Improving Quality of Care Based on CMS Guidelines

Volume 5, Issue 3

Preventing
Pneumonia
in the Elderly
Population

Pressure
Ulcer Risk
Assessment

Palliative
Wound
Care
FREE CE!
Never Say “Zero” PAGE 18
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2 Healthy Skin
 HEALTHY SKIN
Improving Quality of Care Based on CMS Guidelines

11 Five Things You Need to Know about the New Quality

Survey Readiness

Sue MacInnes, RD, LD

Editor

Indicator Survey (QIS)

12 Why is Pressure Ulcer Risk Assessment So Important?
Margaret Falconio-West, BSN, RN, APN/CNS,
Clinical Editor

62 Extreme Bathroom Makeover: Resident Safety Edition

CWOCN, DAPWCA

Alecia Cooper, RN, BS, MBA, CNOR 20 Weʼre Spotting a Nationwide Trend
Managing Editor Prevention
Page 12
24 A Focus on Prevention
Andy J. Mills, MBA 43 The Transfer Challenge
Contributing Editor

48 Infection Control: Pneumonia

Mike Gotti 53 Recommendations on Infection Prevention in Long-Term Care
Art Director

Laura Kuhn
Copy Editor

30 When Negative is Positive

Treatment

36 Palliative Wound Care

Cynthia A. Fleck, RN, BSN, CWS, DAPWCA, MBA,
40 End-of-Life Care for Residents and Their Families
Clinical Team

Page 34
FACCWS
46 Case Study: Debridement, Pain and Odor Control Using
Janet L. Jones, RN, BSN, PHN, CWOCN,
a Hydrogel with a Superabsorbent Polymer Core Dressing
DAPWCA
54 Culture Change In Briefs
Joyce Norman, RN, BSN, CWOCN, DAPWCA
57 Say Goodbye to Soap and Water
Elizabeth OʼConnell-Gifford, RN, BSN,
61 10 Tips to Create a More Enjoyable Resident Dining Experience
CWOCN, DAPWCA, MBA
Amin Setoodeh, BSN, RN
Deb Tenge, RNC, MS, CWOCN, 5 Medline Announces Prevention Above All Discoveries Grant
Special Features

Licensed Administrator
Jackie Todd, RN, BSN, CWCN, DAPWCA
Wound Care Advisory Board
Janie Arndt, MS, RN, CWOCN, CNS-BC
Ann Blackett, MS, AP RN-BC, CNS, CWOCN
Mary R. Brennan, RN, MBA, CWON
Patricia Coutts, RN
Pat Emmons, RN, MSN, CNS, CWOCN
Dawn R. Fortna, RN, BSPA, MSEd, CDE, CWOCN
Evonne Fowler, RN, CNS, CWOCN
Lynne Grant, MS, RN, CWOCN
Dea J. Kent, RN, MSN, NP-C, CWOCN
Diane Krasner, PhD, RN, CWCN, CWS,
BCLNC, FAAN
Andrea McIntosh, RN, BSN, CWOCN, APN
Cathy Milne, MSN, APRN, CWOCN, CS, ANP
Linda Neiswender, RN, BSN, CPN
Ann H. Poplin, RN, MSN, FNP-C, CWOCN
Lynne Whitney-Caglia, RN, MSN, CNS, CWOCN
Laurel Wiersema-Bryant, RN, BSN, BC, ANP
Linda Woodward, RN, BSN, OCN, CWOCN
28 Incorporating a Magnet Approach in Wound Care Page 36
34 Special Guest Editorial: Never Say “Never,” Never Say
“Always,” Never Say “Zero”
59 Bathing the Elderly with Dignity
64 How to Thrive in a Tough Economy
70 Why Canʼt We All Just Get Along?
75 Medline Supports Breast Cancer Awareness 365 Days a Year
6 Two Important National Initiatives for Improving Quality of Care
Regular Features
Page 40
18 CE-Credit Crossword Puzzle: Why is Pressure Ulcer Risk
Assessment So Important?
74 Building Unshakable Self-Confidence
Caring for Yourself
76 Recipe: Guacamole
79 Pressure Ulcer Prevention Policy and Procedure
Forms & Tools
Page 48
84 Predicting Pressure Ulcer Risk
86 Infection Control Activities and Their Relevance to
Pneumonia in LTC

Improving Quality of Care Based on CMS Guidelines 3

 Healthy Skin Letter from the Editor

Dear Reader,
Solutions. Thatʼs what everyone wants. How often
do you hear “Donʼt keep telling me about the prob-
lems if you canʼt suggest some solutions”?
I just went to a conference where an excellent group
of speakers laid out new regulations, discussed
changes in reimbursement, changes in healthcare
policy, risk factors, economics, you name it. I ended
up exhausted – and I had a really big headache.
Then, I went back to work. I was welcomed with all
the problems that I had missed while I was out at the
meeting. Sound familiar?
Letʼs make our lives easier. Itʼs time to share. Itʼs time
to learn from each other, provide support for each
other and focus on whatʼs really important: providing
our residents with the best health care possible. Weʼre
lucky to be a part of the changes that are taking place
in every facet of health care. I can clearly see that the
next trend will be meetings not restricted by specialties,
but crossing over the lines of hospital, nursing home
and home care to health care for the patient…patient-
centered health care.
In this edition of Healthy Skin, there will be some
crossover of information by providers. Many of the
articles are long-term care focused and some are hos-
pital-focused. Why? Because the concerns we all face
with quality are even more of a concern as the patient
moves from one setting to another. Letʼs take pres-
sure ulcers. How much clearer can CMS get than the
9th Scope of Work, released August 1, 2008 (see
Page 6)? Pressure ulcers are one of the patient safety
themes for Quality Improvement Organizations. Pressure
ulcers are being considered a community problem
and so the QIOs will be looking at nursing homes with
a high incidence of pressure ulcers AND the corre-
sponding hospitals in the same county. Why?
Because the data supplied by the nursing home MDS
and the data supplied by the hospital Present on
Admission Indicator is going to find the source of
pressure ulcers.
Now more than ever, communication between health-
care settings is important. We can help each other by
sharing what weʼve learned, communicating with each
other. Quality improvement can be a whole lot easier
with a team approach inside and outside of our core
business.
Please read about new nursing home initiatives, with
the Quality Indicator Survey that is currently being
rolled out in nine states with more soon to follow
(Page 11). Learn about the importance of pressure
ulcer risk assessment, follow a patient from the
hospital to the nursing home and learn along the way
(1 CE credit available), on Page 12. To understand
the patient as an individual, we need to understand
and know when to implement a palliative wound care
“
Now more
than ever,
plan (Page 36).
communication
between health-
As we continue to learn about each other and share care settings is
ideas, keep this in mind – one thing that will never
change is our desire to hear from you, our readers.
”
important.
Weʼre always interested in knowing what you like
about Healthy Skin, what you want to see more of or
if you have an interesting story to share. Just send an
email to smacinnes@medline.com and tell us whatʼs
on your mind.
Finally, one important opportunity that we hope each
and every one of you will consider: Medlineʼs Pre-
vention Above All Discoveries Grant. Please take a
look at Page 5 for more details. We look forward to
hearing from you.
Sincerely,
Sue MacInnes, RD, LD
Editor

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

Medline Announces
Prevention Above All
Discoveries Grant
Medline is proud to announce the creation of the
Prevention Above All Discoveries Grant. Be sure to
check out future editions of Healthy Skin for more details
on this exciting opportunity! To request additional information,
please visit www.medline.com/special/paa/contact.asp.
Program outline
Focus
• To provide new intelligence and guiding knowledge to
healthcare institutions on successful targeted interven-
tions that show evidence of reducing medical errors,
risks, hazards and harms associated with healthcare-
acquired conditions (identified by CMS in 2008
IPPS rule).
• The results from these grants will inform providers,
payers, policy makers and the public about how
targeted, evidenced-based interventions can:
– be successfully implemented in healthcare settings
– lead to safer, better care for patients
– reduce cost to the healthcare system
Objectives
• Stimulate research that will increase the adoption of
evidence-based solutions into clinical practice to reduce
hospital-acquired conditions.
• Disseminate practical solutions to healthcare providers
leading to a reduction in hospital acquired conditions
Award detail
• Medline intends to commit up to $1 million in total costs
over several years to fund new grants focused on the
hospital-acquired conditions that CMS has targeted.
Grants can be pilot work to develop or apply solutions
to reducing HACs, or more rigorous empirical studies to
test solutions on a larger scale. In either case, monitoring
the impacts of the intervention is essential. The grantee
should indicate whether they are submitting a pilot grant
or an empirical study.
• Annually we will select qualified grant recipients to be
awarded up to $25,000 each for pilot grants or
Improving Quality of Care Based on CMS Guidelines 5
Special Feature
$100,000 each for an empirical study. We expect that
some grantees will receive a pilot grant first to
develop/apply a solution in a feasibility study and then
apply for a larger grant to conduct an empirical study
based on the pilot grant. Others may just conduct a pilot
grant, and others who have already pilot tested a
solution may apply for an empirical study as long
as they present evidence from their pilot work.
• Because the nature and scope of the projects will vary
from application to application, it is anticipated that the
size and duration of each award will also vary. Accord-
ingly, funding will be dispersed in a tiered schedule
based on project durations and milestones.
• Grants will be awarded and funded in 2009 in several
areas – pressure ulcers, hand hygiene compliance,
retained surgical objects, catheter-associated urinary
tract infection, surgical site infection and other pertinent
safety and quality areas.
• An independent Review Panel, whose members
represent a breadth of research and practice
knowledge, will evaluate and score each application.
The panel will consist of a multi-disciplinary team of
distinguished representatives from academia, healthcare
institutions and public and private organizations.
2008-2009 Grant program schedule
August 18, 2008: Program creation announced at
Prevention Above All conference
November 1, 2008: Request for proposals announced
January 5, 2009: Letters of intent due
February 1, 2009: Notification, request for full proposals
April 15, 2009: Full proposals due
June 1, 2009: Notification of awards
 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. Reviews will focus on improving
coordination across the continuum of care and evaluations of performance will include the contract, the program
and the attribution of success to QIO interventions.

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
 Regular Feature

The 9th Scope of Work Content Themes

4. Improving inpatient surgical safety and heart failure

treatment in hospitals
Theme #1: Beneficiary Protection

1. Case reviews
Activities will focus on nine Tasks:
5. Improving drug safety
2. Quality improvement activities (QIAs)
6. Providing quality improvement technical assistance to
3. Alternative dispute resolution (ADR)
4. Sanction activities nursing homes in need
5. Physician acknowledgement monitoring
6. Collaboration with other CMS contractors
7. Promoting transparency through reporting
Theme #4: Prevention

8. Quality data reporting 1. Recruiting participating practices

Activities will focus on nine Tasks:

9. Communication (education and information) 2. Identifying the pool of non-participating practices

3. Promoting care management processes for preventive
services using EHRs
4. Completing assessments of care processes
Theme #2: Care Transitions

1. Community and provider selection and recruitment 5. Assisting with data submissions
Activities will focus on three Tasks:

2. Interventions 6. Monitoring statewide rates (mammograms, CRC screens,

3. Monitoring influenza and pneumococcal immunizations)
7. Administering an assessment of care practices
8. Producing an Annual Report of statewide trends, showing
baseline and rates
Theme #3: Patient Safety

1. Reducing rates of health care-associated methicillin- 9. Submitting plans to optimize performance at 18 months
Activities will focus on six primary Topics:

resistant Staphylococcus aureus (MRSA) infections

2. Reducing rates of pressure ulcers in nursing homes
and hospitals
3. Reducing rates of physical restraints in nursing homes

Clinical and Operational/Process Goals

Goal 1: Reducing high-risk pressure ulcers Goal 5: Establishing individual targets for
Clinical Goals: Operational/Process Goals:

Goal 2: Reducing the use of daily physical restraints improving quality

Goal 3: Improving pain management for longer-term
nursing home residents
Goal 4: Improving pain management for short-stay,
post-acute nursing home residents
Goal 6: Assessing resident and family satisfaction
with quality of care
Goal 7: Increasing staff retention
Goal 8: Improving consistent assignment of nursing
home staff so that 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: 7,005

Goal 1: 70.2% Goal 5: 31.7%
Percentage of participating nursing homes*: 44.4%
Goal 2: 44.8% Goal 6: 63.3% Participating consumers: 1,636
Goal 3: 54.4% Goal 7: 40.9%
Goal 4: 39.4% Goal 8: 31.4%

Visit this Web site to view progress by state!

www.nhqualitycampaign.org/star_index.aspx?controls=states_map
Represents a 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

 News Flash
A CDC Resource for Battling Bugs in Long-Term Care
Maybe you read about the CDCʼs Campaign to Prevent
Antimicrobial Resistance in Healthcare Settings when it was
launched in 2002. Almost six years later, the campaignʼs
goals are just as relevant as ever. Why not brush up on the
campaignʼs goals and explore its resources?
The campaign has four central goals: prevent infection, diagnose
and treat infection, use antimicrobials wisely and prevent trans-
mission.1 To help meet these goals, the CDC offers specific tools
for clinicians who treat hospitalized adults, dialysis patients,
surgical patients, hospitalized children and long-term care residents.1
The CDC lists the following as basic steps that can be taken to
help prevent infections and antimicrobial resistance among
nursing home residents1:
• Plan and implement influenza and pneumococcal vaccine
campaigns to prevent pneumonia.
• Use indwelling catheters only when necessary and follow
appropriate insertion techniques to reduce urinary
tract infections.
• Reposition residents frequently and inspect pressure points
for redness or skin irritation to prevent pressure ulcers.
• Use recommended infection control precautions to prevent
transmission of infectious agents from resident to resident.
• Practice hand hygiene and promote hand hygiene among
residents and visitors.
For more information on the campaign, visit
http://www.cdc.gov/DRUGRESISTANCE/healthcare/default.htm.
Reference
1 Centers for Disease Control land Prevention. Campaign to Prevent Antimicrobial
Resistance in Healthcare Settings. Available at: http://www.cdc.gov/DRUGRESIS-
TANCE/healthcare/default.htm. Accessed August 7, 2008.
Improving Quality of Care Based on CMS Guidelines 9
The Results are In!
We at Healthy Skin would like to thank the 310 of you who
took the time to complete our online readership survey!
Weʼve learned a lot from what you had to say, and we wanted
to share some of the results with you!
We were thrilled to see that 97 percent of you rated the rele-
vance of the topics covered in Healthy Skin as “excellent” or
“good.” Ninety-two percent of you gave the same ratings to the
educational opportunities provided in the magazine, and 93
percent of you find the information in the magazine to be useful.
Weʼve learned that Treatment is the most-read section of
Healthy Skin, with 77 percent of you reading articles in that
section. Seventy-one percent of you read Special Features, 55
percent read Forms & Tools and 51 percent check out Survey
Readiness.
The last question we asked you was about your facilityʼs priorities.
Hereʼs how you responded when asked if the following areas
were important to your facilities.
Prevention: 83 percent
Safety: 77 percent
Reimbursement: 54 percent
Education: 53 percent
Thanks again for your participation! We will use what we have
learned from you as we continue to create future editions of
Healthy Skin!
Where else can you find such
a complete and integrated
solution for survey readiness?
Actually, nowhere.

