investigated pain management among 42 hospice
and 65 non-hospice nursing home residents, data from nurse interviews
disclosed that staff were inadequately prepared to provide end-of-life
care. Many of the nurses either lacked pain assessment skills or did not
have time to perform assessments.12
At HWR, staff education features orientation, life-long learning and
evaluation as integral components. During general orientation, all new
employees attend a presentation, “Pain at the End of Life: Myths,
Realities, and Responsibilities.” All clinical disciplines also must attend
a comprehensive pain management class.1
HWR enhances life-long learning by offering advanced-level pain
classes, publishing a monthly newsletter with articles on pain man-
agement and sharing current literature from journals and conferences
among staff members. Pain management competency is evaluated
annually. Staff members must complete a multiple choice test, com-
ment on a case study and demonstrate hands-on clinical skills, such
as how to use an infusion pump.1
 Summary
As shown here, using Hospice of the Western Reserve as an exam-
ple, implementation of a transdisciplinary pain management model
is achievable when all team members are willing to work together
to develop and implement a plan. At minimum, such a plan should
include mechanisms for pain assessment, pain screening and

No More
education. Another critical element is performance achievement
measures to track and improve patient outcomes.

“OUCH!”
Note: All HWR forms and tools mentioned in this article are provided
in the “Forms & Tools” section of this issue, beginning on page 74.

References
1 Hospice of the Western Reserve in: Approaches to Pain Management: An Essential Guide for
Clinical Leaders. Joint Commission Resources: Oakbrook Terrace, IL. 2003.
2 Middleton-Green L. Managing total pain at the end of life: a case study analysis. Nursing Standard,
2008:23(6);41-46.
3 Centers for Medicare and Medicaid Services (CMS). Memo to State Survey Agency Directors.
January 2, 2009. Page 50. Available at http://www.cms.hhs.gov/EOG/downloads/EO%200643.pdf.
Accessed April 20, 2009.
Medline’s Sureprep® No-Sting wands are a convenient and
4 Delivering comfort and dignity: the role of hospice in pain management. Nursing Homes. painless, alcohol-free and environmentally friendly solvent-free
February 2005. suppl. 6-7.
5 Littlehale SB, Niemi JM, Capitosi SG. Advancing excellence in pain assessment: elements for an
way to protect even damaged skin from adhesive trauma.
effective pain management system. Long-Term Living magazine Web site. Posted December
10, 2008. Available at http://www.ltlmagazine.com. Accessed April 17, 2009.
6 Leleszi JP & Lewandowski JG. Pain management in end-of-life care. Journal of the American The specially formulated blend of polymers in each Sureprep
Osteopathic Association. 2005;105(3):suppl 1. S6-S11. wand forms a clear, waterproof barrier on the skin to help
7 Theories of Mechanism of Action for CAM Pain Management Interventions. Tufts University School
of Medicine Web site. Available at www.tufts.edu/med/ebcam/pain/theoriesMechanism.html. reduce adhesive trauma and irritation from bodily fluids,
Accessed April 20, 2009.
incontinence or wound exudate.
8 Byock I. Dying Well: Peace and Possibilities at the End of Life. Riverhead Books:New York, 1997.
9 Timmins F & Kelly J. Spiritual assessment in intensive and cardiac care nursing. Nursing in Critical Care.
2008;13(3):124-131.
10 Miles P. Palliative care service at the NIH includes Reiki and other mind-body modalities.
Sureprep dries in less than one minute and leaves behind no
Advances. 2004;20(2):30-31. sticky or oily residue. Studies have shown that the Sureprep
11 Lynn J, Schuster JL, Kabcenell A. Improving Care for the End of Life: A Sourcebook for Health
Care Managers and Clinicians. Oxford University Press: New York, 2000.
barrier is more robust than other solvent-based skin preps in
12 Kayser-Jones JS, Kris AE, Miaskowski CA, et al. Hospice care in nursing homes : does it contribute saving skin from trauma.1,2 It lasts up to 72 hours, depending on
to higher quality pain management? The Gerontologist. 2006;46(3):325-333.
13 Herr K, Coyne PJ, Manworren R, et al. Pain assessment in the nonverbal patient: position statement degree of friction and exposure to fluids, and removal is a snap!
with clinical practice recommendations. Pain Management Nursing. 2006;7(2):44-52.

To learn more about Sureprep No-Sting wands,

About the author
M. Susan Stanek, RN, is a community
hospice nurse for Lifetime Care in
Rochester, New York. She is also a level
III Reiki master and owner of Conscious
Healing, a Reiki therapy practice. Stanek is
currently enrolled in a BSN program and will
be completing her degree in February 2010.
contact your Medline sales representative, call us at
1-800-MEDLINE or visit www.medline.com/woundcare.
References
1 Shannon R, Chakravarthy, D. Effect of a water-based no-sting, protective barrier
formulation and a solvent-containing similar formulation on skin protection from
medical adhesive trauma. International Wound Journal. Publication pending.
2 Research report 506-71. Data on file.

Sureprep is a registered trademark

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©2009 Medline Industries, Inc. Medline is a
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www.medline.com
48 Healthy Skin
 Treatment

The Pain-Relieving Touch of

Reiki
Reflections from hospice nurse
M. Susan Stanek, RN

Nurses are known to have a sixth sense, or “nurse’s intuition.” It is the

ability to know when to check on a patient, when to request a doctor to recheck
a patient or when to make an unplanned visit to a home care patient just
because the nurse “has a feeling.” Reiki training enhances this ability to hone in
on subtle signs.1

As in nursing, Reiki therapy entails practicing the art of presence and compassion.
Reiki practitioners learn to relate to patients’ core or essence, not personality, to
listen without judging patients’ actions, to be willing not to know or understand
the “whys” associated with patients’ presentation, and to let go of viewing
patients’ responses following Reiki treatment as the practitioner’s personal
achievement.2

What is Reiki?
Reiki is a Japanese energy therapy that promotes relaxation and healing.
Similar to what some nurses know as “healing touch,” Reiki can work with any
medical therapy to decrease pain, reduce side effects and support healing. It
works on the physical, emotional, spiritual and mental levels to balance the whole
person.3

Reiki is based on the principle that we are alive because life force flows through
us. The life force becomes disrupted by negative thoughts or feelings, which
attach to the energy field and cause a disruption in the flow of life force. Reiki
helps by flowing through the affected parts of the energy field, infusing them
with positive energy and causing the negative energy to break apart and fall
away.3

Reiki in the palliative care setting

I was able to use Reiki in a medical setting when I spent a few months volun-
teering with the palliative care team at a local hospital. I recorded the patients’
pain level, provided Reiki, and then reassessed the patient’s pain. I cannot
remember when a patient did not state some level of pain relief.

Improving Quality of Care Based on CMS Guidelines 49

 The most remarkable experience was a gentleman who described his
pain at a level of 8 out of 10 before treatment. He appeared to relax as
I provided Reiki, and at the conclusion of his treatment he stated tear-
fully that his pain “just floated away.” He was completely pain-free after
a 20-minute Reiki session.

Hospice nursing has been the first area in my nursing career that has
allowed me to incorporate my abilities as a Reiki master. The home
health agency I work for offers volunteer services for hospice patients
that include massage therapy, music therapy and Reiki therapy. Reiki is
not part of every patient’s treatment plan, but when a nurse feels that a
patient may benefit from Reiki, I am asked to provide nursing care along
with some Reiki.

Relieving physical pain – and more

Pain relief is a top priority for all of our hospice patients, but their pain is Where to find more information on Reiki
not always just physical. Because Reiki treats the whole person, hospice www.ahna.org
patients benefit from the mental, spiritual and emotional components, as The American Holistic Nurses Association offers information about
well as the physical relief. Reiki has provided many remarkable results for education, research, resources, conferences and certification for
the patients I have treated. holistic nursing practice.

One male patient had no pain with the insertion of a foley catheter after www.reiki.org
10 minutes of Reiki to relax him. Another patient stated that he had The International Center for Reiki provides online access to a monthly
some troubling mental issues to deal with before his death, and the Reiki newsletter, articles, stories and a magazine.
treatments allowed him to work through the issues and find peace.
www.reiki.ca
Reiki is a therapy that is requested with increasing frequency, is easy to The Canadian Reiki Association is a federally chartered, national
learn, does not require expensive equipment, and in preliminary research not-for-profit registry of Reiki practitioners and teachers.
has been shown to elicit the relaxation response and help patients feel
more peaceful and experience less pain.4 With its many applications, www.reikiinhospitals.org
Reiki has endless potential to assist hospice patients. Alleviating physi- Sponsored by the International Center for Reiki, this site lists hospitals
cal pain is only the beginning. offering Reiki and Reiki studies funded by the National Institutes
for Health.
References
1 Lipinski K. Enhancing nursing practice with Reiki. Reiki Web site. Available at http://www.reiki.org/
Healing/NursingandReiki.html. Accessed March 30, 2009.
www.reikiinmedicine.org
2 Bossi LM, Ott MJ, DeCristofaro, S. Reiki as a clinical intervention in oncology nursing practice. This site is sponsored by nationally known Reiki master Pamela
Clinical Journal of Oncology Nursing. 2008;12(3):489-494. Miles. It includes training information, resources, articles and a monthly
3 How does Reiki work? Reiki Web site. Available at http://www.reiki.org/FAQ/HOwDoesReikiWork.html.
Accessed March 30, 2009. Reiki update.
4 Miles P. Palliative care service at the NIH includes Reiki and other mind-body modalities.
Advances. 2004;20(2):30-31.