Whether you’re preparing for a Quality Indicator Survey
(QIS), looking to improve your traditional survey outcomes
®
or dealing with past survey issues, abaqis will lead
the way to providing a comprehensive and accurate
assessment of your facility.
abaqis® is the only quality assessment and reporting
system for nursing homes tied directly to the QIS. It was
developed by Nursing Home Quality, the same company
the Centers for Medicare & Medicaid Services uses to
train State Survey Agencies on QIS.

abaqis® uses the same forms, analysis and thresholds That gives you a unique advantage in preparing for your
State Agency surveyors do. Rich reporting capabilities survey – and in managing your risk.
on 26 Care Areas guide you to what surveyors will be
targeting in your facility. abaqis® is sold exclusively through Medline.
Learn more by signing up for a free webinar
Even if your state isn’t currently implementing the QIS, demo at www.medline.com/abaqisdemo.
the drill-down capabilities of abaqis® provide root cause
analysis on both a facility-wide and individual resident
basis, showing where you should focus your efforts for
quality improvement.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 Survey Readiness

Over the last several years, CMS has been developing and

S Y OU
5 testing a new revised survey process for long-term care
called the Quality Indicator Survey, or QIS. This is one more
step to improve the quality of care and provide a more resident-
THING
T O KNOW centered focus. It is a federally approved survey process being
NEED used by state surveyors and CMS regional offices. There is
E NEW
widespread discussion and some confusion about this new survey.
T T H
ABOU INDICATOR
ITY Here are five things you need to know about QIS:
QUAL E Y (QIS)
SUR V

4. QIS is technology-based
Surveyors are using sophisticated computer software sup-
By Andrew Kramer, MD
porting a very structured process. The software guides the
surveyor, provides a unified platform regardless of the state or
1. QIS is coming the individual surveyor, calculates the data and identifies
Currently, there are nine states in the training program for
triggers of potential noncompliance based upon predeter-
statewide rollout of the Quality Indicator Survey process.
mined thresholds. Those triggers set the wheels in motion for
These are Connecticut, Florida, Ohio, Kansas, Louisiana,
a Stage 2 in-depth investigation process. The nursing home
Minnesota, North Carolina, New Mexico and West Virginia.
survey readiness goal is to know their areas of risk prior to
Two more states will be added by mid-2009. CMS has sent a
the survey process and work on continuous improvements to
request for applications from other states to see who will be
reduce or eliminate triggers for a Stage 2 investigation.
next as they roll QIS out nationwide over the next several
years. For a brief overview of QIS and the QIS training
5. Providers have found that the
process, go to www.cms.hhs.gov/SurveyCertificationGen-
QIS tools can be used for QA
Info/downloads/SCLetter08-21.pdf.
By obtaining training in the QIS methods and using the QIS
approach, nursing home staff have successfully used the QIS
2. QIS is based on research process to assess the quality of care and quality of life of their
The methods used in QIS were developed at the University of
residents in accordance with the federal code of regulations.
Colorado in the early 1990s as a research protocol for evalu-
They have found that using the QIS process year-round for
ating the quality of life and quality of care provided to nursing
QA not only helps to improve care, but also prepares them for
home residents. Under CMS contract, these methods were
the survey continuously without mock surveys. For more
adapted as the basis of the QIS process, making the survey
information, contact your state healthcare association or go to
both more objective and based on scientific methodology.
www.nursinghomequality.com.
Following a demonstration of this approach, CMS decided to
implement QIS nationwide.
About the author

3. QIS is more replicable and predictable

than the traditional survey
Larger, statistically valid samples of residents are reviewed in
order to obtain a more complete view of care in the facility.
These random samples are taken from census residents, new
admissions and MDS data. Surveyors follow structured
protocols that include scripted questions to ask of residents,
family and staff. In comparison to the traditional survey
process, resident interviews, resident observation and family
interviews make up a much larger portion of the revised
survey process.
Andrew Kramer, MD is Head of the
Department of Medicineʼs Health Care
Policy and Research Division at the
University of Colorado and the first
recipient of the Peter W. Shaughnessy
Endowed Chair in Health Care Policy. His
research interests focus on strategies for
improving 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 Secretary for
Planning and Evaluation, Senate Committee on Aging and
the Institute of Medicine.

Improving Quality of Care Based on CMS Guidelines 11

 Why is
Pressure Ulcer
Risk Assessment
So Important?

Letʼs examine what a resident and nursing student have to say!

By Alecia Cooper, RN, BS, MBA, CNOR
My name is Euretha and I have a story to tell you. I think it
could help folks like you who work in nursing homes and hos-
pitals alike. My granddaughter is studying to become a nurse
and she thinks what she and I have learned about my experi-
ence can help everyone. So I agreed to help.
I am 79 years old and have been in pretty good health all of my
life until I started getting feeble these last few months. Since
the passing of Theodore, my beloved husband, three years
About 70 percent of
ago this past September, I have lived all pressure ulcers
alone and got along pretty well caring occur in people 70
for myself. But as of late, I have been years and older.1
getting “blue” more often than not. I
donʼt have much of an appetite and I canʼt get around as well
as before. I become dizzy in the early mornings and I have
taken a fall several times. Most of my friends are either too sick
to get out much or they have passed on. These days, I just do
not have many folks to talk to or visit with.

12 Healthy Skin

Then things got worse. I tripped walking back from the mailbox
a few months back and skinned my arm, my nose and bruised
my left hip. My whole body was bruised up pretty bad. My
daughter June insisted that I go see my doctor, Dr. Hill. I have
been cared for by Dr. Hill for more than 30 years and pretty much
think he is one of the smartest doctors I know of, so when he told
me that he thought it was time for me to go live in a nursing
home, only for a while, so I could get stronger, eat better and
find out what was causing all these dizzy spells, I didnʼt much
Improving Quality of Care Based on CMS Guidelines 13
Survey Readiness
argue with him. June and the kids found me a good spot, close
to our home, and we all agreed this would only be for a little
while. Also, June told me she would have my house painted and
the floors redone while I was gone, so it would be in mint
condition when I returned.
On September 1, I went to
stay at Happy Valley Nursing About 1.5 million Americans
Home for what I thought was reside in the nationʼs 16,400
only temporary, no more than nursing homes on any
a couple of months. Today is given day. 2
Thanksgiving Day and I hope
the kids get here soon as I just cannot bear the thought of being
away from home on my favorite holiday. As hard as I tried
to persuade him otherwise, Dr. Hill said I am not ready to leave
yet. You see, what I have not told you yet is that I had one of
those dizzy spells 14 days after I came to Happy Valley.
It was early that morning when I got out of bed to go to the bath-
room. I lost my footing, slipped and fell hard on my right hip and
it broke. We were not sure it was broken at first, but once I got
to the hospital, they were sure. I had surgery and a stay at the
hospital and then came back
to Happy Valley with this Why is pressure ulcer risk
doggone bedsore on my assessment so important?
other hip. It is not healing too Because it helps identify which
well. In fact, it just keeps get- patients or residents may benefit
ting worse. Those “blue” most from preventable measures.3
days have just been getting
worse. I thought I would cry The best way to prevent pressure
all day when Dr. Hill let me ulcers may be through the use of
know that he now thinks that evidence based of pressure ulcer
this bedsore could be
risk assessment tools.4
infected. But remember how
I told you my family always comes through?
This whole situation worried my poor granddaughter to death, so
she talked to one of her
nursing instructors who Confinement to a bed or chair
gave her an idea for a
for a week has been found to
school research project. And
increase the prevalence of pres-
you know what that sweet
thing did? She said she sure ulceration by 28 percent.
5
needed my help. Imagine
that. I get to help her figure out what could have prevented my
bedsore from developing after I broke my hip.
I asked her how could I possibly help, and she told me that we
needed to go through every event from the time my injury
occurred until the bedsore developed. She explained that she
would take every part of the story and research the prevention
measures that, if they had been done, might have prevented that
bedsore from developing. To prove her point, she brought me an
article to read that she found in one of her nursing journals. That
article said that the experts say bedsores can be prevented in
Continued on Page 15
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most cases. If all this is true, then I think we need to all work
together to prevent them from happening. Oh, I know that mis-
takes can happen unintentionally. People can forget when they
are working so hard, under stressful situations, but letʼs find out
what we can do to keep bad things from happening. Lord knows
I have nothing better to do to occupy my time these days. Hereʼs
a look back at what was going on when that bedsore developed.
23.9 percent of residents
September 15, 2007
5:47 a.m. in long-term care develop
I remember that I had tossed pressure ulcers at some
and turned all night, and even point.1
though I was still so tired, I
just could not fall back to A resident is most likely to
sleep no matter how hard I develop a pressure ulcer
tried. So I got up to use the during the first four weeks
bathroom and fix my den- after admission.6
tures so I could go to break-
fast. Maybe I got up too fast, or I was dizzy for some reason, but
as soon as my feet hit the floor, I slipped and fell hard on my
right hip. I think I remember hearing something snap, but I was
not certain. I yelled for help and that nice girl Sheila ran in and
found me lying on the floor. She told me not to move if possible
and she quickly ran to get some help. The head nurse came in
and they got me stretched out as best they could and said they
called my doctor and an ambulance was on the way to come
get me and take me to Mercy Medical Center so I could be
checked out.
7:46 a.m. Pressure ulcer incidence is
The ambulance comes to over 60 percent for high-risk
take me to the hospital (1 hr patients with femoral fractures
and 59 minutes after the and/or hip fractures.1
incident occurred). I looked
at the very small stretcher with that tiny mattress – I donʼt think
it could have been more than one or two inches thick – and wor-
ried how they were ever going to get me on and off that safely,
but they did. And trust me, it was one of the most uncomfortable
beds that I have ever laid on. They strapped me in and got me
into the ambulance. I was in so much pain, but the emergency
medical personnel told me they could not give me anything to
dull it until I was checked out at the hospital. I could not even
have anything to drink. I think that was the worst part, but they
said if I needed to have surgery it could hurt me.
8:37 a.m.
I am rolled off the ambulance Pressure ulcers are defined
and rolled into the hospitalʼs as areas of localized damage
emergency room. Finally, to the skin and underlying
after some confusion, I am tissue caused by pressure,
moved from that tiny shear, or friction.7
stretcher to a bigger bed that
was a little wider, but that mattress was not much better than the
one before. They nurses and doctors told me that I had to lie still
while they checked me out, otherwise I might further injure my
Improving Quality of Care Based on CMS Guidelines 15
hip. For what seemed like forever, they checked me out. Then
they told me they had called Dr. Hill and that he was on his way,
but had given them orders over the phone for me to have an
EKG, a chest X-ray and an X-ray of my hip. Also, June and the
kids had arrived by now and they let June come back to sit
with me for a while until it was time for me to go to the
X-ray department.
For consideration:
1. Was a pressure ulcer risk and skin assessment
performed and documented on admission
to the nursing home?
2. Was an admission pressure ulcer risk and skin
assessment performed, documented and compared
to the assessment performed at the nursing home?
9:57 a.m. 70 percent of nurses consider
I am rolled down the hallway their basic wound education
to the X-ray department for to be insufficient.8
the X-rays that Dr. Hill
ordered. The boys moved me from my stretcher to a very hard
and very cold table in a darkened room. A very nice lady came
in and explained what was going to happen. Pictures were taken
of my chest and hip and then those sweet boys came back and
moved me off that hard table and back to that uncomfortable
stretcher and I was rolled back to the emergency room. When I
got back, Dr. Hill was waiting on me and the first thing I asked for
was a drink of water as I was so parched. I remembered that I
had not had anything to drink since before 8 p.m. the night be-
fore and nothing at all to eat since dinner. He said he knew that
I was dry, but it was unsafe to give me anything to drink until we
knew whether I needed surgery. I asked if they could please
hurry and find out.
Nurses need more education8:
• Risk assessment (interpretation of Braden scale)
• Pressure ulcer staging
• Proper positioning (including bed and chair)
• Effects of moisture on the skin (including incontinence,
humidity and maceration)
• Pressure relieving products
• Proper application and usage of prevention products
11:02 a.m.
The nurse comes in to tell me that the X-rays show that my right
hip was indeed broken and that the surgeon, a Dr. Cloud, or one
of his assistants would be here soon to discuss the plan for sur-
gery with me. I was getting so tired of just laying in one spot for
so many hours, but she explained to me that they had to keep my
body straight so I did not injure my hip more. I asked her what
time it was, and when she said 11:02, I realized that it had been
over six hours since I fell and that I had been in one position for
as many hours. No wonder I was getting so stiff. If I could have
only turned over and had a glass of water.
 For consideration:
1. Did the stretchers pads used in the ambulance
and in the emergency room have pressure
redistribution capability?
2. Were pressure-relieving devices used to frequently
reposition the patient?
11:35 a.m.
Common factors that
Dr. Cloud comes in, intro-
duces himself and explains increase the risk for
that I need to have surgery. developing pressure ulcers
He was dressed in what include immobility, circulatory
looked like pajamas with a problems, infections,
white coat and a blue cap. incontinence, passivity
He told me that he had been and decrease in
in surgery all morning and consciousness.
that he had one more proce-
dure to finish and then he
would be able to get me all fixed up. I told him how sore I was
and how much pain that hip was giving me, so he told the nurse
to give me a shot for pain and that he would go ahead and have
me moved to the surgery holding area, where they could get me
ready for surgery. About 20 minutes later, a boy who was
dressed like Dr. Cloud came in and told me he was there to roll
me up stairs to where the Surgery Department was located. I
said my goodbyes to June and the kids and they told me not to
worry, that I was going to be fine. I told them I knew that, I just
wanted to get this over with.
1:08 p.m.
I am finally being rolled back to the operating room to get this
old hip fixed. They started an IV in the holding area and gave
me some medicine that was making me very drowsy. I now
had on one of those blue hats, too. They moved me over to
a table that looked just as uncomfortable as that gurney I had
been lying on for the past five or six hours. After that, I donʼt
remember much, so I have to turn the story over to my grand-
daughter to explain what happened in surgery.
For consideration:
1. Each time the patient was moved from stretcher
to stretcher and table to table, were the staff well
trained in transfer and positioning techniques
that reduce friction and shear?
Granny was positioned on Pressure ulcers can develop
her left hip, prepped and within two to six hours of the
draped with a full-body drape onset of pressure.1
and only her right hip
exposed to the operative field. The procedure started at 1:45
p.m. and was completed at 3:30 pm., lasting one hour and forty-
five minutes. During the surgery, Granny has some reason-
able blood loss and the hip was irrigated with antibiotic fluid. At
3:45 p.m., after an immobilizer was positioned between her legs
16 Healthy Skin
to keep her in proper body alignment, she was rolled onto her
bed and taken to the recovery room, where she remained for
two hours until she was stable enough to be taken back to her
own room. Iʼll let Granny tell you how she was feeling when she
got out of surgery.
For consideration:
1. Was the OR table pad a pressure redistribution pad?
2. Were all bony prominences and pressure points
padded appropriately to minimize pressure that might
occur during a surgical procedure?
6:00 p.m.
June and the kids were all waiting for me when I got to my room.
There was a pitcher of water waiting and that was the first thing
I wanted – a cold drink. My nurse for the evening came in and in-
troduced herself and checked me out. They gave me some broth
to eat a little later. My hip was beginning to hurt again, so they
gave me some more pain medicine and I drifted back to sleep.
I guess I was really tired because I slept more that evening than
I had in weeks. I woke up a few times during the night and
needed some more pain medicine, but then I went right back
to sleep.
For consideration:
1. Was the patientʼs skin thoroughly cleansed and
inspected after surgery before leaving the operating
room to ensure that there was no pooled blood or prep
solutions under bony prominences?
September 16, 2007
7:00 a.m.
Breakfast arrives and I am awake and ready to eat. Soon after-
ward, the day shift nurse comes in and says she has to check me
out head to toe. In doing so, she finds a big red mark on my left
hip and asked me if it had
been there before I arrived at The greatest incidence of
the hospital. I told her it had- new-onset postoperative
nʼt been as far as I knew, but pressure ulcers for elderly
that I had been falling easily patients with hip fractures
and bumping into things so it occur within the first two
was possible that I was there postoperative days.5
and I didnʼt know it. There
was still some paint from sur- Studies suggest pressure
gery and a few blood spots wounds occur within the first
on my skin, so she got some
two days after the insult and
soap and water and cleaned
that wounds occurring beyond
me up real good. My grand-
daughter can tell you what this time frame are caused by
came out of all of this. continuous soft tissue insults
in high-risk populations (these
may go undetected for as
many as seven days).5
For consideration:
1. Should soap and water be used to cleanse patients
at high risk for development of pressure ulcers?
By now, you must know the rest of the story. Granny was in the
hospital for five days after surgery and then returned to Happy
Valley Nursing Home. The
reddened area eventually When a Stage I pressure
developed into a Stage III ulcer develops, the risk for
pressure ulcer that is now in- additional ulcers on the
fected. From my research, same individual is reported
we have developed a proto- to increase tenfold.5
col for the prevention of
pressure ulcers that includes a community effort between the
nursing home and acute-care facility to prevent facility-acquired
pressure ulcers. In Grannyʼs case, the ulcer could have devel-
oped due to pressure, moisture, friction, shear, poor nutri-
tion, tissue injury or tearing, but most likely from a combination
of all of these factors. Not all pressure ulcers are avoidable, but
many are. I encourage you to work closely within your medical
community to make sure your pressure ulcer prevention meas-
ures and protocols are up to date and that everyone is fully
trained to execute them appropriately.
Critical steps
Critical steps in pressure ulcer prevention and healing include8:
• Identifying the individual resident at risk for
developing pressure ulcers
• Identifying and evaluating the risk factors and
changes in the residentʼs condition
• Identifying and evaluating factors that can be
removed or modified
• Implementing individualized interventions to attempt
to stabilize, reduce or remove underlying risk factors
• Monitoring the impact of the interventions
• Modifying the interventions as appropriate
Avoidable vs. unavoidable pressure ulcers
A pressure ulcer is avoidable if the facility did not do one or
more of the following9:
• Evaluate clinical condition and risk factors
• Define/implement interventions consistent with
resident goals/standards of practice
• Monitor/evaluate impact of interventions
• Revise interventions
A pressure ulcer is unavoidable if it develops even though the
facility did all of the above.9
Risk factors
Risk factors for pressure ulcer development include8:
• Impaired/decreased mobility
• Decreased functional ability
• Co-morbid conditions
Improving Quality of Care Based on CMS Guidelines 17
• Drugs that may affect wound healing
• Impaired diffuse or localized blood flow
• Resident refusal of some aspect of care and treatment
• Cognitive impairment
• Exposure of skin to urinary or fecal incontinence
• Under-nutrition, malnutrition and hydration deficits
• History of a healed ulcer
For Happy Valley Nursing
All members of the healthcare
Home, they not only had to
team need to know their
provide care for Eurethaʼs
mending hip, they also had to responsibilities and how their
deal with her facility-acquired tasks relate to each other in
pressure ulcer that had the prevention and manage-
become infected. Euretha ment of pressure ulcers.
was now a much more com-
plex resident with a much higher acuity, requiring more resources
and services to be provided and at a higher cost burden for both
the payer and the provider. Added on top of this is the at-risk
condition for the development of additional complications, such
as additional pressure ulcers, deep vein thrombosis, pulmonary
embolism and additional infections.
Prevention is paramount. It begins with proper risk and skin
assessment, combined with proper prevention measures
(including the appropriate prevention products). The cement that
holds it all together is proper education and training of personnel
across the complete continuum of health care, including the com-
munity of nursing homes, hospitals and emergency medical
professionals.
Refer to the Forms & Tools section, Pages 77 to 87, to learn
more about how you can prevent pressure ulcers at your facility.
This story is a fictional account based on the real-life experiences
of the author.
References
1 Medical News Today. Clinical Trial Shows 96% Improvement In Pressure Ulcer Healing
Among Nursing Home Residents. Available at:
http://www.medicalnewstoday.com/articles/39327.php. Accessed September 3, 2008.
2 U.S. Department of Health & Human Services. CMSʼ Oversight of Nursing Homes: The
Special Focus Facility & Other Programs to Address Troubled Nursing Homes. Available at:
http://www.hhs.gov/asl/testify/2007/11/t20071115d.html. Accessed September 3, 2008.
3 Ayello E, Braden B. Why is pressure ulcer risk assessment so important? Nursing.
2001;31(11):74-80.
4 Walsh K, Bennett G. Pressure ulcers as indicators of neglect. Nursing & Residential Care.
2000;2(11):536-539.
5 Maklebust J. Pressure ulcers: The great insult. Nursing Clinics of North America.
2005;40(2):365-389.
6 LEEDer Group Inc. F-Tag 314: Making It Stick! Available at: http://leedergroup.com/bul-
letins/f-tag-314. Accessed September 3, 2008.
7 Lepisto M, Eriksson E, Hietanen H, Lepisto J, Lauri, S. Developing a pressure ulcer risk
assessment scale for patients in long-term care. Ostomy/Wound Management.
2007;53(10):34-38.
8 Zulkowski K, Ayello E, Wexler S. Certification and education: Do they affect pressure ulcer
knowledge in nursing? Advances in Skin & Wound Care. 2007;20(1):34-38.
9 Ayello E. Pressure Ulcers as Quality Indicators: Risk and Liability. Presented at November
2006 Canadian Association of Wound Care Conference.
 CE Credit Crossword Puzzle
Why is Pressure Ulcer Risk
Assessment So Important?
Across
4 Prevention includes the appropriate use of
prevention ______.
6 The cement that holds it all together is proper
education and _____.
9 Prevention begins with proper ___ and skin
assessment.
10 Not all pressure ulcers are _______, but many are.
12 23.9 percent of _____ in long-term care develop
pressure ulcers at some point.
13 When a patient is admitted to the hospital, a pressure
ulcer risk and skin assessment should be
performed, documented and _______ to the
assessment performed at the nursing home.
14 Pressure ulcers can develop within two to six _____
of the onset of pressure.
17 __________ to a bed or chair for a week has been
found to increase the prevalence of pressure
ulceration by 28 percent.
20 About ___ percent of all pressure ulcers occur in
people 70 years and older.
21 70 percent of nurses consider their basic wound
education to be _____.
22 Pressure ulcer risk assessment is important
because it helps identify which residents may benefit
most from _________ measures.
23 ___________ interventions to attempt to
stabilize reduce, or remove underlying risk factors
should be implemented.
24 Common factors that increase the risk for
developing pressure ulcers include immobility,
circulatory problems, _____, incontinence, passivity
and decrease in consciousness.
25 The best way to prevent pressure ulcers may be
through the use of evidence based of pressure ulcer
risk __________ tools.
26 Personnel across the continuum of care should be
educated and trained, including nursing homes,
_____ and emergency medical professionals.
18 Healthy Skin
Down
1 It is important to identify and evaluate the
_____ _____ and changes in the residentʼs
condition.
2 Staff needs to be properly trained on transferring
techniques that reduce ______ and shear.
3 Bony prominences and pressure points should be
padded appropriately to minimize pressure that
might occur during a _____ procedure.
5 ________ _______ are defined as areas of
localized damage to the skin and underlying tissue
caused by pressure, shear or friction.
7 About 1.5 million Americans reside in the nationʼs
16,400 __________ on any given day.
8 A resident is most likely to develop a pressure ulcer
during the first _____ weeks after admission.
9 Pressure ulcers can lead to infections, which can
necessitate more _____ and services be provided.
10 Nurses need more education on proper ______ and
usage of prevention products.
11 All members of the healthcare team need to know their
_______ and how their tasks relate to each other in the
prevention and management of pressure ulcers.
12 Stretcher pads should have adequate pressure
_________ capabilities.
15 Studies suggest pressure wounds occur within the first
two days after the insult and that wounds occurring
beyond this time frame are caused by continuous
__________ insults in high-risk populations.
16 Prevention is _____.
18 Additional complications of pressure ulcers can include
deep vein thrombosis, pulmonary _____ and additional
infections, just to name a few.
19 The greatest incidence of _____ _____ postoperative
pressure ulcers for elderly patients with hip fractures
occur within the first two postoperative days.
 1 2

6 7 8

9 10

11

12 13

14 15

16 17 18

19

20

21

22 23

24

25

26

1. Register (free) or log in

www.medlineuniversity.com

2. Click Free Courses tab

3. Locate the puzzle and click Learn
More, then Begin Course
4. Certificates are available online
after puzzle completion

To receive one hour of CE credit, enter your answers

online at www.medlineuniversity.com

Improving Quality of Care Based on CMS Guidelines 19

We’re Spotting
a Nationwide Trend…
State-sponsored pressure ulcer
prevention collaboratives
This is the kind of trend we can all embrace – state-spon-
sored pressure ulcer prevention collaboratives! Read on
to learn what five states (maybe yours?) are up to!
New Jersey
New Jersey is really the “trendsetter”
here. The state had a pressure ulcer
prevalence rate in fall 2004 that was
much higher than acceptable. Accord-
ing to the Centers for Medicare & Medi-
caid Services (CMS) Nursing Home
Quality Initiative, New Jersey healthcare
facilities had consistently held a pres-
sure ulcer prevalence rate of 18 percent
for individuals at high risk, which is
nearly five points higher than the national average.1 This led
to an ambitious collaborative led by the New Jersey Hospi-
tal Association in which they achieved a 70 percent reduction
in the incidence of pressure ulcers among participants in
two years.1 Their results were highly celebrated and pub-
lished throughout the healthcare industry.
Working with its advisory panel, the New Jersey Hospital As-
sociation (NJHA) developed a bundle of preventive practices,
which included evidence-based protocols and practices that
have been tried and tested. The philosophy behind this is
that if one of these practices is proven effective, then grouping
a number together should work even better. By applying the
bundle to all patients and residents, the same high-quality
care is delivered to all, no matter the caregiver or the setting.
The Pressure Ulcer Collaborative bundle included:
• Completing a head-to-toe skin assessment within
eight hours of admission
20 Healthy Skin
• Assessing risk factors, using the Braden Scale,
within eight hours of admission and reassessing weekly
in long-term care (every 24 hours for at-risk patients and
those in acute care)
• Instituting appropriate prevention techniques for those
determined to be “at risk” (i.e., a score of 18 or lower
on the Braden Scale), including the use of pressure
redistribution surfaces.
Many tools and resources were identified to support the
effort, including a pressure ulcer prediction, prevention and
treatment pathway; a treatment product categories table; a
turning and repositioning tool; baseline data elements and
tools and senior leadership reports for monthly submission.
What are other states doing in an effort to follow in New
Jerseyʼs footsteps?
Virginia
In 2003, Virginia initiated a joint public-
private partnership (supported through
resources from state, federal and pri-
vate agencies) that had an overarching
goal of delivering high-quality, easily ac-
cessible geriatric education and training.
This program focused primarily upon
education of direct care providers and other practitioners who
attended a live, interactive videoconference that featured na-
tionally known experts. The content of the educational pro-
gram was drawn from nationally accepted guidelines and
discussed appropriate procedures for wound cleansing,
dressings, positioning techniques, proper nutrition and risk
assessment protocols.2
The education did result in a reduction in pressure ulcers in
the study conducted in 2003, but apparently these results
were not sustained. On January 10, 2008, the Virginia Pres-
sure Ulcer Resource Team (VPURT), a statewide healthcare
coalition, issued a call to action to improve quality of care
within the long-term care system by reducing what they
referred to as one of the highest rates of pressure ulcers in
the country.3 VPURT has identified critical components for
pressure ulcer prevention, including quality enhancement,
regulatory effectiveness and resource revitalization. They
have also identified the following priorities for pressure ulcer
prevention3:
• Make pressure ulcer prevention a key outcome
parameter for Pay for Performance
• Increase staffing levels to meet the critical needs of
the residents for prevention of pressure ulcers
• Increase the pay of the direct care staff in
nursing facilities
• Increase the accountability of every healthcare
professional in pressure ulcer prevention
• Make pressure ulcers a reportable event
• Develop and implement a Uniform Patient
Transfer Form
• Create an independent Center for Pressure Ulcer
Prevention Education
• Redirect unused DMAS $10/day bed supplement
to pressure ulcer prevention in high-risk patients
• Revise COPN for nursing facility beds to
emphasize quality
It appears that – in Virginiaʼs experience, at least – education
alone is not enough to prevent facility-acquired pressure ulcers.
Wisconsin
On June 11, 2008, the Wisconsin
Health Care Association announced a
collaborative effort to certify 200 Wis-
consin registered nurses who work in
long-term care as certified pressure
ulcer specialists. The following organi-
zations are involved in this effort4:
• Wisconsin Department of Health and Family Services
• Wisconsin Health Care Association
• Wisconsin Association of Homes and Services
for the Aging
Improving Quality of Care Based on CMS Guidelines 21
• Wisconsin Directors of Nursing Council
• National Alliance of Wound Care
• Wound Care Education Institute
• West Bend Mutual Insurance
• GuideOne Insurance
• Golden Living
• MetaStar
• Kindred Health Care Foundation
Week-long certification courses will be offered this fall for 200
registered nurses. Wisconsin long-term care facilities will
have the opportunity to send RNs at the cost of $1,000.
The remaining course costs – approximately $2,500 – are
defrayed by the above-listed sponsors of the initiative.
Indiana
On August 25, 2008, the Indiana State De-
partment of Health released the annual report
of the Medical Error Reporting System
(MERS), which includes reported events for
calendar year 2007. According to the 2007
report, 27 of the 105 reported events were
Stage 3 or 4 pressure ulcers acquired after
admission to the facility.5
Indiana health officials call pressure ulcers an example of a
system-based problem. It is not uncommon for a pressure
ulcer to develop in one facility and become worse or treated
in another facility. Reducing pressure ulcers requires close
care coordination between facilities and frequent, thorough
care assessments. The Indiana State Department of Health
also announced that they have already taken the following
steps to address the pressure ulcer problem5:
• Developed and implemented the Indiana Health Care
Quality Initiative - Pressure Ulcer Reduction Campaign,
an 18-month collaboration between the University of
Indianapolis Center for Aging and Community, provider
associations and advocacy groups to provide a systems-
based approach to reducing pressure ulcers. The
program provides education, training and technical
assistance to 150 healthcare facilities and agencies
on best practices and systems for the prevention of
pressure ulcers
Continued
 • Provided an alternating pressure, low-air-loss mattress
and four pressure-reducing wheelchair cushions to
every nursing home in the state
• Held a conference in October 2007 for 1,167 healthcare
providers with national presenters on pressure ulcer
reduction initiatives and experts discussing best
pressure ulcer prevention (PUP) for inclusion in future is-
sues of Healthy Skin! Data may be submitted to
healthyskin@medline.com. We will keep you updated on all
state-mandated PUP initiatives as data becomes available.
References

practices for ulcer prevention and treatment.
It will be exciting to see the results of this comprehensive
community initiative!
1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers.
Extended Care Product News. 2007;122(8):24-29.
2 Benghauser K, Cash K, Coogle C et al. The development of an educational
collaborative to address comprehensive pressure ulcer prevention and treat-
ment. Gerontology and Geriatrics Education. 2004;24(3).
3 Virginia Pressure Ulcer Resource Team. Statewide Health Care Coalition:

Pennsylvania Reduction of Pressure Ulcers Seen as Essential to Improving Long-term Care

On August 25, 2008, Pennsylvania

announced that leading wound care
specialists, including national ex-
pert Dr. Diane Krasner, will present
the latest evidence in pressure
Quality in Virginia. Available at: http://www.vpurt.org/. Accessed September 9,
2008.
4 Wisconsin Health Care Association. Innovative Collaboration Paves the Way
in Pressure Ulcer Prevention. Available at: http://www.whca.com/mediaroom/.
Accessed September 9, 2008.
5 IN.gov. ISDH: 2007 Medical Error Reporting System Report. Available at:

ulcer prevention and treatment at http://www.in.gov/isdh/24056.htm. Accessed September 9, 2008.

6 ECRI Institute. Philadelphia Conference Presents Latest Evidence-based
The Pennsylvania Pressure Ulcer Partnershipʼs Kick-off
Medicine for Pressure Ulcer Prevention. Available at:
Conference on October 21. The kick-off event for the https://www.ecri.org/Press/Pages/Pressure_Ulcer_Conference.aspx. Accessed
Philadelphia area and overall statewide initiative are the re- September 9, 2008.
sult of collaboration by The Health Care Improvement
Foundation, The Hospital & Healthsystem Association of
Pennsylvania, the Hospital Council of Western Pennsylva-
nia, ECRI Institute and Quality Insights of Pennsylvania.6

To prepare key staff to lead ongoing skin-safety efforts,

healthcare organizations in Pennsylvania are encouraged
to enroll multidisciplinary teams in the collaborative. After the
conference, attendees will be engaged in additional activi-
ties, including surveys, conference calls and improvement
monitoring, to support long-term improvement in pressure
ulcer prevention.

We have only mentioned five states in this article and ask for
your help to let us know what is going on in your state!
Please send your state-specific collaboration information for

22 Healthy Skin
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 A Focus on Prevention
Highlights from the Prevention Above All Forum

On August 18 and 19, Medline brought together some of A new community approach
health careʼs thought leaders for its Prevention Above to pressure ulcers
All Forum to discuss healthcare policy changes and In terms of healthcare policy changes
their implications for care. More than 80 chief nursing of- and their implications for care, one with
ficers, chief medical officers and healthcare quality execu- an astounding impact on long-term care
tives from across the U.S. attended the two-day forum. A discussed at the forum was CMSʼs new
select group of healthcare policy experts and professionals community approach to pressure ulcer
provided guidance and knowledge on patient safety strategies Bratzler prevention and care as outlined in the
and an innovative portfolio of targeted interventions that 9th Scope of Work.
translate research findings into practical, evidence-based
solutions to improve outcomes. Several of those speakers Previously, CMS reviewed captured MDS data to help iden-
provided important facts and advice on issues that are tify nursing homes that have high rates of pressure ulcers.
currently facing the long-term care community. With the CMS 9th Scope of Work, which took effect on Au-
gust 1, CMS now directs QIOs to focus not only on nursing
The key to cultural change: homes with a high incidence of pressure ulcers, but to take
mutual cooperation built on real a closer look at hospitals in the same county and hold them
mutual respect accountable as well.
With CMS revamping reimbursement
for hospital-acquired conditions (HACs) “It gets to the sense that pressure ulcers are a community
and expanding implementation of the problem,” said Dale Bratzler, DO, MPH, Medical Director of
Quality Indicator Survey for long-term the Oklahoma Foundation for Medical Quality, speaking at
Nance care facilities into more states, it wasnʼt the forum. “CMS is actively working on building performance
too surprising to hear Keynote Speaker John J. Nance, JD measures that will publicly report hospital pressure ulcer
open the Prevention Above All Forum by saying “the core rates, particularly hospital-acquired pressure ulcers. Once
culture of medical practice has to be drastically changed.” they complete that, then I think there is going to be a strong
incentive for nursing homes and hospitals to work together
Nance, founding member of the National Patient Safety to figure out the best ways to prevent pressure ulcers.”
Foundation and author of Why Hospitals Should Fly: The
Ultimate Flight Plan to Patient Safety and Quality Care, Learn more about the 9th Scope of Work by visiting
touched on how the October 1 CMS reimbursement mile- www.providers.ipro.org/index/9SOW_summaries - 39k.
stone for HACs provides the opportunity for healthcare
providers to “re-commit” to improving patient safety by Implications of the CMS Guide-
becoming engaged professionals dedicated to barrierless lines on pressure ulcer prevention
communication. and treatment
Thereʼs a great variability in terms of
“Youʼre not only going to solve the CMS problems (of HAC how organizations have prepared for
prevention),” said Nance. “But you are going to get to the the October 1 deadline and where they
point of asking doctors ʻWhy donʼt we have 100 percent are at on that continuum of preparation.
compliance on handwashing?ʼ and ʻIs it okay if my nurses According to Diane Krasner, PhD, RN,
Krasner
remind you?ʼ That consistent cross-checking of each other, CWCN, CWS, BCLNC, FAAN, Wound
completely devoid of professional defensiveness, and a real and Skin Care Consultant, a lot of that preparedness comes
caring for each other as full members of a team dedicated to down to education.
the patientʼs best interests, is the key to safe practice.
“If you just look at the pressure ulcer part of the CMS ruling,
Why Hospitals Should Fly by John Nance is available at thereʼs a high training and education component that each
www.whyhospitalsshouldfly.com. facility is going to have to grapple with,” said Krasner.