50 Healthy Skin
 QAPI
for Hospice
Tracking performance as a condition
for Medicare participation
Leaders from the top 25 hospice agencies met in Orlando,
Florida, in February to participate in Medline’s first Roundtable
Forum for Hospice Executives. Guest presenters covered timely
subjects, including new federal rules that have the potential to
greatly change the way hospice organizations conduct business.
Participants learned valuable tips on preparing for these new
regulations.
New hospice performance requirements
One of the topics covered was the new quality assessment
and performance improvement (QAPI) requirement, which
places increased attention on how hospices perform. QAPI
builds off the existing quality assurance requirements for hospice,
which were originally introduced as part of the Balanced Budget
Act of 2005 under section 418.58.1 Hospice organizations must
follow these rules in order to remain eligible for Medicare funding.
It’s all about the data
Under the revised rules, hospice organizations are required to
gather data as a way to assess and improve quality in all aspects
of hospice care. The intent is for the data to enable hospices to
develop a clear understanding of their strengths and weaknesses
in a wide variety of areas.2
At this time, QAPI is not prescribing which areas each hospice
must examine or the precise mechanisms for gathering data.
Each hospice is free to decide how to implement the QAPI
requirement in a manner that reflects its own unique needs and
goals. The hospice must document evidence of its QAPI program
and be able to demonstrate its operation to the Centers for
Medicare & Medicaid Services (CMS).
Program requirements
Hospice leaders must ensure that their organization’s QAPI
program:2
• Reflects the complexity of the hospice and its services
• Involves all hospice services
• Focuses on indicators related to improved palliative
outcomes
• Takes action to demonstrate improvement in hospice
performance
Improving Quality of Care Based on CMS Guidelines 51
Survey Readiness
Beginning February 2, 2009 hospices must develop, imple-
ment and evaluate specific performance improvement projects.2
• The number and scope of distinct performance
improvement projects are to be based on the needs of
the hospice and must reflect the scope, complexity
and past performance of the hospice’s services and
operations. The projects are to be conducted annually.
• The hospice must document what performance
improvement projects are being conducted, the reasons
for conducting these projects and the measurable
progress on each.
First Steps for Beginning a QAPI Program
1. Identify important aspects of care1
Examples:
• Pain and symptom management
• Use of standing orders
• Delivery and setup of oxygen
2. Select measurable indicators1
Patient and family outcomes
Examples:
• Pain control to patient’s desired level of comfort within
24 hours
• Shortness of breath relieved to patient’s desired level
of acceptance within 24 hours
• Family satisfaction with timeliness of response from
hospice staff after hours
Care processes
Examples:
• Equipment delivery (timeliness, quality, patient education)
• Timeliness of completion of interdisciplinary care plan
• Timeliness of completion of initial assessment
3. Select or develop data-gathering tools1
References
1 Laff L. Weathering the Storm: Hospice Quality Assurance & Performance Improvement. Medline’s
Hospice Roundtable Forum. Presented February 22-24, 2009, Orlando, Florida.
2 Federal Register. June 5, 2008. 32193, 32207. Available at http://edocket.access.gpo.gov/2008/
pdf/08-1305.pdf. Accessed April 28, 2009.
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Special Feature

Caring for
U.S. Veterans
at Missouri
Veterans
Home
It’s a
Privilege
By Maria Hanschen, BSN, RN-BC

Waiting at the airport for a flight to see my son,

I have time to people watch, one of my favorite
pastimes. I watch a small group of soldiers; coffee
cups in their hands, lugging heavy olive green duffels
– back from deployment or maybe on their way.
Their young faces and camouflage uniforms make
me think of the residents I care for each and every
day at the Missouri Veterans Home in Cape Gi-
rardeau, Missouri.

I have been Director of Nursing Services there for

almost 19 years, and the men and women I
serve, all veterans from World War II, Korea or
Vietnam, were once young and strong like the
heroes in front of me. Forty, fifty or sixty years
ago, my residents were traveling to far-off
places answering the call for their country.

A different kind of fight

It has been a privilege for me to be part of this
community of veterans. These patriots, as they are
known in our home, are again away from their homes.
They are not in a foreign country fighting for our freedom,
and they are no longer enjoying the freedom of good health

Improving Quality of Care Based on CMS Guidelines 53

and living in their homes. This time it was not popular in the private sector.
they may be fighting hopelessness, Residents are to be bathed daily if they
helplessness and boredom in a long-term wish, and they can eat a sandwich any
care facility. Each day, from day one after I never could allow time of day or night, if they want one.
they are admitted, we are dedicated to my staff to settle for The Missouri Veterans Commission
keeping them engaged in life and with “getting by” with care. demands resident-focused care, and
others. Fishing, St. Louis Cardinals base- We always have given we always have felt our residents
ball games, BINGO, casino trips, cook- individualized care, earned the best we could offer them.
outs, shopping and even flying kites – we
even when it was
fight to keep them wanting to be part of Not everyone is fully prepared for the
not popular in the
life. They come here to live, not to die. personal attention I expect and strive
private sector. to foster between my staff and our res-
The amount of time they have left to live is idents. Many will tell stories of my get-
not my or my staff’s decision; however, the ting upset when a resident is served a
quality of life we provide for them is not only our job, it is cold tray that was supposed to be warm. I have asked
our duty. Our passionate volunteers, who donated more many new employees, “Would you want your father to
than 22,000 hours last year alone, makes it possible for have cold food? Then why would you want some else’s
our veterans to have father to have cold food?”
special care. These
wonderful men and Adjustment to our home and to our quality is not always
women read to our vet- easy for new staff. Many of them learned bad habits in
erans, help with mail, other places, and here, well, you are just expected to do
help with outings and the right thing for these men and women who put every-
even help our patriots thing in their lives on the back burner to protect us. Our
not burn the marsh- residents are not placed in pajamas before dinner. They are
Maria Hanschen with a “patriot.” mallows on the sticks dressed as they wish to be dressed, most often, appropri-
at cookouts.

Quality has been a standard at this facility since I opened

the home in June 1990. Our nurses stay current with the
latest technology and evidence-based practice. I person-
ally have been in long-term care since 1980, and I have al-
ways felt it was my obligation to ensure that the standards
of the industry were raised to the highest level possible.
I have demanded that my community of professionals
ensure quality to all geriatric residents living in long-term
care facilities. I understand the importance of consistent
and persistent quality care and how it enriches everyone’s
lives, not only the residents.

High-quality, individualized care

I would never allow my staff to settle for “getting by” with Generations of heroism.
care. We always have given individualized care, even when
 ately for dinner, just as A choice and a privilege
they did when they As I look up, I notice the last of the soldiers boarding their
lived at home. plane. A sense of pride comes over me, yet I am not sure
exactly why. Am I proud of these men and women who are
Our residents are en- flying to some distant
couraged to stay up reaches of the world to
after supper. We do protect my freedom?
not want anyone laid Am I proud of the fact
down for bed until a that I am part of a
Dancing with a U.S. veteran.
reasonable time un- community providing
less they have major excellent care to veter-
health issues, or they have requested it. It is so much ans of times past? I
better for them to enjoy BINGO, television, cards or what- realize “yes” is my an-
ever the activity might be that evening, versus lying in bed Sharing war stories. swer to both questions
in a darkened room. as I walk down the jet
bridge to my plane. However, as I take one last look at the
I often have been asked if there are any special, unique camouflage and laughing faces, I realize the true answer. I
things we do to honor our veterans. The most emotional am proud that, like them, duty is expected, but service is
and special thing we do is celebrate our patriots’ lives with a choice, and exceptional service is a privilege.
a “Hero’s Homecoming” when they die. We decided years
ago that our residents come to us through the front door,
and they should leave through the front door as well.

“A Hero’s Homecoming”
When one of our residents passes away, we announce Maria Hanschen, BSN, RN-BC, is direc-
tor of nursing services for the Missouri Vet-
over the intercom, “There will be a Hero’s Homecoming for
erans Home in Cape Girardeau, Missouri.
-------- in five minutes.” Staff, visitors and residents line
the halls to honor the resident who has died. Taps
is played, and the residents stand at attention and say a
military prayer. The family is given the patriotic quilt that
covers the body as it passes through the halls to the front
door. It is a very moving experience, even if you do not
know the resident. Families can see that their husband, or
father or sister or uncle or grandma was loved and honored.

I have so many special memories of the past men and

women I helped care for. Most of them became dear to my
heart. As a nurse and a manager, I understand the disease
process and its effects on our bodies and that we all will
die. Still, I have cried a few tears for many of them when
they departed this world. It is hard to love someone as a
friend and not miss them when they leave.