24 Healthy Skin
Krasnerʼs presentation highlighted the need for nurses
to receive more education on:
• Risk assessment (interpretation of Braden Scale)
• Pressure ulcer staging
• Proper positioning (including bed and chair)
• Effects of moisture on the skin (including incontinence,
humidity and maceration)
• Pressure-relieving products
• Proper application and usage of prevention products
The following documents – currently in use at Krasnerʼs
facility, Rest Haven-York – are also available:
• Pressure Ulcer Protocol
• Pressure Ulcer Protocol – Avoidable versus
Unavoidable Pressure Ulcers
• Pressure Ulcer Notification Fax
• Pressure Ulcer Risk Factors tracking chart
• Wound Photo Documentation
APIC: Spreading knowledge, preventing infection
Sometimes a few changes need to be made in order to
clarify goals and continue to move toward them. Kathy
Warye, CEO of the Association for Professionals in Infection
Control and Epidemiology, Inc. (APIC) shared the associa-
tionʼs recommendation of changing the title of Infection
Control Professional to Infection Preventionist with
Prevention Above All forum attendees.
“Language creates culture, and if the goal is around prevention,
then our name needs to incorporate prevention,” Warye said.
Warye distributed copies of APICʼs MRSA guidelines and a
DVD on hand hygiene geared toward patients. To download
a copy of the DVD video, please visit www.cdc.gov/handhy-
giene. For more APIC resources, please visit www.apic.org.

If you are interested in receiving any of these documents,

please email us at healthyskin@medline.com.

Surgical studies can inform LTC

Heidi Wald, MD, MPH, along with her
co-authors of the study “Indwelling Uri-
nary Catheter Use in the Postoperative
Period,” reviewed data from 35,904
Medicare patients at 2,965 acute care
Be sure to visit the Prevention Above All Web

hospitals across the United States to

site at www.medline.com/special/PAA/ for

determine the relationship between

continued updates and additional resources.

Wald
catheter use and postoperative out-
comes. “This was probably the first national study of really
whatʼs going on in surgical patients,” Dr. Wald said. Although
the study was surgical in nature, its findings can certainly
inform long-term care as well.

Dr. Wald and her colleagues concluded that indwelling

urinary catheters that are left in place for longer than two
days postoperatively may result in catheter-acquired urinary
tract infections (CAUTI) as well as an increase in 30-day
mortality and an increased length of stay.

To view the study, please visit http://archsurg.ama-assn.

org/cgi/content/short/143/6/551.

Improving Quality of Care Based on CMS Guidelines 25

 Prevention Above All
Targeted interventions, practical solutions
Medline introduces six practical and targeted interventions to
help improve outcomes. The programʼs strategically inte-
grated portfolio of focused and achievable evidence-based so-
lutions is designed to fit into the everyday processes and
systems most healthcare providers already have in place.
Target: Catheter-Associated
Urinary Tract Infections (CAUTIs)
The Prevention Above All
Intervention: Silvertouch® Catheters
A bundled solution of advanced silver technology with Med-
lineʼs Silvertouch Foley catheters and educational training to
reduce CAUTIs.
Silvertouch Foley catheters incorporate the power of silver
through a patented process that binds silver ions to the
catheterʼs lubricious coating, delaying the onset of biofilm for-
mation. Educational materials provide summarizations of the
major recommendations from the CDC and provide a policy
and procedure template guide for proper catheterization. Also
included are validation tools that can be utilized during training
or re-education classes, and a troubleshooting guide book to
help caregivers work through issues.
Target: Harm Avoidance
and Patient Satisfaction
The Prevention Above All Inter-
vention: Educational Packaging
To help reduce medical errors, Medline redesigned its Advanced
Wound Care packaging in a format that allows each package
to serve as a 2-minute course on advanced wound care.
The innovative packaging design is an improved delivery and
communication system to help healthcare professionals better
understand and more easily deliver wound care at the patient's
bedside. It replaces confusion with clear, step-by-step
information, eliminating the clutter and highlighting
critical information.
Target: Objects
retained after surgery
The Prevention Above All
Intervention: RF Detect
RF system designed to alert the OR nurse when a RF-tagged
surgical items remain in the patient before closing the procedure.
26 Healthy Skin
The system consists of three components: a micro RF tag em-
bedded in gauze, sponges and towels and a sterile handheld
wand that is connected to the third component, an easy-to-
use, self-calibrating console. By passing the wand back and
forth and side to side over the patient, hospital personnel will be
able to accurately detect, within seconds, retained surgical dis-
posables before site closure.
Target: Hospital-
Acquired Infections
The Prevention Above
All Intervention: Hand
Hygiene Compliance Program
A program of products that stresses appropriate application
techniques and education to achieve hand hygiene compli-
ance while dramatically improving the skin condition of health-
care workers.
The Hand Hygiene Compliance Program contains three prod-
ucts – Sterillium Comfort Gel™, Medline Remedy™ products
and Aloetouch® exam gloves – clinically proven to nourish dry
skin. The program includes an intensive educational module
developed by an expert panel of infection control profession-
als. Healthcare workers can earn up to four continuing edu-
cation credits by completing the training program. Additional
components include testing for skill and competency valida-
tion through the use of Visirub and a UV light box. Patient
education pamphlets, facility posters and a rewards program
are also included to reinforce positive behavior change.
Target: Pressure Ulcers
The Prevention Above All
Intervention: Pressure
Ulcer Prevention Program
A program of products, tools and resources to implement
an effective prevention program and immediately begin
reducing the incidence of pressure ulcers.
The Pressure Ulcer Prevention Program is a strategic product
bundle to assist in reducing or preventing pressure ulcers
and incontinence-associated skin conditions, which may
include dermatitis and skin tears. Products include Remedy™
Advanced Skin Care Products, Ultrasorbs® AP Dry Pads,
Restore®/Remedy™ Adult Brief, and Supra DPS alternating
pressure and low-air-loss mattresses.
This program also packages together education and train-
ing tools so a healthcare team can implement an effective
pressure ulcer prevention program and immediately begin
reducing the incidence of healthcare-acquired pressure
ulcers. Included are workbooks, patient and family educa-
tion brochures and a rewards program.

Target: Wrong Site Surgery

The Prevention Above All
Intervention: S.T.O.P. Drape
A surgical drape set that incorporates a “Time Out” sticker
strip that must be removed prior to the surgical case
and provided to the circulating nurse to be placed on the Wayne Brannock of
Lorien Health Systems in
patientʼs chart. Maryland asks a question
during a session.
The Medline S.T.O.P drape has a sticker in the shape of a
red stop sign and tells the staff to stop, forcing them to
perform the time-out required prior to beginning surgery. The
sticker provides a location to write and confirm the patientʼs
name, procedure, site and side, date, time and surgeonʼs
initials. By requiring the surgeon to initial the sticker, the
surgical team is again reminded to perform the time-out
immediately prior to the incision, thus encouraging improved
compliance with performing the time-out procedure.
Dr. Andrew Kramer speaks
to Prevention Above All
Forum attendees about
patient safety.

Attendees review Medlineʼs Pressure Medline Chief Marketing Officer Sue MacInnes addresses attendees during the Prevention
Ulcer Prevention Program materials. Above All Forum.

Improving Quality of Care Based on CMS Guidelines 27

 Special Feature

Incorporating a Magnet
Approach in Wound Care
By Cindy Kiely, RN, MSN, CWOCN

Although the skin is the largest organ of the body, skin integrity
has rarely, if ever, been considered a fundamental aspect of pa-
tient care. The development of a pressure ulcer was thought of as
an unfortunate outcome during a patientʼs hospitalization. Today,
pressure ulcers are considered a preventable occurrence of
unnecessary harm. There has never before been a time in health
care in which pressure ulcers have been such a force to be
reckoned with.

The revised Centers for Medicare & Medicaid Services (CMS)

policies that take effect on October 1 reflect the social and
economic concerns voiced regarding pressure ulcers. Pressure
ulcers are termed “never events” by CMS and the implementation
of no reimbursement for facility-acquired pressure ulcers will
undoubtedly have a huge financial impact. Facilities are scram-
bling to implement and promote preventative measures, but the
costs of products and support surfaces may limit some facilitiesʼ
abilities to maintain a best-practice approach.

What is a “Magnet” approach?

Incorporating a “Magnet philosophy” into a wound care program
may be one of the most cost-effective and interdisciplinary
approaches to preparing for the new CMS guidelines. The American
Nurses Credentialing Center (ANCC) awards Magnet status to
healthcare organizations that satisfy a certain set of criteria
designed to measure the strength and quality of nursing care.1
Magnet status is awarded to institutions that deliver outstanding
patient outcomes while simultaneously incorporating nurse
involvement in data collection and decision-making in the patient
care delivery system. Magnet values an open communication about the subject accomplishes more than a team that is forced
between nursing and leadership along with encouraging and to participate.
rewarding them for advancing in nursing practice.
Since the staff nurses are the ones with the most hands-on
Assembling a team experience with pressure ulcers, their opinions should be of ut-
The first step in implementing a Magnet philosophy in wound care most importance. Distributing a confidential survey querying the
is to uncover the nursing staff who are attracted to the field. The nurses on their understanding of wound care and products can
creation of a wound care team can focus on the positives as well generate new approaches to education and training. The wound
as the negatives in a facilityʼs wound care approach. Assigning care team would be able to generate information from the survey
staff without seeking their preference will surely doom the com- that can help pinpoint the areas needing improvement and may
mittee. Asking the nurse manager who they feel may have an in- even ignite new ideas. For instance, the creation and implemen-
terest and then sending an invitational letter to that person makes tation of pressure ulcer standing orders may facilitate treatment
a positive first impression. A team that is energetic and enthused more rapidly than waiting for a physicianʼs order.

28 Healthy Skin
Letters of gratitude may spark additional confidence as well as
interest within the field of wound care. Acknowledging a nurseʼs
exceptional preventative care may encourage ongoing quality
care, thereby reducing that nurseʼs unitʼs incidence of pressure
ulcers. Simple acts of gratitude can empower the nurse.
Education, empowerment and support
The Magnet approach relies upon evidence-based care. Wound
care can no longer take a “weʼve always done it that way”
approach. For example, wet-to-dry dressings have been a popular
treatment choice despite their detrimental side effects, such as
pain and non-selective properties of removing granulation as well
as devitalized tissue. Education, empowerment and support of
the nursing staff with evidence-based facts can encourage nurses
to question the treatment ordered and encourage research-based
treatments instead of “the old standby.”
The solutions to improving patient care are not always found fi-
nancially. Empowering the nursing staff can bring forth greater re-
wards fiscally along with improved patient outcomes. Encouraging
nurse involvement and truly listening to their experiences can help
shape the culture of an entity as well as promote excellence in
care.
What is Magnet status?
Magnet status is an award given by the American
Nursesʼ Credentialing Center to hospitals that satisfy a
demanding set of criteria measuring the strength and
quality of their nursing. Specifically, a Magnet hospital is
one where nursing delivers excellent patient outcomes,
where nurses have a high level of job satisfaction, low
staff nurse turnover rate and appropriate grievance res-
olution. There is nursing involvement in data collection
and decision-making in patient care delivery. Magnet
nursing leaders value staff nurses, involve them in
shaping research-based nursing practice and encour-
age and reward them for advancing in nursing practice.
Magnet hospitals have open communication between
nurses and members of the healthcare team and have
an appropriate personnel mix to attain the highest pa-
tient outcomes and optimal staff work environment.
Reference
http://www.nursingadvocacy.org/news/2004feb/hopkins_billboard.html

Reference
1 The Center for Nursing Advocacy. What is Magnet Status? Available at:
http://nursingadvocacy.org/faq/magnet.html. Accessed August 6, 2008.

About the author

Cindy Kiely, RN, MSN, CWOCN, is the
wound specialist at Good Samaritan Hospital
Medical Center. She has specialized in wound
care for almost 10 years and is a member of
the Wound, Ostomy and Continence Nurses
Society. Cindy has played an active role in
health care by speaking to members of Con-
gress regarding diabetic foot care as well as
having been published on this topic.

Improving Quality of Care Based on CMS Guidelines 29

 Treatment
When Negative is Positive:
A Review of Negative
Pressure Wound Therapy
By Cynthia A. Fleck, RN, BSN, ET, WOCN, CWS, DAPWCA,
and Lisa D. Frizzell, RN, BSN, ET, CWOCN
Despite recent press, marketing efforts, and commercializa-
tion of a “kit” in the last decade, [negative pressure wound
therapy, or NWT] is anything but new. The theories that we
know as modern day NPWT were arranged as a convenient
kit of equipment and supplies, presented to the Food and
Drug Administration (FDA), and approved as a device in 1995.
NPWT applies subatmospheric pressure or negative force to
the wound bed by means of a suction unit, dressing, a non-
collapsible, fenestrated evacuation tube, and a transparent
semi-occlusive, vapor-permeable outer dressing or “drape”
and is connected to a collection container. The concept is to
turn an open wound into a controlled, closed wound while re-
moving excess fluid from the wound bed, thus enhancing
30 Healthy Skin
circulation and disposal of cellular waste from the lymphatic
system. It is considered for complex and difficult-to-
manage wounds.
It is hypothesized that NPWT works clinically by removing ex-
cessive interstitial edema, thereby decompressing the small
vessels and restoring local blood flow, removing chronic
wound fluid that contains matrix metalloproteinases (MMPs)
that can inhibit wound healing, and stimulating proliferation of
fibroblasts and endothelial cells and vascular smooth muscle
by mechanically deforming the cells.
The clinical benefits include increasing local blood flow,
decreasing bacterial colonization, facilitating the ability to
measure and assess wound fluid, and increasing the rate of
granulation tissue creation, contraction, and epithelialization.
The wound is additionally uniformly drawn closed by ap-
plying controlled, localized negative pressure. NPWT sup-
ports granulation tissue formation through the promotion of
wound healing.1
Clinical indications:
Who, what, where and when
A thorough assessment should be performed on every pa-
tient considered for NPWT. Generally, NPWT can be consid-
ered in a chronic wound if the wound size decreases by less
than 30 percent after four weeks following debridement
or if excessive exudate cannot be managed effectively with
daily dressing changes. Areas of contemplation include the
patientʼs ability to heal, nutritional assessment together
with albumin/pre-albumin levels, diabetes complications, and
systemic steroid, immunosuppressant, or anticoagulant use.
Patient compliance with dressing changes and follow-up
care are important to determine prior to dressing applica-
tion. Patients with a history of noncompliance with other
dressing regimes should be monitored closely. If the wound is
on a bony prominence, appropriate pressure relieving
and/or offloading measures should be initiated.
NPWT, when ordered by a surgeon or physician medically
directing the patientʼs wound care regime, is deemed
A thorough assessment
appropriate for the following conditions: should be performed on
• Acute wounds
• Partial- and full-thickness burns
every patient considered
• Surgically created wounds and surgical dehiscence— for NPWT.
Patients with other medical problems, i.e., diabetes,
coronary artery disease, and renal disease, may be days, then therapy discontinued before the patient is
more susceptible to wound dehiscence and delayed discharged home.
wound healing. NPWT may provide increased
wound stability. Preparing the wound bed
• Neuropathic (diabetic) ulcers Wounds treated with NPWT should be debrided, cleaned,
• Venous or arterial insufficiency ulcers unresponsive and prepared as with any wound.2 If there is not a large
to standard therapy amount of necrotic tissue present or if gentle cleansing is
• Traumatic wounds (i.e., flap or meshed graft) indicated (pain in or around the wound; clean, granulating
• Pressure ulcers (stage 3 and stage 4). wound bed), a noncytotoxic commercially prepared wound
cleanser can be applied.
Contraindications for NPWT include:
• Necrotic tissue with eschar present if debridement Continued on Page 33
has not been attempted
• Malignant or neoplastic diseases in the wound margin
• Untreated osteomyelitis—The patient should be on
antibiotics to address the underlying infection
• Presence of a fistula to an organ or body cavity
within the cavity of the wound
• NPWT dressings should not be applied directly over
exposed blood vessels or organs.

NPWT can be utilized in a variety of care settings and

applied by any trained, licensed healthcare professional.
The key word here is trained. Failure of NPWT is often due
to inadequate staff education and skill, particularly in
smaller chronic care facilities. Work directly with your man-
ufacturers and distributors to make sure that your staff is
adequately trained, periodically inserviced, and has the
necessary tools to apply and remove the NPWT device
safely and effectively.

Dressing changes should occur routinely every 72 to 120

hours depending on the dressing type, amount of
drainage, and physicianʼs order. In acute care, dressings
are typically changed on Monday, Wednesday, and Friday.
If the wound is infected, however, dressing change
frequency should be increased to every 12 to 24 hours to
assess any changes in wound status. NPWT should not
be off for more than two hours during a 24-hour period as
maceration of the periwound skin can occur. For the home
care patient, always provide an alternative dressing in case
the dressing becomes dislodged or there is a disruption in
electrical power. Dressings over meshed grafts are usually
placed in the operating room, typically left for three to four

Improving Quality of Care Based on CMS Guidelines 31

TenderWet Active
TenderWet Active polyacrylate wound dressings rinse
and debride necrotic wounds for up to 24 hours! Plus,
they won’t stick to the wound bed, reducing patient
discomfort at dressing removal.
TenderWet Active dressings have a “rinsing” effect as
large-molecule proteins found in dead tissue and bacteria
are attracted to TenderWet Active's core. Even under
compression, TenderWet Active can retain large amounts
of fluid.
By debriding necrotic tissue, absorbing and retaining
pathogens and keeping the wound moist, TenderWet
Active helps create an ideal healing environment.
To learn more about TenderWet Active and
Medline’s complete line of advanced wound
care products, call your Medline representative,
visit www.medline.com/woundcare or call
1-800-MEDLINE.

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

than wet gauze therapy because TenderWet Active can be
left in place for up to 24 hours without drying out while
simultaneously providing a barrier against microorganisms.

www.medline.com
 Failure of NPWT is often due to
inadequate staff education and
skill, particularly in smaller
chronic care facilities.
Before placing the dressing, the periwound skin should be
carefully dried and prepared by using a skin prep or by cut-
ting a thin hydrocolloid wafer to the exact shape of the wound.
The actual NPWT packing dressing should be cut to fit the
size and shape of the wound bed, including tunnels and any
undermining. Often, more than one piece is necessary.
Settings
According to expert opinion, the optimal setting for NPWT is
125mmHg.14 Pressures should be continually evaluated
based on changes in wound status. Patients on anticoagu-
lants, the elderly, or emaciated patients should be started at
a lower setting (75 to 100mmHg) then adjusted up as toler-
ated. There is also an option of continuous versus intermit-
tent therapy. Continuous therapy is indicated if there is
significant discomfort during the intermittent therapy mode, if
there are tunnels or undermined areas, if there are high
levels of wound exudate beyond the first 48 hours, or if it is
a difficult site to maintain a seal, e.g., perirectal area,
fingers, or toes. Intermittent therapy (five minutes on/two
minutes off) has been shown to increase granulation
tissue formation.
Sizes, shapes, types and configurations
All suction systems used in the clinical setting have similar
components and mechanisms to provide a vacuum. The
components include a suction drainage device, extension
tubing connecting the drain to an inlet port on the collection
unit, a vessel that provides the source of vacuum, an occlu-
sive or semi-occlusive dressing or drape, and an exit port
through which air is expressed. The factors that vary among
products are drain design, the power source used to create
suction, the dressings, and the method used to control and
contain wound fluid.
Improving Quality of Care Based on CMS Guidelines 33
These systems rely on some form of vacuum pressure to
create suction force. The power that creates a vacuum may
be a manually activated drum or a power-driven pump.
Pumping devices may be stationary, a line-powered pump, or
a portable device. There are currently several sizes and spe-
cial versions of NPWT from which to choose.
References
1. Fox J, Golden G. The use of drains in subcutaneous surgical procedures. The American
Journal of Surgery November 1978;132:573–4.
2. Montgomery BA. Easy dressing of large, draining abdominal wounds using moisture vapor-
permeable film. In: OʼLeary JT, Wontering EA (eds). Techniques for Surgeons. New York, NY:
Wiley and Sons, 1985:417–8.
3. Everett WG. Wound sinus or fistula? In: Wound Care. London, UK: William Heinemann Med-
ical Books Ltd., 1985:84–90.
4. Betancourt S. A method of collecting the effluent from complicated fistula of the small intes-
tine. SG&O 1986;163:375.
5. Clowes GH Jr, George BC, Villee CA Jr, Saravis CA. Muscle proteolysis induced by a circu-
lating peptide in patients with sepsis or trauma. N Engl J Med 1983 Mar 10;308(10):545–52.
6. Chariker ME, Jeter KF, Tintle TE, Bottsford JE. Effective management of incisional and cuta-
neous fistulae with closed suction wound drainage. Contemporary Surgery Jun 1989;34:59–63.
7. Nakayama Y, Soeda S. A new dressing method for free skin grafting in hands. Ann Plast
Surg 1991;26:499–502.
8. Brock W, Barker D, Burns R. Temporary closure of open abdominal wounds: The vacuum
pack. Am Surg 1995;61:30–5.
9. Blackburn J, Boemi L, Hall W, et al. Negative-pressure dressings as a bolster for skin grafts.
Ann Plast Surg 1998;40:453–7.
10. Kostiuchenok I, Kolker V, Karloc V, et al. The vacuum effect in the surgical treatment of pu-
rulent wounds. Vestnik Khirurgil 1986;9:18–21.
11. Argenta L, Morykwas M. Vacuum-assisted closure: A new method for wound control and
treatment: Animal studies and basic foundation. Ann Plast Surg 1997;38:553–62.
12. Joseph E, Hamori CA, Bergman S, et al. A prospective randomized trial of vacuum-assisted
closure versus standard therapy of chronic nonhealing wounds. WOUNDS 2000;12(3):60–7.
13. Fleck CA. Wound bed preparation: The good, the bad, and the ugly. Extended Care Prod-
uct News 2003;86:24–7.
14. Sibbald RG, Mahoney J, the VAC Therapy Canadian Consensus Group. A consensus re-
port of the use of vacuum-assisted closure in chronic, difficult-to-heal wounds. Ost Wound
Manag 2003;49(11):52–66.
15. Krasner DL. Caring for the person experiencing chronic wound pain. In: Krasner DL, Rode-
heaver GT, Sibbald RG (eds). Chronic Wound Care: A Clinical Source Book for Healthcare
Professionals, Third Edition. Wayne, PA: HMP Communications, 2001:79–89.
Adapted from: Fleck CA, Frizzell LD. When negative is positive: a review of neg-
ative pressure wound therapy. Extended Care Product News. 2004;92(2):20-25.
Reprinted with permission.
 Special Guest Editorial
Never Say “Never”
Never Say “Always”
Never Say “Zero”
By Diane L. Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
Introduction
The wound worldʼs abuzz about zero: “Chasing Zero,” “Journey
to Zero,” “Never Events”* and other such slogans abound. But
I propose the opposite stance: Never say “zero” – especially when it
comes to pressure ulcers.
I remember the first time I heard Evonne Fowler, RN, CNS, CWON
say, “Never say ʻnever,ʼ never say ʻalwaysʼ” like it was yesterday. We
were at the first Symposium on Advanced Wound Care, 21 years ago
in Long Beach, California. This powerful phrase opened my eyes and
I would quote Evonne countless times in the intervening years.
So today, I have another phrase to add to the wisdom: Never say
“zero.” Hereʼs why. As of October 1, when the new CMS Inpatient
Hospital Care Present on Admission (POA) Indicators/Hospital-
Acquired Condition (HAC) Ruling goes into full effect, those of us in
the wound care community will be forced to confront the currently pop-
ular notion that zero pressure ulcers should be the target for clinical
outcomes in each and every one of our facilities (infection control
34 Healthy Skin
practitioners will face a similar problem with infections). But should
zero pressure ulcers be set forth as the benchmark, the conceptual
ideal? Are all pressure ulcers avoidable? Is there evidence that pres-
sure ulcers can be “reasonably prevented through the application of
evidence-based guidelines” (wording from the Deficit Reduction Act
2005, DRA Section 5001[c])?
Are all pressure ulcers avoidable?
The pressure ulcer literature contains both qualitative and quantitative
evidence to support the conclusion that not all pressure ulcers are
avoidable. A literature search of the terms “skin failure,” “Kennedy
Terminal Ulcer” and “end-of-life pressure ulcer” will lead you to a grow-
ing body of qualitative literature on skin conditions associated with
end of life. Look for the Preliminary Consensus Statement on Skin
Conditions At Lifeʼs End that is being presented for public comment
and review by the SCALE Expert Panel in fall 2008 (for further
information contact dlkrasner@aol.com).
There is also a growing body of quantitative evidence that suggests
that baseline pressure ulcer incidence rates exist even when
standards of care are met. Dr. David R. Thomas explains:
“
Epidemiological data demonstrates a stability in the incidence of pres-
sure ulcers despite drastic improvement in understanding of pressure
”
ulcers, increased regulatory oversight and improvement in technolo-
gies available for prevention of pressure ulcers …. No intervention
strategy has been reported that consistently and reproducibly reduces
the incidence of pressure ulcers to zero …. The published data on
prevention of pressure ulcers does not support an assumption that all
pressure ulcers are preventable.1
“
In an article by Bennett et al titled “The Increasing Medical
Malpractice Risk Related to Pressure Ulcers in the United States,”
”
the authors state:
Most facilities will have stable prevalence and incidence rates. Hospital
prevalence rates of 1-2% and nursing home prevalence rates of 5 to
10% occur typically in well run institutions with vigorous monitoring
“
programs.2
”
Dr. Jeffrey Levine recently wrote the following in a two-part series
addressing the new CMS ruling:
One of the issues challenging Medicare is that all pressure ulcers are
not avoidable, and it is unclear at this time which criteria will be used
to deem them as such.3
If evidence suggests that baseline prevalence and incidence rates
exist and that not all pressure ulcers are avoidable, benchmarking to
zero pressure ulcers is neither evidence-based nor evidence-informed
practice.
The legal implications of zero
Pressure ulcer litigation is on the rise and legal experts expect it to in-
crease further once the HAC/POA ruling goes into full effect, just as it
increased after the OBRA Ruling in 1987.2 From a legal perspective,
benchmarking to zero can be disastrous – when it comes to human
behavior, zero anything is rare.
If a facility sets a goal of zero pressure ulcers, how do you explain
and defend the facility when a pressure ulcer does occur? A more pru-
dent approach from the legal perspective is to assume a certain base
prevalence and incidence of pressure ulcers in a facility and to ana-
lyze data on a regular basis to assure that the base prevalence and
incidence rates remain consistent. Facility-based prevalence and in-
cidence rates can be extremely variable, depending on the patient
population, admitting patterns and catchment area. You should know
your facilityʼs base prevalence and incidence rates – just like you know
your own Social Security number. If the prevalence goes up, a root
cause analysis should be done and interventions put into place to ad-
Improving Quality of Care Based on CMS Guidelines 35
dress any identified problems. Additionally, on an individual basis,
each facility should put a plan in place to demonstrate an individual
patientʼs risk factors and comorbidities.4 This documentation, coupled
with a pressure ulcer policy and procedure that meets national and
setting-specific standards of care, will go a long way toward protect-
ing your facility from litigation.5
So, in conclusion, remember: Never say “never,” never say “always”
and never say “zero.”
* The IPPS FY 2008 Final Ruleʼs inclusion of “serious preventable
events,” also known as “never events,” included three such events:
object left during surgery, air embolism and blood incompatibility. Note
that pressure ulcers were not designated as “never events.”
References
1 Thomas DR. Are all pressure ulcers avoidable? JAMA. 2001;2(6):297-301.
2 Bennett RG, OʼSullivan JO, DeVito EM. The increasing medical malpractice risk related
to pressure ulcers in the United States. JAGS. 2000;48:73-81.
3 Levine JM. Preparing for the new Medicare Reimbursement Guidelines: Part II – Doc-
umentation of Altered Skin Integrity in the Hospital. Clinical Geriatrics. 2008 July: 17-20.
4 Stotts NA, Wipke-Tevis D, Hopf HW. Co-factors in impaired wound healing. In Krasner
DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for
Healthcare Professionals. 4th ed. Malvern, Pa: HMP Communications; 2007.
5 Krasner DL. Safeguarding your wound and skin care practice from litigation. ECPN.
2007 April: 28-32.
About the author
Dr. Diane L. Krasner is a board certified wound specialist with extensive ex-
perience in wound, ostomy and incontinence care. She is a Fellow of the Amer-
ican Academy of Nursing. Dr. Krasner is a wound and skin care consultant in
York, Pennsylvania and works part-time at Rest Haven - York as the
WOCN/Special Projects Nurse.
Dr. Krasner is the lead co-editor of Chronic Wound Care: A Clinical Source
Book for Healthcare Professionals (4th edition, 2007, HMP Communications).
She currently serves on the editorial boards of WOUNDS, Kestrel Wound
Product Sourcebook, The International Journal of Wound Care and World
Wide Wounds. Since 1992, Dr. Krasner has served on the board of Directors
and as an officer of several national wound care organizations, including the
American Academy of Wound Management, the Association for the Advance-
ment of Wound Care and the National Pressure Ulcer Advisory Panel.
36 Healthy Skin
 Treatment

By Eva Russell,
RN, BS, CWS, FACCWS, CHPN

Wound care for terminally ill patients can be

complex and challenging. The goals for termi-
nally ill patients with wounds are to alleviate
symptoms such as pain and odor, manage
exudate, prevent deterioration of the wound and
enhance quality of life.

lia tiv e Palliative wound care follows the guidelines set

Pal forth by the National Pressure Ulcer Advisory
Panel (NPUAP), the Agency for Healthcare

W o u n d Research and Quality (AHRQ) and Wound,

Ostomy and Continence Nurses Society (WOCN).

Guidelines for wound care include:

Care • Assessment
• Treatment based on moist wound healing1
• Debridement if appropriate2
ar e goals • Appropriate support surface selection
if e c • Prevention
End-of-l
• Nutrition
• Monitoring and documentation

Tools for care

The Pressure Ulcer Scale for Healing (PUSH
Tool, version 3) is one of two evidence-based
tools proven valid and reliable. The PUSH tool
was developed by the NPUAP as a “quick
reliable tool to monitor the changes in pressure
ulcers over time.”3

The other-evidence based tool is the Bates-

Jensen Wound Status Tool (originally known as
the Pressure Sore Status Tool), developed by Dr.
Barbara Bates-Jensen.4 These tools provide
all the essential components for assessment,
monitoring and documentation.