Improving Quality of Care Based on CMS Guidelines 55

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Point-of-Care Testing
Evolution or Revolution?
By David L. Phillips
Let’s start with a scene from the movie you may remember
from almost 20 years ago, “Other People's Money.” Gregory
Peck, as the beleaguered president of New England Wire and Cable,
is making an impassioned plea to the stockholders to save the com-
pany, the plant and the jobs. Danny DeVito, playing Lawrence
Garfield (a.k.a. Larry The Liquidator), speaking for the stockholders,
says that it’s not that New England Wire and Cable makes a bad
product or provides poor service; in fact, just the opposite. However,
the market demands fiber optics. As it turns out, the female lead
comes up with an idea to retool the plant to make the wire mesh
used in the manufacturing of automobile airbags, then sell the wire
mesh to the Japanese. The plant is saved, the jobs are secure and
everyone lives happily ever after.
The moral of this story is clear. Adaptation or evolution has been key
to the survival of American industry. However, this same story could
have taken place in a medical facility where market demands are call-
Improving Quality of Care Based on CMS Guidelines 57
Special Feature
ing for another “evolutionary” change: testing closer to the patient.
I have clearly stretched this analogy to make a point. The manufac-
turers of point-of–care testing (POC) kits and instrumentation know
that near-patient testing will never replace a visit to the doctor in the
same way that fiber optics replaced wire cable. Rather, point-of-care
should be an addition to the current method of managing patients.
It meets the market demands to improve the care of an aging
population.
Is the addition of point-of-care testing evolutionary or revolutionary?
In order to answer the question, let's first look at forces driving this
trend. For example, why are demands for testing closer to the patient
suddenly on the rise?
To begin with, there are two forces that are accelerating this trend: An
increase in outpatient care and an increase in the acuity of illness of
the inpatient population. Attending physicians, therefore, need
 quicker results to make critical diagnostic and therapeutic
decisions. But in addition to being rapid, these results must be
accurate and reliable to provide any real benefit.
A new generation of POC testing
In the last decade, a new generation of reliable point-of-care test-
ing systems has provided a way to fulfill this need, further driving
the trend toward patient-side testing. By combining convenience
and fast turnaround time with the reliability of laboratory testing,
these new testing systems can prevent unnecessary delays in crit-
ical therapeutic decisions or provide more convenient patient man-
agement methods for both the healthcare provider and the patient.
This new generation of systems combines precision engineering
with integrated reagents, therefore minimizing operator interven-
tion and making laboratory-quality information available to virtually
any healthcare provider anywhere. Many of these systems are self-
calibrating and have onboard comprehensive self-diagnostics as
well as integrated quality controls to eliminate believable but erro-
neous results that could harm the patient.
Taken together, accurate, reliable and rapid results can directly
improve the care of any patient, especially those with a chronic
condition that needs routine and reliable information.
Clearly, the implementation of point-of-care testing raises issues
about accuracy, precision, reliability and cost. Is the test result
accurate? Are the testers proficient? How will POC testing fit into
the requirements of CLIA?
The products that are considered to be point-of-care tests have
proliferated over the last 20 years since the CLIA ’88 regulations
were developed. In the beginning, there were only a handful of tests
– approximately 7 – that met the requirement to be considered
“waived” tests. Today, in 2009, there are literally hundreds that
meet the waived test standards.
These tests cover many conditions that need routine monitoring or
screening. The list includes but is not limited to: glucose, PT/INR,
cholesterol and lipid screening, cardiac markers, infectious dis-
eases such as flu and strep throat, HCG for pregnancy, HIV, fecal
occult blood and drugs of abuse.
Commitment, communication and cooperation
When implementing a point-of-care program in any institution, it is
important to incorporate three very non-technical ingredients: com-
mitment, communication and cooperation. By combining these
58 Healthy Skin
measures with the required technical standards for quality control,
any program should realize gains in patient management and
organizational efficiencies very quickly.
No matter what strategy is implemented, and no matter to what
degree any of the point-of-care tests are adopted, certain key fac-
tors should be addressed. These are listed in the checklist below,
organized into key areas of focus.
Key Factors to Consider When Choosing
a Point-Of-Care Testing Device
Instrument Verification and Maintenance
• Performance of initial validation studies: correlation,
accuracy and precision.
• Maintenance of records for each instrument, including
preventive maintenance, cleaning, storage,
troubleshooting and calibration.
Reagent Verification and Maintenance
• Designation of reagent supplies purchaser.
• Maintenance and control of reagent supply ensuring proper
storage and expiration dates.
• Maintenance of reagent supply performance records.
Training Program
• Designation of users.
• Development of initial user training program and
certification tests.
• Development of continuing education activities and
recertification tests.
• Maintenance of user training records.
Other Documentation
• Development of written standard operating procedures for
the central laboratory and near-patient testing site.
• Development of documentation procedure for
patient results.
• Development of procedure for the proper disposal of
infectious waste.
• Documentation of compliance with other standard
safety procedures.
So, is the continuing trend toward point-of-care testing evolution-
ary or revolutionary for healthcare providers? Their adoption of
point-of-care testing will not only improve the delivery of necessary
diagnostics, but it can have a very positive impact on the future of
testing as well. Today, healthcare delivery is in a position to broaden
its product and service offering. And now more than ever, the lab-
oratory can be moved to the patient’s side for a larger number of
tests. Moreover, in many instances, the patient actually can
become part of the healthcare team.

Decentralization of healthcare services

If we continue the analogy between American industry and health
care, decentralization of healthcare services is no different from
what has already occurred in several American industries. For
example, it is not unlike the decentralization of information we have
experienced in the computer industry. The personal computer has
come close to replacing the central processing unit (CPU) but not
totally. It has enhanced and improved the processing of vital data
that can be used more efficiently, because it is immediate and pres-
ent with the individual most in need of the information.

Perhaps an even better analogy is the railroad business. In the

1940s and '50s, railroad executives were determined to provide
the best rail service possible. If you asked them what business they
were in, they proudly responded, “the railroad business.” Had they
instead responded, “the transportation business,” they would have
known about and prepared for a market demand that required a
faster and more flexible means of transportation. Instead of a com-
petitor, air travel probably would be another product offering. Sim-
ilarly, healthcare providers are not exclusively in the diagnostic
testing business, but rather in the patient care business. As such,
there will be times when centralized laboratory testing will not be
the best solution for optimizing patient care.

Putting patients first

So, if we are “stockholders” like Larry the Liquidator, we look to the
healthcare industry to adapt and evolve. As many physicians state,
“If we are honest about making patient care our primary concern,
we will welcome the arrival of new, reliable point-of-care testing
systems.” No matter how much we reduce the dwell time of a
process in the laboratory, there are other components, including
transporting the sample, or even the patient, to a testing facility.
These remain limiting factors.
Meet Ace Combat Nurse
Ace is a tribute to the thousands of real-life
healthcare heroes serving in the U.S. military.
Turn to page 53 for a story about U.S. veterans from
World War II, Korean War and Vietnam War, who are
residents at the Missouri Veterans Home in Cape
Girardeau, Missouri.

Healthcare providers must recognize that there are times when the
Contact your Medline sales representative to learn
needs of the patient are best met by a system at the patient’s side more about Ace Combat Nurse.
and not at the doctor’s office.

Finally, is the trend toward point-of-care testing evolutionary or rev-

olutionary? I believe it is clearly an evolutionary change where the
decentralization of laboratory testing is an “extension” of labora-
tory services, not a replacement. And like a surprise ending to a
story, the outcome for healthcare providers could be a Hollywood
finish, where the real winner in all of this is the elderly or chronically
ill patient.

David Phillips is vice president of marketing for Inverness Medical.

Improving Quality of Care Based on CMS Guidelines 59

 u r J ob
ep Y o
Ke To ug h
Du rin g
Tim e s

60 Healthy Skin
 Caring for Yourself

by Wolf J. Rinke, PhD, RD, CSP

Given the topic I feel compelled to start with a caveat. Yes,

times are tough—even for many in health care. But they are not
nearly as disastrous as the media wants you to believe. Here is
what the media keeps telling us: “Unemployment is like weʼve
never seen before and no one is hiring.” Really? Here are the
facts: The current unemployment rate of 7.2% is bad, but,
according to the Bureau of Labor Statistics, it has occurred nine
previous times in the United States since 1948. In 1982 it was
at 10.8%. (That means, on average our current level of unem-
ployment has occurred about every six years.) So, yes itʼs bad,
but certainly not unusual. The media may also have convinced
you that no one his hiring. Really? The fact, according to the
Feb. 2, 2009 issue of Fortune magazine, 72 of the 100 Best
Companies to Work for (72%) are currently hiring, and each has
at least 50 open positions. By the way, of the 100 Best, 11 are
healthcare organizations, and of those, eight (~73%) are
currently hiring. The moral of the story: donʼt let the media con-
trol how you feel. Cut what they tell you in about half, and you
may be somewhat close to reality. Having said all that, the fact
remains that many people are fearful of losing their job. Here is
what to do to make sure that does not happen to you.

Be visible
No one likes to fire people. So when it comes time for layoffs
your boss will likely take the path of least resistance by select-
ing people “who are never around.” So be visible. Show up early
and leave late, attend critical meetings with important people,
let the “powers-that-be” know what you are working on, and
make every effort to get to know your boss really well, including
having lunch with her at least once a month. It also means that
you avoid telecommuting even if it is offered to you, and if you
are currently doing it, change it—because Woody Allen was
correct: “80 percent of success is just showing up.”

Donʼt be a “squeaky wheel”

Several of my clients are actually doing pretty well (believe it
or not), and yet they are selectively laying people off. Why?
Because the bad economy is a good excuse to get rid of people
who are “squeaky wheels,” high maintenance, troublemakers,
or whiners or who exhibit persistent negative attitudes or donʼt
contribute to the bottom line.