Wound care for the dying patient may not be an

option or may impair quality of life if pain and
repositioning for the patient is not done with care.
However, providing curative wound care may

Improving Quality of Care Based on CMS Guidelines 37

 lead to wound healing, even among terminal patients.5 Initial
assessment should include identifying the type of wound and
correcting or modifying the causes of tissue damage.6
Addressing complications
Complex wounds, such as fungating tumor wounds, occur as
skin and supporting blood and lymph vessels are infiltrated by a
local tumor or spread from a primary tumor. These wounds can
be quite challenging because it is difficult to predict their course.
They are often highly vascular and bleeding can be an issue.
Using calcium alginate for its hemostatic properties can be
effective and having topical powder bandage on hand to stop
bleeding is helpful. Secondary dressings for these wounds can
be difficult and knowing which products are available is invalu-
able. This can be creative nursing at its best.
The goals for terminally ill patients with
wounds are to alleviate symptoms such
as pain and odor, manage exudate,
prevent deterioration of the wound and
enhance quality of life.
Edema is another challenge frequently seen in terminally ill
patients and can compromise wound management. Diuretics
and corticosteroids can reduce edema, depending on the cause.
Exudate management is vital; using foams and highly absorbent
products can prevent wound and skin deterioration.
Pain is often undertreated and needs to be the first consideration
in wound care.5 Use of analgesics and opioids should be based
on pain severity and type of pain (whether pain is nociceptive –
somatic or visceral – or neuropathic). Another consideration is
whether the patient is opioid naïve or has an analgesic history.
The use of adjuvants such as tricyclic antidepressants, corticos-
teroids, non-steroidal antiinflammatories, neuroleptics, antihista-
mine, anticonvulsants and calcitonin for pain management are
often overlooked and can enhance traditional analgesics.
Debridement is often underutilized in terminal patients as it may
be seen as aggressive treatment. Debridement is the removal
of necrotic tissue, exudate and metabolic waste from a wound to
improve or facilitate the healing process.2 Removing necrotic
tissue and slough also reduces odor and must occur for healing
to take place. Necrotic tissue can present as moist yellow, green
38 Healthy Skin
or gray tissue or as black eschar. Tissue that is moist yellow and
stringy is usually referred to as slough. The most common
types of wound debridement include sharp/surgical, mechanical,
autolysis, polyacrylate and enzymatic agents.
There are also other forms of debridement, including maggot
therapy, high-pressure fluid irrigation and ultrasonic mist, which
are typically not used in palliative wound care.7 Once necrotic
tissue is removed and the wound bed is pink or beefy red, odor
will be greatly reduced and exudate will be diminished.
The AHRQ guidelines discourage debridement of dry, stable
eschar ulcers of the heel if there are no signs of edema,
erythema or drainage.8 Treatment can include skin prep to the
necrotic area and wrapping the foot with gauze or bandages and
elevating the heel to eliminate pressure. Evaluation of the heel
should occur every two to
three days for any changes.
An effective treatment to
reduce odor before debride-
ment is completed is the use of
metronidazole, an anti-infec-
tive. Kalinski et al showed a
significant response, (100 per-
cent in odor elimination) with
10 patients on a 14-day treatment duration with odor reduc-
tion response on day one.9 Metronidazole can be ordered in gel
form for dry wounds or powder form for moist wounds from a
compounding pharmacy or capsules can be crushed and placed
on the necrotic areas of the wound bed. Silver dressings can
also be effective at reducing odor, as they are bacteriostatic.
Evaluating support surfaces
Support surfaces should be selected based on the needs of the
patient for prevention, treatment and comfort. There are multiple
support surfaces for beds and seating. Factors to consider are
pressure, friction, shear, weight of the patient, presence of a
wound and cost. The most common pressure-reducing support
surfaces are foam, gel, alternating pressure, fluid-filled, low-air-
loss and air-fluidized beds.2 Comfort of the patient should be a
primary consideration for palliative care.
Nutritional needs
Nutritional needs for palliative and terminal patients vary greatly.
Decreased protein intake, muscle wasting, immunosuppression
and dehydration increase a patientʼs risk for developing pressure
ulcers. Encouraging small, frequent meals that include protein,
providing sips of preferred fluid throughout the day and offering
any snacks that are tolerated are suggested for this patient
population.

Many wounds can heal at the end of life when wound care guide-
lines are followed. Wound care is essential in providing effective
palliative care for terminally ill patients with existing or developing
wounds.5 While nurses may not change a terminal prognosis
with optimal wound care, they can make a positive impact on
Continue your CE
patient comfort and quality of life.
coursework at

References
Medline
1 Bolten L. Operational definition of moist wound healing. Journal Wound Ostomy University
Continence Nurs. 2007;34:23-29.
2 Baranowski S, Ayello EA. Wound Care Essentials: Practice Principles. Philadelphia,
Pa. Lippincott Williams & Wilkins; 2004.
Courses you can attend at any
time, from anywhere you have
3 National Pressure Ulcer Advisory Panel. PUSH Tool Information & Registration
Form. Available at: http://www.npuap.org/archive/pushins.htm. Accessed August 27,
2008. Internet access.
4 Bates-Jensen B. Quality indicators for prevention and management of pressure

Medline University offers more

ulcers in vulnerable elders. Annals of Internal Medicine. 2001;135:744-751.
5 Hughes RG, Bakos AD, OʼMara A, Kovner CT. Palliative wound care at the end of
life. Home Health Management & Practice. 2005; 17:196-202. than 50 self-study nursing
6 Kirshen C, Woo K, Ayello EA, Sibbald RG. Debridement: a vital component of
CE-credit courses.
wound bed preparation. Advances in Skin & Wound Care. 2006; 19: 506-517.
7 Gray M. Is larval (maggot) debridement effective for removal of necrotic tissue
from chronic wounds? Journal Wound Ostomy Continence Nurs. 2008;35:378-384. An affordable online resource.
8 Agency for Healthcare Research & Quality. Treatment of pressure ulcers, clinical
Visit www.medlineuniversity.com
practice guideline No 15. U.S. Dept of Health & Human Services, AHCPR Publication
No.95-0652. Rockville, MD; 1994.
9 Kalinski C, Schnepf M, Laboy D, et al. Effectiveness of a topical formulation con-
taining metronidazole for wound odor and exudates control. Wounds. 2005; 17:84-90.

About the author

Eva Russell, RN, BS, FACCWS, CWS, CHPN is the Director of
Nursing at Samaritan Hospice in Marlton, New Jersey. As a wound
care specialist and certified hospice and palliative care nurse, Eva
has developed palliative wound care policies and protocols and a
wound care team at Samaritan Hospice to enhance end-of-life care.
She is a fellow of the American College of Wound Care Specialists
and is currently pursuing her MSN at Walden University.

Improving Quality of Care Based on CMS Guidelines 39

 Treatment

End-of-Life Care
for Residents and
Their Families
Guidance for clinicians

By Megan Schramm, RN, CNOR, RNFA

Dying is the final portion of the life cycle for all of us. Providing humane care to
persons near the end of life is an essential part of medicine.1 Just because the healthcare
team has determined that the illness or disease process can no longer be controlled
and medical treatment should be halted does not mean that the patient no longer
requires care.2 Every effort must be made to ensure that a resident's last days are
spent in as much comfort and dignity as possible and according to the residentʼs
wishes. 1 Although it is natural and happens to everyone, many caregivers are
uncomfortable with death and do not have the proper training on how to deal with
residents who are in this final stage of life.3 The following are guidelines and tools for
clinicians to use as they help residents and families through this difficult time.

In the final hours of life, care providers must be the support system for both the resident
and their family. They not only provide physical care to the patient, but also act as
educators and advocates, offering calm and empathetic reassurance that is critical to
helping residents and families at this time. Clinical issues that often occur include the
management of feeding and hydration, changes in consciousness, delirium, pain,
breathlessness and secretions. These concerns are dealt with in similar fashions in
both the institutional and home healthcare settings. However, matters such as
assuring privacy, cultural observances and communication can be more difficult in
the institutional setting. In anticipation of the event, it is imperative to inform the family
and other members of the healthcare team about what to do and what to expect. Care
does not end until the family has been supported with their grief reactions and those
with complicated grief have been assisted in receiving care.3

About the author

Megan Schramm, RN, CNOR, RNFA, currently a clinical nurse
consultant, has been an RN for more than 10 years. Previously,
she worked as a nurse at a number of acute care facilities and
trauma centers.

References
1 Lipson S. End of life care: A guide for seniors and caregivers. Available at:
www.americangeriatrics.org/education/forum/endoflife.shtml. Accessed September 3, 2008.
2 National Cancer Institute. End-of-Life Care: Questions and Answers. Available at: http://www.cancer.gov/
cancertopics/factsheet/Support/end-of-life-care. Accessed September 3, 2008.
3 Yox S (ed). The last hours of living: Practical advice for clinicians. Available at:
www.medscape.com/viewarticle/542262. Accessed September 2, 2008.

40 Healthy Skin
Resident status: What to look for3
• Decreasing function
• Poor hygiene
• Tired all the time
• Bruising over bony prominences
• Skin breakdown, wounds that donʼt heal
• Anorexia
• Poor food intake, “just not hungry”
• Aspiration
• Peripheral edema
• Dehydration
• Tachycardia
• Hypertension followed by hypotension
• Cooling of the peripheries
• Bluing or cyanosis of the extremities
• Mottling of the skin (livedo reticularis)
• Dark urine followed by anuria
• Increased drowsiness
• Difficulty awakening
• Unresponsive to verbal and then tactile stimuli
• Verbally unresponsive or delayed and inappropriate responses
• Early signs of cognitive failure (for example, day and night reversal)
• Agitation, restlessness
• Purposeless, repetitious movements
• Moaning, groaning
• Change in respiratory rate: more rapid at first and then slowing
• Decreased tidal volume
• Abnormal breathing patterns: Apnea, Cheyne-Stokes respirations,
agonal respirations
• Loss of the ability to swallow
• Incontinence of bowel and bladder
• Facial grimacing
• Loss of the ability to close oneʼs eyes

Rare, unexpected events3

• Bursts of energy just before death; the “golden glow”

Guidelines for communicating with family3

• Talk to the family in the appropriate setting: Bring the family to a
private area, such as a conference room, where personal information
can be shared and they are free to share their feelings and emotions.
• Ask what they understand: Make sure everyone is up to date on the
status of their loved one.
• Tell the news: Be polite but donʼt try to “sugarcoat” the news.
Come right to the point.
• Respond to their emotions with empathy: Families will express a
wide variety of feelings: sadness, anger, relief. Let them know it is
okay to feel the way they do.
• Conclude with a plan: Help the family to make arrangements such
as funeral, financial or care of a spouse.

Improving Quality of Care Based on CMS Guidelines 41

 Rest assured
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1232 hi-low bed no matter the height. Staff aren’t forced to use

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Risk managers value the built-in battery back-up system that

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Residents love the comfort and style of the Alterra 1232 hi-low
bed by Medline.

Additional features:
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www.medline.com

By Jayne Barkman, RN, BSN, CNOR
Brianna and Monica drove to the back of Shady Oak
Long-Term Care Facility and got out of the car. They
spent a few minutes gazing at the lake and taking in the
serene environment before locking arms and walking
through the door. Today, after signing the appropriate
paperwork, they would officially change their employment
status at Shady Oak from nursing assistants to gradu-
ate nurses.
They were halfway down the hallway to the Director of Nurs-
ingʼs office when they heard heart-wrenching sobs coming
from Sophiaʼs room. Sophia, a sweet lady in her mid-seventies,
had been a resident at Shady Oak for several years and had
endeared herself to Brianna and Monica. They stopped,
looked at each other and knocked softly on Sophiaʼs door.
They entered Sophiaʼs room to find her lying in bed sobbing
uncontrollably while gasping for air. Brianna gently grasped
Sophiaʼs hand while Monica instructed Sophia to take some
slow, deep breaths. When her breathing was controlled,
Monica asked Sophia why she was crying.
Sophia said she was scared because she had fluid in her
lungs and needed to go to the hospital. She went on to say
that she didnʼt want to go to the hospital because when her
friend Nona went to the hospital she got sick and
never returned to Shady Oak. Sophia then started wailing
that she didnʼt want to go to the hospital and she didnʼt want
to die. Monica again told Sophia to take some slow, deep
Improving Quality of Care Based on CMS Guidelines 43
Prevention
The Transfer
Challenge
Minimize fear,
facilitate communication
breaths. When she started to relax, they explained to Sophia
that she needed to go to the hospital so they could do tests,
including a chest X-ray, so she could get medication that
would help the fluid in her lungs go away.
Sophia asked Brianna and Monica to go with her to the hos-
pital. They explained they could not go with her, but reas-
sured her that she would receive excellent care. The
transport team arrived and rolled a stretcher into Sophiaʼs
room. The nurse on duty handed the transport team had a
copy of Sophiaʼs record as well as the nursing notes and
medication record while Brianna and Monica assisted the
team in moving Sophia onto the stretcher. As she was being
wheeled out the door, the girls reiterated to Sophia she
would receive wonderful care at the hospital and they would
see her soon.
Improving transfers
Residents of long-term care facilities are diverse in age and
primary diagnosis. Common reasons for these residents to
be transferred to acute care facilities include pneumonia,
influenza, urinary tract infections, fluid volume depletion,
heart failure and injury. According to a literature review, eld-
erly residents of long-term care facilities are most vulnerable
when transferred to an acute care facility for treatment
because of physical and or cognitive impairments that place
the elderly population at risk for developing complications
such as delirium, pressure ulcers or a functional decline dur-
 ing hospitalizations. Approximately 25 percent of elderly
long-term care residents are hospitalized annually and 12
percent of this population will die during their acute care stay.

When a resident requires acute care, explaining why the

hospitalization is needed as well as what to expect in the
hospital – along with reassurance that good care will be
provided – will help minimize the residentʼs fears. A report-
ing tool, such as a standardized form or checklist, should be
used when transferring a resident to verify that all pertinent Reference
information about the resident is provided during the transfer 1 Malone M, Danto-Nocton E. Improving the hospital care of nursing facility residents.

to facilitate communication between the long-term and acute

Annals of Long Term Care: Clinical Care and Aging. 2004;12(5):42-49.

care facilities regarding the condition and needs of the resident.

If your facility does not have a checklist or a similar reporting
tool that is used when a resident is transferred from your facility
or to your facility, ensure you have the information listed below.
About the author
Jayne Barkman, RN, BSN, CNOR, has 29 years of perioperative
experience in various roles, including surgical technologist, staff
nurse and clinical educator. She currently works as a clinical
nurse consultant.

When transferring a resident to an acute care
facility, provide1:
• A written description of the acute problem and
chief complaint
• Current vital signs
• Current medication administration record (not the
monthly computerized orders)
• List of resident allergies
• Recent nursing notes
• Progress notes from the physician, physician assistant
or nurse practitioner
• Recent laboratory and diagnostic test results
• Status of skin integrity and pressure ulcers
• Information on what comforts and agitates the resident
• Family and/or emergency contact information for
the resident
When receiving a resident from an acute care
facility, obtain:
• Summary of the hospital admission
• Procedures performed
• Laboratory and test results
• Updated list of medications, including discontinued meds
• Follow-up appointments, suture removal or dressing
changes the resident may need
• Status of surgical wounds or pressure ulcers
• Dietary changes, supplemental oxygen, pain control
or specialized equipment needed for the resident