Improving Quality of Care Based on CMS Guidelines 61


Solve problems
In this tough economy, you can no longer expect to be
compensated for time, only for results and problems
solved. So actively look for a problem, focus on one that
impacts negatively on the bottom line, put a team together
and solve it. Then, let others know (especially the powers-
that-be) what a great job you and your team did and how
much your team improved the profitability of your organi-
zation. Yes, do give your credit away even in tough times,
and be sure not to brag—your boss will figure out that you
are the leader of the team. By the way, keeping your boss
in the loop of your accomplishments is not bragging, itʼs a
smart thing to do during tough times.
Do things your boss does not like to do
Letʼs face it. We all have strengths and weaknesses. Itʼs
a fact that the things we really like to do (our strengths)
always get done. The things that represent our weak-
nesses somehow get pushed off to tomorrowʼs “to-do list”
or donʼt get done at all. To make yourself indispensable,
figure out what your boss does not like to do and do more
of it. Consistently executing this strategy is one of your
best insurance policies against getting laid off. It may even
get you promoted – even during tough times.
Make your boss feel good
Believe it or not your boss, just like most people, likes to
feel good. However, the higher you are up the organiza-
tional ladder the more crap you catch. So make it a point
to let your boss talk about herself—the more she does, the
more you can find out what is important to her, which
makes it easy to exceed her expectations. Also be sure to
catch your boss doing something right, or to find anything
positive to say to your boss whenever you accidentally—
62 Healthy Skin
on purpose—, run into her. (If you donʼt know what to say,
that just means you donʼt know your boss well enough.)
And while you are at it, be sure to do the same for your
team members and colleagues. If you find it difficult to
catch others doing something right and making that pay
off for you, devour my Winning Management book or CD
album, http://www.wolfrinke.com/WMprod.html.
Act as if you own the place
Use this technique any time you are confronted with a
question, challenge or problem. For example, you feel like
going home early, buying a new piece of equipment or
asking for an assistant. Say to yourself, “Given the current
economic climate, what would I do if this were my
company?” Then act accordingly.
Go beyond the expected
It may seem obvious, but people who deliver more than
expected typically are the last to go. So make it your num-
ber one priority to be the best at what you do by reading,
studying and engaging in continuing education, training
and development. And if your employer is no longer will-
ing to pay for it, then pay for it yourself! You canʼt afford it?
I maintain that in these tough times you canʼt afford not to
invest in the most important resource you own—yourself!
I wear an attractive 111 percent pin in my lapel that drives
this concept home. Here is what the card that comes with
the pins says:
Give 100% and youʼll survive.
Give 110% and youʼll thrive.
Give 111% and you will MAKE It a WINNING Life!!!
Fake it till you make it
No matter how tough things are for you right now, choose
to exhibit a positive, can-do attitude. Letʼs face it, no one
likes to hang out with negative “stinking thinking” people.
So when it is time for people to go, guess who gets their
marching orders early? No matter how tough things get,
remember your attitude is always your choice. So choose
to always—yes I do mean always—exhibit a positive atti-
tude. Because if you do it consistently, your subconscious
will internalize it and cause you to “act” accordingly. If you
would like help with this, get yourself a copy of my “Positive
Attitude” CD or DVD at http://www.wolfrinke.com/
MIWL.html, or devour my “Beat the Blues” CPE course at
http://www.wolfrinke.com/CEFILES/cepd.html#C178.
Do a self assessment
Pretend that you are an entrepreneur or a consultant who
is selling services to a client (your employer). To make this
realistic, compute your daily compensation. Be sure to add
your benefits. If you are not sure how much that is, add
30%. Then get in the habit of asking yourself: “Have I cre-
ated value today that exceeded my daily compensation?”
Repeat that question every day you are at work. You may
even find it helpful to place a nice looking sign on your
desk that says: “Have you created $_____ of value
today?” Consistently saying “yes” to that question will dra-
matically increase the probability that you keep your job.
Say good things about others
or say nothing at all
Even though just about everyone seems to like to
complain about something or someone—donʼt be like
everyone else. Be the exception. Donʼt gossip, whine,
complain, or say anything bad about other people, your
boss or your company. Right along with that, avoid office
politics like the plague. And by all means, distance yourself
from people who engage in any of these counter-produc-
tive behaviors.
Become an expert networker
No matter what you do, there is still a chance that you will
be laid off. It simply is a sign of the times and it has noth-
ing to do with you. And when that happens, your network,
more than anything else, will determine how fast you will
find your next dream job. To test your networking effec-
tiveness, ask yourself who you have been eating lunch
with during the past week. If it is pretty much the same
people, you are missing tremendous networking opportu-
nities—opportunities that you wonʼt be able to bring back.
So start today to get in the habit of eating lunch with
different people four out of five days a week. Sit with
people you do not know at meetings and attend confer-
ences that are sponsored by groups you donʼt normally
hang out with. Plus, make sure you take advantage of
electronic marketing techniques and viral technologies
such as LinkedIn (https://www.linkedin.com) or Facebook
(http://www.facebook.com). Heck, itʼs working for Presi-
dent Obama. Why shouldnʼt it work for you?
Keep your finger on the company pulse
Make it your business to know what is going on in your
company or organization. You can achieve that by attend-
Improving Quality of Care Based on CMS Guidelines 63
ing all senior level meetings you get invited to, reviewing
your corporate Web site at least once a week, and setting
a Google alert for your company so you have a better
sense when layoffs are imminent.
If all else fails—donʼt panic—negotiate
So what do you do when your boss tells you that he has
to let you go? Whatever you do, donʼt panic and donʼt get
angry. (It is very likely that he does not like this any more
than you do.) First find out why. If the answer is to save
money, offer to work a reduced work week or maybe even
for less pay – provided it is for a specified time. If that does
not work, negotiate for a substantial severance package.
(Believe it or not, you are negotiating from a position of
strength because your employer does not want to be sued
for wrongful termination.) So negotiate for the fattest pack-
age you can get away with. And donʼt be timid. (After all
what are they going to do, fire you?) To help you with
this, devour my Win-Win Negotiation CPE program,
http://www.wolfrinke.com/CEFILES/cepd.html#C184.
Dr. Wolf J. Rinke, RD, CSP is a keynote
speaker, seminar leader, management con-
sultant, executive coach and editor of the
free electronic newsletters Make It a Winning
Life and The Winning Manager. To subscribe
go to www.WolfRinke.com. He is the author
of numerous books, CDs and DVDs including
Winning Management: 6 Fail-Safe Strate-
gies for Building High-Performance Organi-
zations and Donʼt Oil the Squeaky Wheel and 19 Other
Contrarian Ways to Improve Your Leadership Effectiveness
available at www.WolfRinke.com. His company also
p r o duces a wide variety of quality pre-approved continuing
professional education (CPE) self-study courses available at
www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.
 A world without breast cancer is in our hands.

Medline’s Generation Pink latex-free, third-generation

vinyl exam gloves have the comfort, barrier protection
and price you love. Even better, when you choose
Generation Pink gloves, you’re helping Medline
support the National Breast Cancer Foundation.

For more information on Medline’s exam gloves,

please contact your Medline sales representative
or call 1-800-MEDLINE.

©2009 Medline Industries, Inc. Medline is a registered

www.medline.com trademark of Medline Industries, Inc.

Photo by Rolfe Tessem
‘Bee Stories:
Linda Ellerbee continues to
raise awareness – and noise –
about breast cancer.
By Jerreau Beaudoin
She has often been described as the smart, gutsy,
outspoken journalist who helped pioneer network
television news in the ʼ70s and ʼ80s. But if anything,
Linda Ellerbee, the award-winning television producer,
best-selling author, breast cancer survivor, mother and
grandmother, is a storyteller.
To say she can tell a good story is an understatement –
she has received just about every major television award
there is, including (so far) three Peabody Awards, two
duPont Columbia Awards and eight Emmys. Her direct,
no-nonsense and witty style is uniquely identifiable. A sign
Improving Quality of Care Based on CMS Guidelines 65
Special Feature
Breast cancer survivor Linda Ellerbee spoke
March 16 at Medline Industriesʼ Third Annual
Breast Cancer Awareness Breakfast at the
2009 AORN Congress in Chicago.
on her office door reads “BEWARE THE
STING OF AN ELLERBEE.” Itʼs a testament
to the passion, insightfulness and dogged-
ness she brings to her stories.
So itʼs not surprising that Ellerbee has spoken
and written extensively about her cancer
experience, stressing the need for laughter,
encouragement and appreciation for life.
Breast cancer, despite being second only to
lung cancer as a cause of cancer death in
women, still abounds with myths and misinfor-
mation. In other words, itʼs a prime target for
the sting of the Ellerbee.
Ellerbeeʼs story starts with her finding a lump
in her breast while showering. She informed
her doctor, noting that it was painful, to which
he replied, “Thank goodness. It canʼt be
cancer if it hurts.” His response put her at ease
until six months later when, serendipitously, a
friend invited her to speak at an event aimed at
raising money for breast cancer research and awareness.
“I told her Iʼd be happy to do so but I didnʼt know anything
about it,” she remembers. “I had never had it. No one in
my family had ever had it. I never covered a story about
it.” In doing research for the speech, however, she
discovered that what her doctor had told her was actually
a common myth. “Itʼs now one of the first things I say when
I speak about breast cancer,” she says. “If you have a lump
and it hurts, itʼs your body trying to tell you something.
Go to a doctor.”
So, in February of 1992, she saw a cancer specialist, who
found cancer in one breast and a precancerous condition
 “OVERNIGHT” SENSATION: The television executive who
cancelled the critically acclaimed “NBC News Overnight”
said “sometimes being the best isnʼt good enough.”

in the other. When she first got news of the cancer, she Ellerbee began her career at CBS in 1972 and then moved
was devastated and remembers feeling like she had gone to NBC News, gaining fame for her stints as the networkʼs
“into some out-of-body state. I could not believe I could Washington correspondent and as a reporter on The Today
possibly have cancer.” Show. She anchored the short-lived “Weekend,” and a cou-
ple of years later the late-night news program “NBC News
Ellerbee started reading everything she could find about Overnight,” which has been cited by the duPont Columbia
the disease, piling books on her desk and pumping every- Awards as “the best-written and most intelligent news pro-
body who knew anything about cancer for gram ever.” Her style of mixing humor and
information. “I wanted to be an informed wit, employed today by popular reporters
partner in my treatment,” she said. “I was
“I don’t know if it is such as Keith Olbermann and Rachel Mad-
not 14. I did have a brain. And I didnʼt see therapeutic for me dow, attracted a diverse and dedicated
any good reason why my brain shouldnʼt be following of viewers, particularly college
put to good use too.” students. “If the Nielsens had rated col-
to talk about it, but
leges,” she says, “we would probably still
I do feel that it is
The decision to have a double mastectomy necessary. As long be on the air.”
was hers. When Larry King asked her
about it in a CNN interview, she straightfor- nothing gets done.” Her stories covered everything from poli-
as we whisper,

wardly replied, “Nobody wants to die and
no woman really wants to lose her breast,
but considering I am still on the right side of
the grass, my breasts seemed to be, frankly, a small price
to pay.” She says she can laugh about it today, adding,
“The good news is that I lived. I lost all my hair and both my
breasts. My hair grew back – my breasts did not.”
tics to pop culture, often in an offbeat way,
helping to cement her reputation as a mav-
erick newswoman before she left to form
Lucky Duck Productions in 1987. Her experience became
a best-selling book, And So It Goes: Adventures in Television
and supplied inspiration for one of the all-time classic
sitcoms – “ Murphy Brown.”

Ellerbee says unequivocally that there is nothing about her
breast cancer story that she isnʼt willing to talk about. She
told Coping magazine that she loves it when women spon-
taneously share their cancer experiences with her. “I donʼt
know if it is therapeutic for me to talk about it, but I do feel that
it is necessary. As long as we whisper, nothing gets done.”
Not that anyone has ever accused Ellerbee of being
a whisperer.
“Executive producer of ʻMurphy Brown,ʼ Diane English, told
me that she wanted to do a series with Candice Bergen
about an anchorwoman whose mouth always got her into
trouble, and could they follow me for a couple of months?”
Ellerbee told PopEntertainment.com in an interview. “An
anchorwoman whose mouth always gets her into trouble?
Whatʼs not to like?”
“Murphy Brown” was so successful that after winning her
fifth Emmy – the character was nominated for the award

66 Healthy Skin
 REALITY TELEVISION: Blurring the line between fiction
and reality, Ellerbee guest-starred as herself with Candice
Bergen on a 1989 episode of “Murphy Brown.”

seven times and won five – Bergen declined future nomi- at such a thing? Either you laugh or you cry your eyes out.”
nations for the role. Ellerbee even guest-starred as her- Ellerbee continued to work while she received her cancer
self in a 1989 episode, in which it was revealed that she treatments – just four days after her surgery, she was sit-
had been Murphyʼs main competition for the fictional ting on a step doing a Nickelodeon special on AIDS fea-
showʼs anchor job. In a memorable scene, Murphy claims turing Magic Johnson (which would later garner a Cable
Ellerbee stole the catchphrase “And so it goes...” from her ACE award for best news program). The chemotherapy left
after they had shared a flight. her nauseated and exhausted, but memories of two little
girls from the special stick out in her mind.
The showʼs final season would feature a
poignant art-imitating-life twist: a year-long
“I have to be careful The first involved a little girl sitting behind
story arc in which Murphy battled breast because unless I her who, out of nervousness, swung her
cancer. The showʼs handling of the subject foot into her back at breast height through-
was credited with a 30 percent increase in out the entire two-hour show. “I still had
consciously stop
the number of women getting mammo- surgical drains under my arms, underneath
and think, I will start
grams, but the storyline was not without rushing so fast that my sleeves in my shirt at that point. Itʼs
controversy. Conservative groups attacked funny now,” she chuckles, “but at the time...”
an episode in which she used medical mar-
I’ll go, ‘Whoops,

ijuana to relieve side effects of chemother- The other pertained to little girl named
there goes another
apy, and a womenʼs health group protested
flower.’ I have to Hydeia Broadbent, who had HIV and was
an episode in which Murphy, while shop- remind myself again struggling to talk about how she felt. Finally,
ping for prosthetic breasts, uttered the line prompted by Johnson, she said in a break-
“Should I go with Demi Moore or Elsie ing voice as she began to weep: “I want
that I’m not going to
the Cow?” people to know that weʼre normal people.”
be around forever.”
That moment, says Ellerbee, is “one of the
Cancer and comedy seem like strange ways the world has of kick starting you to
bedfellows, but Ellerbee insists that if women are open to start smelling the flowers again.”
it, they will find laughter in the experience. Take, for exam-
ple, one of her own experiences with prosthetics, which “Any life-threatening disease changes you. It takes your
she wrote about in McCallʼs: illusions of immortality, which we tend to live with for as
long as possible. It does remind you to stop and smell the
“I bought some breast prostheses to use while swimming, flowers. Iʼm 17 years out after breast cancer. I have to be
but instead of fastening them to my skin with Velcro as the careful because unless I consciously stop and think, I will
directions instructed, I simply inserted the prostheses into start rushing so fast that Iʼll go, ʻWhoops, there goes
my bathing suit. When I came out of the water, one had another flower.ʼ I have to remind myself again that Iʼm not
migrated around to my back. Now, how can you not laugh going to be around forever.”

Improving Quality of Care Based on CMS Guidelines 67

 KIDS SAY THE DARNEDEST THINGS: In 1991, Ellerbee
began producing, writing and hosting “Nick News.” Known
for the respectful and direct way it speaks to children about
the important issues of our time, the show has won four
Emmy Awards.

While Ellerbee never missed a day of work during her treat- able to. I consider that a major component of my healing.”
ment, she admits that owning Lucky Duck Productions, They also gave her something else that was crucial –
which has produced programs for every major cable net- permission to laugh in the face of a life-threatening disease.
work and has as its flagship program the childrenʼs news
program “Nick News,” played a factor in that. “I had a sofa “All of a sudden I belonged to the worldʼs biggest support
in my office and I could shut the door and lie down for 20 group,” she says. “Women still come up to me and whisper,
minutes if it got too bad. Some days I just felt awful. At one ʻIʼm in the club,ʼ or theyʼll say straight out, ʻIʼve had breast
point I came to judge New York cab drivers cancer.ʼ When it comes to the people who
by their reaction to my words ʻCan you pull really made a difference in my recovery,
over to the side of the road, please – I am
“All of a sudden they are at the top of the list, followed by
going to throw up.ʼ Some assumed that I I belonged to the my family and friends. After that would be
was drunk, but others caught on that I was nurses, and then doctors and other health-
sick and would run into a deli and come care workers.”
world’s biggest
back with paper towels and other things
support group,”
for me.” she says. “Women She pauses for a moment and then dryly
still come up to me adds, “And I suppose way at the bottom
While going through chemotherapy, Eller- and whisper, ‘I’m in somewhere I would have to put my HMO.”
bee rarely saw her doctor, noting instead
that “it was a six-month relationship with my
the club ...’ ” Ellerbee built her reputation on just such
nurse.” She has a fond appreciation for the direct commentary, and she uses it when
role nurses play in patient care. “OR speaking to women, telling them, “Look at
nurses, in particular, will have a special place in heaven,” me, Iʼm alive! And you know why? I told my doctor about a
she said, “Because one, they have to put up with arrogant lump and ignored him when he said it was nothing. I did
doctors, and two, often the person being operated on doesnʼt my research and decided, ʻTo hell with what the world
even know of their existence, or meets them only in a expects from my body. Iʼm having a bilateral mastectomy,
confused and dazed state. And almost never do any of us and Iʼll still be a woman.ʼ”
remember to say thank you.”
The intent is to send a message that you can live through
From an emotional perspective, however, the best help cancer and have a life, even while undergoing treatments.
Ellerbee says she received was from other women who But for many breast cancer survivors, Ellerbee says, the
have had cancer. When her story became public, she says hardest thing of all is when the treatments end. “When you
women began stopping her on the street and writing her to are finally taking no treatment of any kind for breast cancer,
share their own experiences. According to Ellerbee, “the there is a part of you that gets very frightened, because
letters and the hugs in the airport gave me encouragement you donʼt feel as if you are doing something proactive to
that neither my family, friends or healthcare workers were fight the return of the cancer.”
Continued on page 70