44 Healthy Skin
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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 Debridement, Pain and Odor Control
Using a Hydrogel with a Superabsorbent
Polymer Core Dressing*
Problem
Analysis of our wound healing rates
with the digital planimetry** wound
tracking program revealed we were
debriding wounds anywhere from five
to 10 weeks. There were significant
complaints of wound pain and peri-
wound damage with our current
debridement methods.
Methodology
Current methodology methods
included alginates, gels, enzymes and
an occasional surgical debridement. A
new hydrogel dressing* comprising a
knitted polyprylene fabric cover with
an absorbent core containing super-
absorbent polymers, saturated with
Ringerʼs solution, was utilized. The
pres-saturated pads come in different
sizes and styles. The pad was placed
on the wound and covered with a
secondary dressing and changed
every day and as needed if soiling or
strikethrough occurred.
Rationale
Maintaining a moist wound environ-
ment will facilitate debridement of
necrotic tissue through autolysis or
“autolytic” debridement. Ringerʼs solu-
tion is isotonic and skin friendly,
containing sodium, potassium, cal-
cium and chloride. Wound odor often
increases with necrotic tissue and can
be offensive to the patient and staff.
Outcomes
All patients showed significant
improvement in seven to 10 days with
softening and liquefication of necrotic
tissue. All the wounds were debrided
in four weeks. There were no com-
plaints of pain or other complications.
Once the wound bed was prepped,
the patients were advanced to another
dressing.
46 Healthy Skin
Case study: MR
MR is an 87-year-old male who presents with a
Stage IV pressure ulcer on his sacrum. Other med-
ical diagnoses include diabetes, PDV, dementia,
HTN and malnutrition. MR was admitted from the
hospital on May 8, 2007 with this chronic sacral
pressure ulcer. The wound measured 9.1 cm x 5.3 Sacrum 5/8/07
cm by 0.1 cm with a thin layer of yellow slough and
a nongranular wound bed. The periwound skin was
indurated with rolled edges. The hydrogel super-
absorbent polymer core dressing was used to treat
the wound; the periwound skin was treated with
Olivamine-containing repair cream.*** Diapulse
treatment with six peak power by 600 frequency for
Sacrum 7/10/07
30 minutes six days per week was also performed.
On July 10, 2007, the wound showed significant
progress and edges were starting to advance. Sig-
nificant improvement was also noted on the peri-
wound skin. Because of the continued progress,
the wound care team felt that the current treatment
regimen should continue. The wound was resolved
on November 13, 2007. Sacrum 11/13/07 resolved ulcer
Case study: TM
This 69-year-old female was admitted on May 24,
2007 with diagnoses including a CVA with right
hemiplegia, dementia, diabetes, Parkinsonʼs dis-
ease, a Stage IV pressure ulcer on the left heel and
a Stage IV sacral pressure ulcer. The sacral pres-
sure ulcer measured 4 cm x 6 cm c 3 cm with pres-
Sacrum 5/29/07
ence of necrotic slough and significant erythema to
the periwound skin. The inner wound bed had
brownish necrotic tissue. The initial treatment in-
cluded irrigating the wound with an antimicrobial
cleanser**** and the hydrogel superabsorbent
polymer core dressing. The periwound skin was
protected with the Olivamine-containing repair
cream.*** By May 29, 2007, the sacral wound bed Sacrum 10/9/07
had significant granulating tissue, limited scattered
yellow slough and the periwound with no erythema.
By November 30, 2007, the sacral pressure ulcer
was decreased in size to 1 cm x 1 cm x 0.4 cm.
Carline Joseph, RN, ANP, Anne Captain, PTA, Paul Rosenstock, MD,
Kay Gittens CNA, Phyllis Quinlan, MSN DON
Sephardic Nursing Center
Brooklyn, NY
Elizabeth OʼConnell-Gifford, MBA, BSN, RN, CWOCN, DAPWCA
Medline Industries, Inc.
Berne, NY
Case study: NH
NH is a 76-year-old bedbound female who pres-
ents with diagnoses of Alzheimerʼs, CAD, HTN and
breast cancer with left mastectomy. She is at high
risk for the development of pressure ulcers and
presents with multiple pressure ulcers, including a
necrotic tissue-filled sacral wound. The initial treat-
ment included cleansing the wound and various
treatments of silver sulfadiazine cream, Miconazole
cream and an enzymatic debriding agent.***** On
October 23, 2007, the wound care team observed
significant change in the sacral pressure ulcer with
induration and increase in necrotic tissue. Treat-
ment was changed to the hydrogel with a super-
absorbent polymer core dressing, diapulse
treatment and antibiotic coverage. On November
13, 2007, the sacral pressure ulcer was filled with
granulation tissue.
Case study: LG
LG is a 75-year-old male who was admitted with
diagnoses of CAD, renal failure, sacral pressure
ulcer and bilateral BKA with multiple surgical
wounds to the right stump. The sacral pressure
ulcer measured 15 cm x 10 cm x 3 cm with yellow-
ish-grayish slough. The initial treatment included
hydrogel superabsorbent polymer core dressing
and protecting the periwound skin with an Oli-
vamine-containing zinc barrier paste.****** Dia-
pulse treatment of six peak power by 600
frequency for 30 minutes six days per week was
also performed. On May 19, 2007, the sacral pres-
sure ulcer was re-evaluated and improvement was
observed with a decreased amount of necrotic yel-
low slough and treatment continued. By May 29,
2007, the sacral pressure ulcer measured 12 cm x
8 cm x 0.6 cm. On June 6, 2007, the dressing was
changed to an antimicrobial dressing as the wound
was thought to have a high bacteria load. On
March 11, 2008, the sacral wound was progress-
ing well.
CASE STUDY
Conclusion
This polyacrylate pad not only main-
tained a moist environment, it also
a b s o r b e d e x u d a t e a n d o d o r,
d e creased pain in the wound bed and
was non-irritating to the periwound
skin. The digital planimetry improved
the way we document our wound
Sacrum 10/23/07
progress and brought our wound team
closer together.
References
1 Brugisser R. Bacterial and fungal absorption
properties of a hydrogel dressing with a super
absorbent polymer core. J Wound Care.
2005;14(9).
2 Konig et al. Enzymatic versus autolytic
Sacrum 11/13/07 debridement of chronic leg ulcers: a prospective
randomized trial. J Wound Care. 2005;14(7).
3 Paustian C, Stegman MR. Preparing the
wound for healing: the effect of activated
polyacrylate dressings on debridement.
Ostomy/Wound Management. 2003;49(9):34-43.
* TenderWet from Medline Industries, Inc.,
Mundelein, IL
** PictZar Digital Imaging by BioVisual
Technologies Inc., Brooklyn, NY
*** Microklenz from Carrington Laboratories,
Inc., Irving, TX
**** Remedy Skin Repair Cream from
Medline Industries, Inc., Mundelein, IL
***** Remedy Calazime from Medline Industries,
Sacrum 5/19/07 Inc., Mundelein, IL
****** Accuzyme from Healthpoint, Fort Worth, TX
Sacrum 5/29/07
Sacrum 3/11/08
Improving Quality of Care Based on CMS Guidelines 47
 Streptococcus

Infection Control:

PNEUMONIA
Overview
Pneumonia is a common infection and a major cause of morbidity, mortality and
hospitalization among nursing home residents.1,2 It is especially common in
winter and early spring months when respiratory diseases are prevalent.3 The
most common cause of bacterial pneumonia in LTC residents is Streptococcus
pneumoniae. Other bacterial causes of pneumonia include Chlamydia pneumo-
niae, Legionella pneumophila, and Mycoplasma pneumoniae. Respiratory viruses
such as Influenza virus can also cause pneumonia.4

48 Healthy Skin

Careful selection and use of antibiotics is an important
strategy for discouraging the emergence of antibiotic
resistant bacteria.6,7 Today, bacterial resistance to flouro-
quinolones is seen more commonly among nursing home
residents than among the community-dwelling elderly popula-
tion.5 Antibiotic resistance is encountered in the treatment of
pneumonia. In particular, Strep. pneumoniae strains have
become increasingly resistant to antibiotics such as penicillin,
erythromycin, trimethoprim-sulfamethoxazole, cephalosporins,
and fluoroquinolones.4 The significance of bacterial resistance
to antibiotics is that treatment of infections caused by such
bacteria can entail the use of multiple antibioitics and may
require hospitalization.
Outbreak prevention and control
To prevent pneumonia, follow the steps below:
1. Identify residents at risk. These are residents who:1,2,9,10,11
• Are older
• Live in close proximity to others
• Are confined to bed
• Have had a recent hospitalization
• Experience episodes of aspiration (Residents with
dementia, stroke, or feeding tubes are particularly
at risk.)
• Develop viral respiratory infections, especially Influenza.
• Have certain chronic conditions
– Pulmonary diseases such as asthma, bronchitis,
– ephesema, bronchiectasis, as well as those who smoke
– Heart disease
– Alcoholism
– Malnutrition
– Immunosuppression
2. Immunize these residents with polyvalent
Streptococcal vaccine.6,8
3. Reduce opportunities for transmission by separating
residents with symptoms of active pneumonia from
asymptomatic residents at risk of becoming infected.
Practical guide to quality improvement
Effective infection control is essential for preventing transmission
and outbreaks of pneumonia.
Improving Quality of Care Based on CMS Guidelines 49
Prevention
Part 1: Vaccination against Pneumococcal pneumonia
1. Develop an administrative framework for vaccination.
a.Designate a single person to be responsible for
the nursing home's vaccination plan (e.g., your
infection control practitioner).
b.Establish standing orders for pneumococcal
vaccination.4
c. Develop written policies covering vaccine
administration for residents.
2. Establish a vaccination program using the ACIP
vaccination algorithm for all residents.
a.Seek consent from the resident or family member
to provide vaccination at admission. Give the
vaccination to residents aged >65 years upon
admission when4:
– There is no prior documentation of pneumococcal
vaccination.
– Prior vaccination was administered when the resident
was <65 years of age and >5 years have elapsed
since first dose.
3. Use the time of yearly influenza vaccination as an opportunity
to identify residents in need of the pneumococcal vaccine.4
Keep in mind that the influenza vaccine is administered
yearly, whereas the pneumoccocal vaccine is most often
given only once.4Administering both vaccines together
is safe.
4. Keep resident vaccination records available and up to date.
5. Use a centralized vaccination log in addition to recording
vaccination information in a part of your clinical record that
will not be thinned.
Part II: Organizational strategies for treatment
and outbreak control
Although pneumonia outbreaks are uncommon, they have
occurred in nursing homes with low vaccination rates.6,8 Use
active surveillance to identify outbreaks, and have a plan for
controlling the spread of infection should an outbreak occur in
your facility.
1. Develop a written policy for managing a pneumonia
outbreak. This policy should:
a.State your specific activities for pneumonia surveillance.
Continued

b.State the criteria for pneumonia diagnosis (e.g.,
confirmation by cultures of blood or pleural fluid).7
c. State the criteria for cluster identification (e.g., finding
three people on the same ward who have developed
pneumonia-like symptoms).
d.Assign responsibility for outbreak management to a
particular individual (e.g., your infection control
practitioner).
e.Develop isolation standards for the occurrence
of pneumonia.
2. Use routine surveillance to detect pneumonia outbreaks
early. Look for residents with pneumonia-like symptoms.13
a.Single shaking chill
b.Fever
c. Pain with breathing
d.Sputum producing cough (may be dry initially)
e.Dyspnea
3. Notify the facility medical director whenever there is a
suspected case of pneumonia.
4. Develop and maintain a complete infection control record
of suspected cases, including:
a.Name, age, and sex.
b.Influenza and pneumococcal vaccination status.
c. Date of symptom onset.
d.Date personal physician notified.
e.Room location (i.e., wing, floor, and room number).
f. Major underlying medical conditions.
g.Initial signs and symptoms (e.g., temperature, pulse,
respirations, etc).
h.Diagnostic results (e.g., chest x-ray, lab results).
i. Interventions and treatments provided.
j. Outcome.
Be sure to check out our Form & Tool
on pneumonia control on Page 86!
50 Healthy Skin
Influenza
References
1 Vergis EN, Brennen C, Wagener M et al. Pneumonia in long-term care: A
prospective case-control study of risk factors and impact on survival. Archives of
Internal Medicine. 2001;161(19):2378-81.
2 Muder RR. Pneumonia in residents of long-term care facilities: Epidemiology,
etiology, management, and prevention. American Journal of Medicine.
1998;105(4):319-30.
3 Pneumococcal disease. In: Centers for Disease Control and Prevention. Epi-
demiology and Prevention of Vaccine-Preventable Diseases, 7th Edition (The
Pink Book). Atlanta, GA. 2003.
4 Centers for Disease Control and Prevention. Prevention of pneumococcal dis-
ease: Recommendations of the advisory committee on immunization practices
(ACIP). Morbidity and Mortality Weekly Report. 1997;46(RR-8):1-25.
5 Kupronis BA, Richards CL, Whitney CG, Active Bacterial Core Surveillance
Team. Invasive pneumococcal disease in older adults residing in long-term care
facilities and in the community. Journal of the American Geriatrics Society.
2003;51(11):1520-25.
6 Nuorti JP, Butler JC, Crutcher JM et al. An outbreak of multidrug-resistant pneu-
mococcal pneumonia and bacteremia among unvaccinated nursing home resi-
dents. New England Journal of Medicine. 1998;338(26):1861-68.
7 Palleres R. Treatment of pneumococcal pneumonia. Seminars in Respiratory
Infections. 1999;14(3):276-84.
8 Centers for Disease Control. Outbreak of pneumococcal pneumonia among un-
vaccinated residents of a nursing home - New Jersey, April 2001. Morbidity and
Mortality Weekly. 2001;50(33):707-10.
9 Musher DM. Pneumococcal pneumonia including diagnosis and therapy of in-
fection caused by Penicillin resistant strains. Infectious Disease Clinics of North
America. 1991;5(3):509-21.
10 National Institute of Allergy and Infectious Diseases. Fact Sheet: Pneumococ-
cal Pneumonia. August 2001.
11 ReichmuthKJ, Meyer KC. Management of community-acquired pneumonia in
the elderly. Annals of Long-Term Care. 2003;11(7):27-31.
12 Bernstein JM. Treatment of community-acquired pneumonia-IDSA guidelines.
Chest. 1999;115(3):9S-13S.
13 Pneumococcal pneumonia. In: Beers MH, Berkow R, eds. The Merck Manual
of Diagnosis and Therapy. 17th edition. Merck & Co. 2003.
14 Centers for Medicare and Medicaid Services. New Pneumonia Guidelines
Can Improve Care. 9/8/00.
15 Centers for Medicare and Medicaid. Pneumonia National Project Overview.
Reprinted with permission from the Texas Department of Aging and Disability
Services.
 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.

©2008 Medline Industries, Inc. Medline and Silvertouch are registered trademarks of Medline Industries, Inc. www.medline.com
For all the lives you touch.

Now more than ever, hand hygiene compliance is crucial. The Hand Hygiene Compliance Program includes:
Beginning October 1, 2008, the Centers for Medicare & • An instructor’s manual that takes the guesswork out of
Medicaid Services will no longer be reimbursing for eight planning lessons
hospital-acquired conditions, including urinary tract, surgical • A customizable plug-and-play CD that contains
site and bloodstream infections.1 We know that hand presentations, posters and more
hygiene is the number one line of defense against hospital- • Forms and tools to serve as reminders and reinforcements
acquired infections.2 • A cost calculator to help you determine the cost of
prevention vs. the cost of an infection
There’s no such thing as • A rewards program to recognize those who complete
“overeducating” when it the course
comes to hand hygiene. • Patient and family education materials
Enhance your current • CE-credit courses for staff
strategy with Medline’s • A how-to guide on enhancing your presentation skills
Hand Hygiene
Compliance Program! For an on-site presentation of the Hand Hygiene
Compliance Program and our Healthy Hands Product
Bundle, contact your Medline representative or visit
www.medline.com/handhygiene.
References
1 Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal
year 2007 rates. Available at: www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf. Accessed November 20, 2007.

www.medline.com
2 Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Healthcare Purchasing News. Available at:
http://www.hpnonline.com/inside/2003-11/1103hygiene.htm. Accessed November 20, 2007.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Recommendations
on Infection Prevention
in Long-Term Care
In May 2008, the Association for Professionals in Infection
Control and Epidemiology (APIC) issued five steps every
resident and their family can take to become their own
advocate and reduce the risk of developing an infection
during a facility stay.
1. Infection Prevention and Control Program
Ask the long-term care facility (LTCF)/nursing home about their
infection prevention and control program. Talk with the assigned
infection prevention and control professional (ICP). Discuss the
strategies in place in the facility for infection prevention.
2. Hand Hygiene
Germs may be present on a resident, visitor and/or staff and
also on many surfaces in healthcare facilities including bed
rails, over-bed tables, wheelchairs, walkers, faucets and even
the TV remote control. Residents, visitors and staff can carry
these germs on their hands. Proper hand hygiene is essential.
Hand hygiene means washing hands with soap and water for
15 seconds to 20 seconds or using a 60 percent alcohol hand
sanitizer. It is not impolite to insist that anyone who is giving
care or touching a resident practice hand hygiene. This includes
doctors, nurses, nursing assistants and visitors. In caring for
residents with memory loss, it is important to remember that
everyone needs to help with resident hand hygiene.
3. Antibiotics
If antibiotics are being given, ask the reason antibiotics were
prescribed. Once prescribed, the full course of medication
should be taken as directed. Donʼt insist on antibiotics if the
doctor doesnʼt advise them because overuse can lead to
resistance and other problems.
Improving Quality of Care Based on CMS Guidelines 53
Prevention
4. Urinary Catheters
Sometimes urinary catheters are necessary; however they can
significantly increase the risk of infection. Urinary catheters
should be removed as soon as they have fulfilled the need for
placement. Ask about the need for a catheter. If you are a family
member and help to give care to the resident, talk to the ICP
about what you should do to prevent an infection.
5. Immunizations
It is very important to have up-to-date immunizations. On
admission to a nursing home, a resident should be asked
about their immunization status and offered any immunizations
they need. This includes the Pneumococcal pneumonia vaccine
if not already done before admission and the influenza vaccine.
Family and visitors should also make sure they receive the flu
vaccine during flu season to minimize the risk of transmission
to residents. Ask the facility about the influenza program for
nursing home staff.
Source: The Association for Professionals in Infection Control and
Epidemiology, Inc. (APIC)
APICʼs mission is to improve health and patient safety by reducing
risks of infection and other adverse outcomes. The Associationʼs more
than 11,000 members have primary responsibility for infection
prevention, control and hospital epidemiology in health care settings
around the globe, and include nurses, epidemiologists, physicians,
microbiologists, clinical pathologists, laboratory technologists and
public health practitioners. APIC advances its mission through edu-
cation, research, collaboration, public policy, practice guidance and
credentialing.

Culture Change In Briefs
Using disposable undergarments
to boost satisfaction and protection
By Deb Tenge, RNC, MS, CWOCN,
Licensed Administrator
Thornapple Manor, a 138-bed facility located in
Hastings, Michigan, provides skilled and intermediate
care for residents. For more than 100 years, Thornapple
Manor had been addressing continence with reusable cloth
products, most recently a cloth brief with rubber backing
and snap closures. When the CMS guidelines for Tag
F315 were revised, the staff considered switching to dis-
posable briefs. This coincided with a major renovation
wherein “neighborhoods” replaced institutional hallways.
Thornapple Manor had never seen a need to move to
disposable briefs because they had so few skin issues due
to incontinence. Jackie Schantz, DON suspects this could be
traced to good skincare protocols and their policy of open-
airing on a cloth underpad when residents were in bed,
which allowed air to flow to the skin. However, this also
54 Healthy Skin
Treatment
meant that many bedridden residents would be nude from
the waist down during the day. This didnʼt fit the new resi-
dent-centered culture, however – after all, these residents
would not have been nude in bed at home. In the past, some
families had questioned why their loved one was not allowed
to wear clothes under the sheets. The new disposable briefs
allowed the residents to be clothed in bed, improving dignity
and comfort. Also bolstering dignity was the fact that the new
disposable briefs were trim enough to be virtually invisible
under clothing.
Another positive result was odor control, thanks to the poly-
mer used in most brands of disposable absorbent briefs. The
highly absorbent polymer powder helps to neutralize urine
odors in addition to absorbing fluids.
Education plays a big part in good skin care at Thornap-
ple. The CNAs are all knowledgeable about proper skin
cleansing, performing skin checks, the importance of
nutrition and hydration and moisturizing and protecting
with barrier products. Bathing assistants are also on the
lookout for changes in the skin. “All staff has a focus on
skin,” says Jackie. “Pressure ulcers are not allowed here.”