68 Healthy Skin
TenderWet Active
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www.medline.com

SOUL SURVIVOR: In 2000, Ellerbee became
the first person to be inaugurated into the
Cancer Survivors Hall of Fame.
70 Healthy Skin
In her case, Ellerbee had six months of chemotherapy, fol-
lowed by five years of Tamoxifen. “As happy as you are
that treatment is over, thereʼs also this little worry that if I am
not taking this little pill, or shooting this stuff inside me, well
then what am I doing to fight this cancer? You feel sort of
out there, all alone and unprotected.” Another thing she
wished someone had told her about was
the ongoing effects of chemotherapy. “I
think I thought that when chemo ended Iʼd
“There is a part of
you that gets very be the way I used to be the next weekend.
frightened, because No one told me that the side effects would
stay with me for another six months.”
you don’t feel as
if you are doing And so, 17 years after her diagnosis, the
spitfire from Texas continues to tell women
to not only laugh in the face of breast cancer,
something proactive
but fight for better medical treatments as
to fight the return
well. Itʼs important to remind women who
of the cancer.”
owns the disease, she said. “Itʼs not the
doctor, the hospital or the HMO; itʼs not
your friends or family. You own it. You have a right to know
everything and to have a say in what your treatment will be.”
Clearly, breast cancer hasnʼt taken the fight out of Ellerbee.
If anything, itʼs made her louder because, in her words, “it
was not talked about for so many years. I talk about it be-
cause I am a woman, and because I have a daughter and
a granddaughter. I talk about it because we donʼt have a
cure. And I will keep on talking about it until we do.”
Then, without missing a beat, she adds, “I am from the
ʼ60s, you know – I like a little noise.”
 Residents come in all
shapes and sizes.
As the bariatric population of the country grows, the likeli- Medline has a complete line of bariatric patient aids, including:
hood that you will have more obese patients admitted to your • Wheelchairs (up to 700 lb capacity)
facility increases. But bariatric patients can’t use patient aids • Walkers (500 lb capacity)
designed for smaller people. You want to give bariatric pa- • Canes (500 lb capacity)
tients the freedom to move around, not forced to stay in bed • Crutches (650 lb capacity)
because he or she didn’t have a wheelchair or walking aid to • Bath benches (550 lb capacity)
use. You also don’t want to risk patient or staff injury by using • Transfer benches (550 lb capacity)
equipment not rated for bariatric use. • Commodes (up to 850 lb capacity)

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www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 Healthy Eating
Nutritional
Information
Servings: 8

Amount per serving

Calories: 429
Total fat: 26.1 g
Sodium: 809 mg
Fiber: 3.3 g
Bangers and Mash
with Golden Onions
(8 servings)

• 8 large potatoes
• 3/4 cup milk
• Salt, to taste
• Freshly ground pepper, to taste
• Fresh rosemary
• Fresh thyme
• 3 tablespoons olive oil
• 21/2 tablespoons butter
• 2 onions, finely sliced
• 6 garlic cloves, finely chopped
• 12 smoked pork and/or
beef sausages
• 1 cup beer
• Worcestershire sauce
• Whole grain mustard
• Sauce thickener, such as
corn starch or flour

Peel and dice the potatoes into even pieces. Cook in lightly
salted water until tender. Drain well.

Bring the milk to a boil. Begin mashing the potatoes, gradually

adding the hot milk and butter, to taste. Season to taste and
set aside. Finely chop the fresh rosemary and thyme and
add to the mashed potatoes.
Heat the oil and butter in a large non-stick pan and sauté
the onions and garlic until they are slightly soft.
This recipe, created by Medline employee Maria M. Rodriguez,
won the Gold Medal at Medlineʼs International Cook Off during
Employee Appreciation Week in 2008. The award qualified Maria
to compete further in Medlineʼs Master Chef contest, where she
won the Grand Prize.

Heat the oven to 350 degrees.
Using the same pan as the onions and garlic, pan fry the
sausages until they are browned all over. Add the beer,
Worcestershire sauce and mustard to taste. Add sauce
thickener until you reach the desired consistency.
Place pan in the oven and cook for 30 minutes, turning the
sausage after 15 minutes.
Place mashed potatoes on a platter and top with the
sausages and sauce.
In addition to being Medlineʼs Master Chef, Maria works in the
human resources department processing all employee-related
data. Sheʼs enjoyed cooking from a young age, picking up tips and
techniques watching her parents and grandparents create authentic
Mexican specialties.
“Cooking is huge in our family,” she said. “We use lots of fresh
herbs, and Iʼm always recording and watching cooking shows on
television to learn new ideas.”
Maria developed her bangers and mash recipe, a traditional British
dish, by reviewing several different recipes and combining different
ingredients from each.

72 Healthy Skin
 FORMS & TOOLS

The following pages contain practical tools for implementing

patient-focused care practices at your facility.

Pain
Transdisciplinary Pain Flow Sheet ....................74
Pain Assessment Cards ....................................76
Patient and Family Education ............................78
Pain Algorithm ....................................................80

Diabetes
Taking Care of Type 2 Diabetes
English ..............................................................84
Spanish ..............................................................86

Improving Quality of Care Based on CMS Guidelines 73

 LOCATION OF PAIN: TYPE OF PAIN EDUCATION SEDATION SCALE

S = Somatic A = Pain Assessment 4 = Somnolent, minimal or no response to physical or verbal

Techniques stimulation
V = Visceral

123-50 (10/01)
A. C.
M = Medication Teaching 3 = Frequently drowsy, arousable, drifts off to sleep
N = Neuropathic
NI = Non-Pharmacologic 2 = Slightly drowsy, easily aroused

74 Healthy Skin
B. D. E = Emotional Intervention
1 = Awake and alert
O = Other R = Reinforcement of Teaching
S = Asleep, easy to arouse
Forms & Tools

SIDE EFFECTS RATER SCALE NON-PHARMACOLOGIC INTERVENTIONS

A = Anxiety M = Motor Weakness Pt = Patient NS = Numeric Scale C = Cold GI = Guided Imagery / Meditation
Cf = Confusion N = Nausea CG = Caregiver E = Visual D = Distraction H = Heat
C = Constipation P = Pruritus S = HWR N = Non-Communicative E = Exercise M = Massage
E = Epigastric Distress U = Urinary Retention Staff F = Face EB = Energy Based Therapy R = Relaxation Techniques
H = Hallucinations V = Vomiting F = Facility C = CHEOPS P = Presence CS = Counseling
Staff

HOSPICE OF THE
MC = Myoclonus CR = Cries O = Other RP = Repositioning

Current

WESTERN RESERVE, INC.

Pain

WHITE – CHART
Date/ Type
HV/ Location Rating Level of Side Non-Pharm.
Time/ Rater of 0 - 10 Accep- Scale Opioids Non-Opioids Last BM Education PIO Comments
TC of Pain table
Sedation Effects Intervention
Initial Pain
Rating

TRANSDISCIPLINARY PAIN FLOW SHEET

Patient Name:

Patient Number:

Location: (circle one)

EL

YELLOW – FACILITY
Transdiciplinary Pain Flow Sheet

HH
HQ
ME
UC
WH
Signature/ Initial Signature/Initial Signature /Initial

WL
Signature/ Initial Signature/Initial Signature /Initial
A Strong Hold
Has Never Felt
This Gentle

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©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 Forms & Tools Pain Assessment Cards

Pain Assessment Cards for Hospice Care

Developed by Hospice of the Western Reserve

PAIN
Possible Causes:
- Disease Progression - Psychosocial
- Disease Treatment - Spiritual
- Co-Morbid Disease - Emotional

Assessment Will Occur:

- Every visit or contact - Level unacceptable to patient
- New Pain - Perceived change in the non-verbal
- Increase in existing pain patient’s behavior

Essential Components of a Pain Assessment

- Location: Where is the pain? Can it be identified? Does it radiate?
- Quality: What does it feel like?
Visceral – dull, gnawing, throbbing, poorly localized
Somatic – aching, sharp, well localized
Neuropathic – shock-like, burning, shooting, lancinating
- Intensity: What is the rating on a 0-10 scale, with 0 being no pain and 10 being the worst you can imagine?
- Onset: Did it begin suddenly or gradually?
- Temporal Pattern: Does is it come and go? Is it only at night?
- Alleviating Factors: What makes it worse?
- Associated Symptoms: Are you experiencing any nausea, vomiting, diarrhea, constipation, weakness,
appetite or sleep disturbance?
- Previous Interventions: What has been tried in the past to manage the pain?
- Effect on quality of life: Does it interfere with your ability to do the activities that are meaningful to you?
- Goals for Pain Control: What pain score would be acceptable to you?

Non-Pharmacological Interventions
- Active listening/Empathy/Presence - Exercise
- Heat/Cold applications - Massage
- Positioning - Energy-based therapy
- Relaxation techniques (Healing Touch, Therapeutic Touch, Reiki)
- Visualization - Expressive therapies (art and music)
- Guided imagery - Transdisciplinary team involvement

© Copyright 2001. Hospice of the Western Reserve.

Reprinted with permission.

76 Healthy Skin
 Pain Assessment Cards Forms & Tools

Pain Assessment Cards (Continued)

Principles of Pain Management
- Believe the patient: Pain is what the patient says it is.
- Reassesss frequently – monitor regularly to provide ongoing pain control: include
non-pharmacological interventions.
- Individualized treatment – Correct dose is the dose that relieves the pain with fewest side effects.
- Choice of analgesic agent depends on many factors:
Renal and hepatic function
Past history of regimens, dosages and side effects or allergies
Available routes of administration
Quality and type of pain
- Provide preventative therapy. Give analgesics regularly.
- Oral, sublingual or rectal route is preferred for drug administration.
- Concentrated liquids or finely crushed tablets mixed with several drops of water can be placed sublingually.
The absorption via the sublingual route is considered equivalent to the oral route for the purposes of
equianalgesic dosing.
- Given rectally, MS Contin tablets are equivalent to the same dose orally.
- Subcutaneous or intravenous therapy is reserved for patients with rapidly escalating pain and/or after failed
therapy with alternative routes.
- Provide an immediate release/short-acting agent for breakthrough pain.
- Breakthrough dosing should be roughly 10 to 15% of the 24-hour dose.
- Maintenance dose is usually increased if three or more breakthrough doses are used in a 24-hour period.

Old Maintenance Dose + Breakthrough Dose = New Maintenance Dose

24 Hours 24 Hours 24 Hours
- Remember the
bowels: Patients will not develop tolerance to constipation.
- Manage side effects for optimal opioid clinical response. Typical opioid side effects include sedation, constipation,
nausea/vomiting, pruritus, sweating, myoclonus, urinary retention, and mental status changes (confusion,
delirium, hallucinations).

© Copyright 2001. Hospice of the Western Reserve.

Reprinted with permission.

Improving Quality of Care Based on CMS Guidelines 77

 Forms & Tools Patient and Family Education

Patient and Family Education Sheet

Hospice of the Western Reserve
CONTROL OF PAIN

What is pain?
Pain is what the patient says it is. No two people feel pain in the same way. Pain can be sudden, intense, mild,
dull, long-term, etc.

What causes pain?

There are many causes of pain: emotional, physical and spiritual. Most of the pain we treat in hospice comes from
a tumor. The tumor presses and sometimes destroys nerves, bones or body organs. Other conditions that cause
pain are arthritis, headaches, past injuries and many other illnesses. Sometimes what appears to be physical pain
may also be emotional or spiritual. Sometimes physical pain is not managed until the emotional and spiritual
issues are addressed.

Why does the hospice team work so hard to relieve pain?

When a patient is relieved of pain, many other problems are relieved as well. It is easier to sleep, eat, move and
do normal activities. Relief of pain helps the patient feel less fearful or depressed.

How is pain treated in hospice?

Choosing the right treatment for each patient takes skill. Your doctor and the hospice nurse will look for the
simplest and most effective pain medicine. Be sure to tell your hospice nurse how the patient feels. This informa-
tion helps them to help the patient. Nearly all hospice patients take pain medication by mouth and have good
pain relief. Some patients will use music, prayer or relaxation tapes to help with pain relief.

Why does the hospice nurse want the pain pills taken on a schedule?
The best way to control pain is to stop the pain before it starts. Stay on top or ahead of the game. If the patient
waits until the pain is severe, then the pain pill has little chance to work well. The goal is to prevent pain.

What can the patient do to help?

First, tell your hospice nurse everything about your pain. Write down times that it seems to increase.
Telling the nurse will help you achieve the best pain relief. Also, tell the nurse about your use of other medications.
Be sure to check with the nurse before using an over-the-counter medicine. Do not take someone else’s pills.
Most important: work with the nurse to set up a plan for medication.

Will the patient become addicted?

No! The patient has an illness that causes pain. Taking a pill to stop this physical pain is the treatment, not a bad
habit. Studies show that pain medicine used this way will rarely cause addiction. It is important that each patient
be supported with the right kind and amount of pain medicine.

© Copyright 2001. Hospice of the Western Reserve.

Reprinted with permission.

78 Healthy Skin
 Patient and Family Education Forms & Tools

Call the hospice nurse or physician with any questions

regarding your medication.

SIDE EFFECTS OF PAIN MEDICATION

All medicines can have some side effects, but not all people experience them. People react in different ways.
Your doctor or hospice nurse can help you work through any side effects you may have.

Sleepiness
This happens when the patient begins taking or increasing a pain medicine. Often after two to three days of
following a treatment plan, this feeling will pass. The body adjusts to the change. Remember, pain is tiring and
with the relief of pain, the patient will sleep.

Constipation (having no bowel movement or small, hard stools)

The patient will feel better when they have a bowel movement. Pain and other medicine often make the patient
constipated. If able, the patient should drink more water and fruit juices. The nurse will talk with the patient about
a laxative. Taking laxatives and/or a stool softener each day will prevent constipation. If the patient gets uncom-
fortable or hasn’t had a bowel movement in three days, call hospice.

Nausea
When the patient starts a new pain medicine, there may be a day or two of nausea. Call the hospice nurse who
will arrange for some medicine to help the patient during these early days. Do not stop taking the pain medicine
without speaking to the hospice nurse first.

ADDITIONAL INFORMATION ABOUT PAIN

What else can the patient do for pain?

There are several things to do for pain. Medicine is important, but try other ways to control pain:
- soaking in a tub of warm water
- guided imagery
- touch, light massage
- ice packs, especially if there is swelling
- music
- relaxation with deep breathing exercises
- distraction

© Copyright 2001. Hospice of the Western Reserve.

Reprinted with permission.

Improving Quality of Care Based on CMS Guidelines 79

 Forms & Tools Pain Scale - Mild

MDD = Maximum Daily Dose

©MCW Research Foundation 2000.
Reprinted with permission. Medical College of Wisconsin.

80 Healthy Skin
 Pain Scale - Moderate Forms & Tools

©MCW Research Foundation 2000.

Reprinted with permission. Medical College of Wisconsin.

Improving Quality of Care Based on CMS Guidelines 81

 Forms & Tools Pain Scale - Severe

©MCW Research Foundation 2000.

Reprinted with permission. Medical College of Wisconsin.

82 Healthy Skin
 Pain Scale - Reference Forms & Tools

©MCW Research Foundation 2000.

Reprinted with permission. Medical College of Wisconsin.

Improving Quality of Care Based on CMS Guidelines 83

 Forms & Tools Diabetes

Taking Care of Type 2 Diabetes

Toolkit No. 3

What is type 2 diabetes?

Everyone’s blood has some glucose (sugar) in it
because your body needs glucose for energy.
Normally, your body breaks food down into
glucose and sends it into your bloodstream.
Insulin, a hormone made by your pancreas, helps
get the glucose from the blood into the cells to
be used for energy. In people with type 2
diabetes, the pancreas doesn’t make enough
insulin or the insulin doesn’t work very well, or
both. Without insulin, your blood glucose rises.

How can type 2 diabetes affect me?

Type 2 diabetes sometimes leads to problems
such as heart disease, stroke, nerve damage, and
kidney or eye problems. But the good news is
that keeping blood glucose, blood pressure, and Regular physical activity can lower your blood glucose,
cholesterol on target can help delay or prevent blood pressure, and cholesterol levels.
problems.
Your Blood Glucose
How is type 2 diabetes managed? Targets established by the American Diabetes
Most of the day-to-day care of diabetes is up to Association (ADA) are listed below. Your
you. Your plan for taking care of your diabetes personal targets may differ. Talk with your health
will include care team about the best targets for you.
• choosing what, how much, and when to eat You’ll check your own blood glucose using a
• including physical activity in your daily routine blood glucose meter. The meter tells you what
• taking medications (if needed) to help you your blood glucose is at a particular moment.
reach your blood glucose, blood pressure,
ADA Targets for My Usual
and cholesterol targets Blood Glucose Results My Targets
What can I do to take care of Before meals:
90 to 130 mg/dl ______ to ______ ______ to ______
my diabetes?
• Choose targets for the ABCs of diabetes care: 2 hours after the
start of a meal:
­ A: your A-1-C check for average blood less than 180 mg/dl less than ______ less than ______
glucose
­ B: your blood pressure At least twice a year, your doctor should order an
­ C: your cholesterol levels A-1-C check. The results will give your average
• Work with your health care team to make a blood glucose for the past 2 to 3 months.
plan that helps you reach your targets. ADA Target for My Last
• Keep track of your numbers. the A-1-C Result My Target
• If you’re not reaching your targets, change
Below 7%
your plan as needed to stay on target.

84 Healthy Skin
Copyright © 2009 American Diabetes Association
From http://www.diabetes.org
Reprinted with permission from The American Diabetes Association.
Your Blood Pressure
At every office visit, your health care team should
check your blood pressure.
ADA Target My Last Result
Below 130/80 mmHg
Your Cholesterol/Triglycerides
Every year, your health care team should check
your cholesterol and triglyceride levels.
ADA My Last
Types Targets Result
LDL cholesterol Below 100 mg/dl
Above 40 mg/dl
HDL (for men)
cholesterol Above 50 mg/dl
(for women)
Triglycerides Below 150 mg/dl
What do I need to know about
meal planning, physical activity,
and medications?
Meal Planning
Many people think that having diabetes means
you can’t eat your favorite foods. But you can
still eat the foods you like. It’s the amount that
counts. Ask for a referral to a dietitian who
specializes in diabetes. Together, you’ll design a
personalized meal plan that can help you reach
your goals.
• Count carbohydrates (also called carbs).
Carbohydrate foods—bread, tortillas, biscuits,
rice, crackers, cereal, fruit, juice, milk, yogurt,
potatoes, corn, peas, sweets—raise your blood
glucose levels the most. Keeping the amount
of carbohydrate in your meals and snacks
consistent can help you reach your blood
glucose targets.
• Choose foods low in saturated fat. Cutting
down on foods that have saturated fat can
help you lower your cholesterol and prevent
heart disease. Foods high in saturated fat
include meats, butter, whole milk, cream,
cheese, lard, shortening, many baked goods,
and tropical oils such as palm and coconut oil.
• Lose weight if needed. Try to lose weight by
cutting back on food portions and increasing
your daily activity.
Diabetes Forms & Tools
• Increase the fiber in your diet. Include
high-fiber foods, such as fruits, vegetables,
dried beans and peas, oatmeal, and whole
grain breads and cereals, in your diet.
My Target
Physical Activity
Regular physical activity helps lower your blood
glucose, blood pressure, and cholesterol levels.
It also keeps your joints flexible, strengthens your
heart and bones, tones your muscles, and helps
you deal with stress. Your health care team may
want to check your heart function before you
My
Target start doing new activities. They can help you
plan what kinds of physical activities are best for
you. The different kinds of activities include
• Being active throughout the day
Examples: gardening, taking the stairs instead
of the elevator, or walking around while you
talk on the phone—working up to about 30
minutes of activity a day
• Aerobic exercise
Examples: walking, dancing, rowing,
swimming, or riding a bicycle—working up
to about 30 minutes a day, 5 days a week
• Strength training
Example: lifting light weights several times
a week
• Stretching
Example: stretching your whole body,
especially your arms and legs
Medications
Many people need medications along with meal
planning and physical activity to reach their
blood glucose, blood pressure, and cholesterol
targets. If you’ve had type 2 diabetes for a while,
you may need a change in your diabetes pills to
reach your blood glucose targets. If you need
insulin shots, it doesn’t mean that your diabetes
is getting worse. It just means that you need a
change in how you reach your target numbers.
If it’s difficult for you to reach your target
numbers, talk with your health care team
about whether medications can help.
American Diabetes Association
1–800–DIABETES (342–2383) www.diabetes.org
©2004 by the American Diabetes Association, Inc. 03/04
Improving Quality of Care Based on CMS Guidelines 85
 Forms & Tools Diabetes Español

Cómo cuidar la diabetes tipo 2

Guía No. 3

¿Qué es la diabetes tipo 2?

La sangre de todas las personas tiene un poco de
glucosa (azúcar) porque el cuerpo necesita glucosa
para tener energía. En lo normal, el cuerpo
transforma los alimentos en glucosa y la envía a la
corriente sanguínea. La insulina, que es la hormona
que produce el páncreas, ayuda a captar la glucosa de
la sangre y la lleva hacia las células para que éstas las
transformen en energía. En las personas con
diabetes tipo 2, el páncreas no produce la suficiente
cantidad de insulina, o bien, la insulina no trabaja
muy bien, o ambas cosas. Sin insulina, la cantidad de
glucosa en la sangre aumenta.
¿Cómo puede afectarme la diabetes tipo 2?
La diabetes tipo 2 algunas veces desarrolla problemas
como enfermedades del corazón, derrames
cerebrales, daños en los nervios y problemas en los
riñones y los ojos. Pero la buena noticia es que si La actividad física regular puede reducir la glucosa en su
mantiene la glucosa en la sangre, la presión en la sangre, la presión de la sangre y los niveles de colesterol.
sangre y el colesterol dentro de los objetivos
establecidos puede retrasar o prevenir los problemas. La glucosa en su sangre
En el cuadro de abajo aparecen los objetivos
¿Cómo se controla la diabetes tipo 2? establecidos por la American Diabetes Association
La mayor parte del cuidado diario de la diabetes (ADA). Sus objetivos personales pueden ser
depende de usted. El plan para cuidar su diabetes diferentes. Hable con el equipo de profesionales que
incluirá: cuida su salud sobre cuáles son los mejores objetivos
• La selección de lo que comerá, el tamaño de sus para usted. Usted mismo examinará la glucosa en su
porciones y sus horarios de comida. sangre usando un monitor de glucosa. Este aparato le
• La actividad física en su rutina diaria. indica el nivel de glucosa en su sangre en un
momento determinado.
• Las medicinas (si son necesarias) para alcanzar sus
objetivos en los valores de la glucosa en la sangre, Objetivos de ADA para Mis resultados
la presión de la sangre y el colesterol. la glucosa en la sangre habituales Mis objetivos
Antes de las comidas:
¿Qué puedo hacer para cuidar mi diabetes? 90 a 130 mg/dl ______ a ______ _____ a ______
• Defina los objetivos para los exámenes clave del
cuidado de su diabetes: 2 horas después de
! 1: El examen de su A-1-C para establecer el empezar a comer:
menos de 180 mg/dl menos de ______ menos de _____
promedio de la glucosa en la sangre
! 2: La presión de su sangre Al menos dos veces al año, su médico debe ordenarle
! 3: Sus niveles de colesterol un examen de A-1-C. Los resultados le darán el
promedio de la glucosa en su sangre en los 2 ó 3 meses
• Trabaje con el equipo de profesionales que cuida anteriores.
su salud para hacer un plan que le ayude a alcanzar
sus objetivos.
Objetivo de Mi último
• Lleve un registro de sus resultados. ADApara A1C resultado Mi objetivo
• Si no está alcanzando sus objetivos, cambie su
plan, según sea necesario, para poder cumplirlos. Menos del 7%

86 Healthy Skin
Copyright © 2009 American Diabetes Association
From http://www.diabetes.org
Reprinted with permission from The American Diabetes Association.
La presión de su sangre
En cada visita que haga al consultorio, los
profesionales que cuidan su salud deben examinarle
la presión de la sangre.
Objetivo de ADA
Mis últimos
Mi objetivo
resultados
Menos de 130/80 mmHg
Su colesterol/Sus triglicéridos
Cada año, el equipo de profesionales que cuida su
salud debe examinar sus niveles de colesterol y
triglicéridos.
Mi último
Tipos Objetivos de ADA resultado
Colesterol LDL Menos de 100mg/dl
Más de 40 mg/dl
(para hombres)
Colesterol HDL
Más de 50 mg/dl
(para mujeres)
Triglicéridos Menos de 150 mg/dl
¿Qué necesito saber sobre la
planificación de las comidas, la
actividad física y los medicamentos?
La planificación de las comidas
Muchas personas creen que tener diabetes significa
que ya no podrán comer sus alimentos favoritos. Pero
no es cierto, porque sí podrá hacerlo. Lo que cuenta
es la cantidad que come. Pida que lo refieran con un
nutricionista especialista en diabetes. Usted y este
nutricionista diseñarán un plan de alimentación que
lo ayude a alcanzar sus metas.
• Cuente los carbohidratos.
Los alimentos que contienen carbohidratos—pan,
tortillas, bizcochos, arroz, galletas, cereal, frutas,
jugo, leche, yogur, papas, maíz, frijoles
(habichuelas), dulces—aumentan al máximo los
niveles de glucosa. Si come la cantidad adecuada
de carbohidratos en sus comidas y meriendas
puede ayudarle a alcanzar sus objetivos de la
glucosa en la sangre.
• Prefiera los alimentos bajos en grasa saturada
La reducción de la cantidad de alimentos con
grasa saturada puede ayudarlo a disminuir su
colesterol y a prevenir las enfermedades del
corazón. Los alimentos con mucha grasa saturada
incluyen carnes, mantequilla, leche entera, crema,
queso, manteca de cerdo, manteca blanca llamada
“shortening”, muchos bizcochitos horneados y
aceites tropicales como el aceite de palma y de
coco.
Diabetes Español Forms & Tools
• Si es necesario, baje de peso.
Trate de perder peso reduciendo el tamaño de sus
porciones y aumentando su actividad diaria.
• Aumente la cantidad de fibra en su dieta.
Incluya en su dieta alimentos con mucha fibra,
como frutas, vegetales, frijoles (habichuelas),
granos, avena, cereales y panes integrales.
La actividad física
La actividad física regular le ayuda a disminuir la
glucosa en la sangre, la presión de la sangre y los
niveles de colesterol. También mantiene la
flexibilidad de sus articulaciones, fortalece su corazón
y huesos, tonifica sus músculos y le ayuda a manejar
Mi el estrés. Antes de que empiece con una actividades
objetivo nuevas, es posible que el equipo de profesionales que
lo atiende desee examinarle el funcionamiento de su
corazón. Ellos pueden ayudarlo a planificar las clases
de actividades físicas que sean las mejores para usted.
Entre las diferentes clases de actividades se incluyen:
• Mantenerse activo durante todo el día
Ejemplos: trabajar en el jardín, usar las gradas en
lugar del elevador o caminar al rededor mientras
se habla por teléfono—aumentando el tiempo
hasta llegar a 30 minutos de actividad al día.
• Los ejercicios aeróbicos
Ejemplos: caminar, bailar, correr o manejar
bicicleta aumentando el tiempo hasta llegar a 30
minutos de actividad 5 días a la semana.
• El entrenamiento tonificante
Ejemplo: Levantamiento de pesas ligeras varias
veces a la semana.
• Los ejercicios de estiramiento
Ejemplo: Estirar todo el cuerpo, especialmente los
brazos y las piernas.
Las medicinas
Muchas personas necesitan tomar medicinas además
de seguir un plan de alimentación y hacer actividad
física para alcanzar sus objetivos en los valores de la
glucosa en la sangre, la presión de la sangre y el
colesterol. Si ha padecido de diabetes tipo 2 por algún
tiempo, posiblemente necesite un cambio en sus
pastillas para alcanzar sus objetivos en los resultados
de la glucosa en la sangre. Si necesita inyecciones de
insulina, no quiere decir que su diabetes esté
empeorando. Simplemente, significa que necesita un
cambio para lograr sus objetivos. Si se le dificulta
alcanzarlos, pregúntele al equipo de profesionales que
cuida de su salud si las medicinas pueden ayudarlo.
American Diabetes Association
1–800–DIABETES (342–2383) www.diabetes.org
©2005 by the American Diabetes Association, Inc. 07/05
Improving Quality of Care Based on CMS Guidelines 87
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1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.
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