Obviously, this type of conversion affects the budget in

several ways. With disposables comes a monthly cost,
but laundry costs at Thornapple were reduced substan-
tially. This savings reflects an 18,000 pound drop per
month in laundry. Thornapple Manor realized approxi-
A shadow box containing items
mately 160 hours of labor savings per pay period. important to the resident hangs
outside each room at Thornapple.
One costly problem that was solved was the issue of
sewer system blockage from cleansing wipes. The facil-
ityʼs policy now is to provide incontinence care and then
place the wipes within the soiled disposable incontinence
product to be thrown away. This has saved the facility
dollars in plumbing mishaps.

Thornapple Manor has seen improvements in:

• Odor control Ruth Hoffman, seven-year
CNA at Thornapple, pulls
• Skin integrity
incontinence supplies.
• Family satisfaction
• Resident satisfaction

Thornapple Manor has continued to keep abreast of the

needs of their community and also maintain regulatory
standards set by the State of Michigan. They have targeted
the needs of their residents and have demonstrated
regulatory compliance with F315 and at the same time
remained cost effective in the challenging reimbursement
world of long-term care.

About the author

Deb Tenge, RNC, MS, CWOCN, Licensed Administrator
has a career in health care that spans 25 years, with 13
years in the acute hospital setting. The past 12 years of
The entry to Thornapple Manor
her career have focused on the long-term care arena. She
was an executive quality assurance nurse for a 31-facility
chain in Iowa and assisted facilities in maintaining com-
pliance with state and federal regulations.

Improving Quality of Care Based on CMS Guidelines 55

 It's another level of
comfort and
protection

The 100 percent breathable side panels in Restore/Remedy

briefs don’t just keep your residents more comfortable.
Improved airflow also helps to reduce skin irritation.

Skin nourishment is built right into every Restore/Remedy

disposable brief. That’s because each brief’s inner liner
is coated with Medline’s Remedy™ Skin Repair Cream.
Using a combination of the Remedy skincare line and the
Restore/ Remedy brief has shown to keep the pressure
ulcer incidence rate and IAD prevalence rate consistently
down in a facility.1

The absorbent UltraCare core helps provide maximum

dryness for improved comfort and healthier skin. And the
anti-leak cuffs perform effectively better than standard cuffs,
which help to protect clothing and bedding. The cloth-like
outer cover is comfortable against the skin,
helping to minimize rash or irritation.
Skin-safe closures with “grab anywhere” technology
allow for the best possible fit and also reduce waste.
Now caregivers can quickly check and refasten briefs.
Restore/Remedy is a unique product of its kind on the mar-
ket with skin nourishment built right in.
For more information about Restore/Remedy dispos-
able briefs, contact your Medline representative or
call us at 1-800-MEDLINE.
Shannon R., Fisher K. A Nursing and Rehabilitation
Center Project in New Jersey: Expected Value of
Remedy Skin Care and Restore Briefs in an At-Risk
Resident Population for Pressure Ulcer and
Incontinence-Associated Dermatitis Prevention.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Say Goodbye to Soap and Water
Bathing modifications for senior skin
By Laura Ballinger, CNA
Can you name the largest organ in the human body? Liver?
Nope. Intestines? Nada. Believe it or not, the skin covers
approximately 1.5 to 2 square meters on the average adult.1 All
of that coverage provides a protective barrier between the envi-
ronment and our bodies. It also mirrors the health status of the
person, giving greater insight into physical, social and psycho-
logical status.2 Although skin care is important at all ages, the
elderly have particular concerns that need to be recognized and
treated effectively.3
Dry skin is common in the elderly. As we age, our skin begins to
thin. As a result, the structures of the dermis are not as well
protected and can be easily damaged.4 The thinner the skin, the
less it is able to retain moisture, thus leading to dry skin. Thinner
skin often contributes to pressure ulcers and skin tears. These
conditions can contribute to infection, as any break in the skin
can allow bacteria to enter.
It is very important to keep older skin clean; however, many
soaps and cleaning products can lead to dryness and itching.
More importantly, they can strip the acid mantle, which can
lead to dryness, infection and itching. Whatʼs more, water ac-
tually has the effect of a drying agent.3
Here are some hygiene guidelines to follow when caring
for elderly individuals:
• Avoid soaps that can strip the skin of its acid mantle.3
• Try not to use lather-rich products, as they often contain harsh
detergents that can quickly dry out the skin.4
• Use products that contain moisturizing agents.3
• Avoid extremes in temperature. Very hot or very cold water
can be damaging to the skin.4
• Be sure to dry the skin thoroughly, using a soft cloth.4
The regular use of moisturizers, especially after washing, can
help to lessen dry, itchy skin.3 These creams help seal in the
bodyʼs natural moisture.4
Improving Quality of Care Based on CMS Guidelines 57
Treatment
Here are some ways to help moisturize residents4:
• Humidify the air.
• Apply a generous amount of moisturizing cream on the skin.
• During the day, especially if the resident spends time outdoors,
apply sunscreen.
The key to good skin care is one-on-one attention to details.
Most of the routine skin care nursing home residents require can
be provided by the staff who care for them daily. Protocols and
procedures for bathing, turning them regularly and keeping their
skin moisturized will go a long way toward preventing many
of the skin problems of the elderly.5
References
1 New World Encyclopedia. Skin. Available at:
http://www.newworldencyclopedia.org/entry/Skin. Accessed September 10, 2008.
2 Pritchard B. Care of the skin in the elderly person. British Journal of Healthcare
Assistants. 2007;1(3):110-112.
3 Starner L. Elderly skin care- what you need to know. Available at: http://Ezine
Articles.com/?expert=Lynn_Starner. Accessed August 21, 2008.
4 British Association of Dermatologists. Looking after elderly skin – a simple guide.
Available at: www.bad.org.uk/healthcare/guidelines/elderly_skin_care.pdf Accessed
August 21, 2008.
5 Norman RA. Caring for aging skin: a geriatric dermatologistʼs expert advice on
skin care for LTC residents. Nursing Homes. 2003 April.
About the author
Laura Ballinger, CNA, has been working with the elderly since
1989. She has worked at Signature HealthCARE Of Columbia, Ten-
nessee for the past 13 years. Laura knows how important skin care
is for the elderly. She strives every day to ensure her residentsʼ well-
being, and a major part of that goal is good skin care.
Rub-a-dub-dub
without the tub.

Make incontinence
care easy for your
staff and comfortable
for your patients

ReadyBath® TPC The soft cloths are formulated specifically for use in the
perineal area to combat and prevent perineal dermatitis.
ReadyBath® TPC (Total Perineal Care) washcloths are
• Soft washcloths and Spunlace wipes will not irritate skin
packaged in both single-use 3-packs and resealable
• Gentle cleansers (BZK) help to reduce bacteria and
packaging so they can be left bedside for quick clean-
control odors
ups. ReadyCleanse™ With Dimethicone wipes are
• Dimethicone seals in moisture
packaged in resealable 24 packs. Both products feature
• Product can be heated for added comfort
disposable pre-moistened cloths that eliminate the
need for water or towels.

For additional information please contact your

Medline sales representative or call
1-800-MEDLINE.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Bathing the Elderly
with Dignity
How to make bath time more
pleasant for everyone
Improving Quality of Care Based on CMS Guidelines 59
Special Feature
By John Vest, CNA
Bathing is such a simple ritual, one many of us
take for granted. Most of us can not only bathe our-
selves, but do so when and where we want to. We can
take as much or as little time as we want and no one will
disturb us. Sadly, due to the importance of bathing and the
large volume of nursing home residents who need assistance,
if not total care, this basic routine often succumbs to the forces of
institutionalization. Baths must be scheduled, worked within tight
time frames, accomplished quickly and performed one after the
other in the most efficient way possible. Over the years, some
bathing equipment has even become more high-tech rather then
relaxing and inviting.1
Of all activities performed by nursing assistants, bathing is the
most time-consuming and strenuous. Often, battles must be
fought with resistant residents, leading to resident frustration.
Bathing facilities are often noisy and cramped. Privacy is com-
promised and, in the hurry to "get it done," one of life's more re-
laxing pleasures is anything but.1
When asked about their bathing experiences, many residents feel
that it is a stressful exercise rather then a restful part of the day.
Even residents who can bathe themselves sometimes cite a fear
of being walked in on by staff. Overall, some residents feel that
dignity has been removed from bathing.1
Adding dignity back into bathing
There are many things that can be done to preserve dignity and
independence when bathing. If they are able to do so, residents
should be encouraged to bathe or shower themselves. The
bathing area should be prepared appropriately by the care-
giver – keeping in mind that each residentʼs needs and abilities
are different.
 Even if the resident needs complete assistance, simply asking
them when they want to bathe, rather then telling them when they
will be bathing, goes a long way. If addressed early in the day or
shift, a convenient time for both resident and caregiver can
often be found.2
Underlying conditions
It is important to remember that some medical conditions, such as
Alzheimerʼs disease or dementia, can contribute to residents being
agitated or combative. When bathing these residents, try to main-
tain a routine and stay calm. Try to bring the resident to the bath
at the same time each day, preferably with the same person. Pre-
pare everything ahead of time – run the bath, test the water and
have towels and a robe handy. Although it is not easy, especially
when there is more then one person to bathe, it helps if staff can
remember that these people are not deliberately trying to frus-
trate them. They truly might not know when they last
bathed and may feel confused, frightened or embarrassed.3
Take it slow
Maybe the desired outcome wonʼt happen the first time, but with
patience, a little more is achieved with each intervention. Care-
givers need to try to make bathing a calming experience. It is all
right to start by just sitting and talking in the bathroom if the resi-
dent is resisting bathing. After a while, you could say, "This bath
water is so nice and warm, and a bath would make you feel so
good" or "Iʼm going to wipe your face now, thereʼs something on
your cheek." If they resist, donʼt push. Try again each day – same
time, same routine. Take it in stages: One day, wash the feet, the
next day, the face. Often it is more effective to sponge one area
than to try to bathe the entire person.3
Adjustments for safety
Some residents have a fear of water or showers and will fight
against attempts to wash or bathe them. The most common fear
is that they will fall. There are many assistive devices available to
reduce the risk of falls. Stepping out of a shower can sometimes
be problematic for seniors. Grab bars and a shower mat are some
helpful tools to ensure safety. Seats can also be installed in show-
ers. Be sure to securely install handles or grab bars in the shower
area to provide stability – donʼt rely on wobbly towel racks. Also
be sure the area just outside the shower stall has a rubber mat
placed on it to halt slipping. If the mat is thin enough, walkers or
wheelchairs can be used right up to the shower entrance.4,5
Allow for modesty
Modesty is another major issue. Help residents understand that
there is nothing wrong with this. If they are able to undress and
60 Healthy Skin
bathe themselves, simply do whatever other preparations are nec-
essary and leave them alone. Be sure to make them aware that
staff is nearby if they need anything and ensure that call bell pulls
are close enough for them to reach if needed. If the resident
requires assistance with bathing, do not undress him fully. Just
wash one area of the body at a time while keeping the resident
partly covered.4
An alternative to traditional bathing
Pre-moistened, disposable wipes might be a good alternative to
the traditional bath for residents who are less ambulatory or more
combative. These wipes gently cleanse the skin and help reduce
cross-contamination from the reusable plastic basins used in basin
baths. There are wipes designed to meet specific needs, such as
total perineal care and antibacterial formulations. For maximum
resident comfort, you can warm them before use.
The fostering of independence while maintaining resident safety
and providing for good personal hygiene are the goals of bathing.
Staff shortages and the increasingly large elderly population do
not make these objectives easy to achieve.
References
1 Piner WD. Restoring dignity to bathing: The Spa at Arbor Acres provides a total
bathing experience. Nursing Homes. 2003 June.
2 Caregiverʼs Home Companion. Timely Tip: Elder Bathing. Available at:
http://www.caregivershome.com/news/timely_tip.cfm?UID=16&StartRow=61.
Accessed August 28, 2008.
3 Caregiverʼs Home Companion. Ask an Expert – Elderly Behavior: How to Overcome
Bathing Resistance. Available at: http://www.caregivershome.com/community/askex-
pert_full.cfm?UID=101. Accessed August 28, 2008.
4 Elderly Care Tips. Washing An Elderly Person. Available at: http://www.elderly-
caretips.info/Washing%20An%20Elderly%20Person.php. Accessed August 28, 2008.
5 LifeTips. How do I know if my bathroom is safe? Available at:
http://eldercare.lifetips.com/faq/41644/0/how-do-i-know-if-my-bathroom-is-
safe/index.html. Accessed August 28, 2008.
About the author
John Vest, CNA, has been working in the medical field since 1983.
He is currently employed at Signature HealthCARE of Columbia,
Tennessee.
 Treatment

10
Tips to
Create
a More
Enjoyable
Resident
Dining
Experience
Compiled by Healthy Skin staff

1. Serve food that smells and looks good, and serve 8. Staff should be quick to offer residents help with
it at the proper temperature.1 their food – opening milk and yogurt cartons,

2.
buttering bread, etc.3
Include menu items based on residentsʼ
own recipes.2 9. Consider offering native ethnic foods to residents

3.
who might have had them as a large part of their
Offer a choice of foods at mealtimes.1 daily diet before coming to your facility.4

4. Plan menus so that foods are not repeated often. 10. Display individual residentsʼ food preferences.3
This can help prevent residents becoming bored
with their meals.2

5.
References
Serve finger foods, such as chicken nuggets, 1 Medicare. Nursing Home Checklist. Available at:

to residents who might be having trouble using their

http://www.medicare.gov/Nursing/Checklist.asp. Accessed August 27, 2008.
2 Illinois Council on Long Term Care. Nutrition: Strategies for Helping Residents
utensils.2 at Risk. Available at: http://www.nursinghome.org/fam/fam_016.html. Accessed

6.
August 27, 2008.
Dietary staff and nursing assistants can make 3 Evans B, Crogan N, Armstrong Shultz J. Quality dining in the nursing home:

eating more pleasurable by chatting and interacting the residents' perspective. J Nutr Elder. 2003;22(3):1-16.
4 Sarfaty C. Nursing home focuses on ethnic needs. Home News Tribune. Avail-
with residents.3 able at: www.alamedacenter.com/docs/HomeNewsTribuneArticle.pdf. Accessed

7.
August 27, 2008.
Form a “resident food council” as a forum for
residents to offer feedback on dining services,
voice concerns and try new food items.2

Improving Quality of Care Based on CMS Guidelines 61

62 Healthy Skin

Extreme Bathroom Makeover:
Resident Safety Edition
The bathrooms in your facility might seem innocent enough,
but to some elderly residents they can become more of an
obstacle course than a convenience. What can you do to make
them a safer, more convenient place to visit?
Color
Close your eyes and picture an institutional bathroom. What is the
primary color you see? Many of us see a lot of white, and that can
be a problem for nursing home residents. Residents who have poor
color discrimination might have trouble locating a white toilet seat if
the flooring is also light or white, and male residents might have
trouble voiding into a toilet while standing if they have difficulty iden-
tifying where the toilet stops and the flooring begins.1
Here, grab this
Ideally, toilets should be placed so that a staff member can stand on
either side of the resident.1 Angled grab bars are preferable to stan-
dard horizontal grab bars, which are typically shorter and require
the resident to have more upper body strength.1 With angled grab
bars, residents can grasp the bar at a lower position and then move
up the bar, which can also increase transfer independence.1
Gain traction
The National Institute on Aging suggests placing non-skid mats,
strips or carpet on all bathroom surfaces that could possibly get
wet.2 Donʼt skimp in this area – environmental hazards, such as wet
floors, account for 16 to 27 percent of falls in nursing homes.3,4
Raise the seat
OSHA recommends using toilet seat risers for independent
residents as well as partially weight-bearing residents who are
cooperative, can sit up unaided, have upper body strength are able
to bend their hips, knees and ankles.5
Improving Quality of Care Based on CMS Guidelines 63
Survey Readiness
Bath boards and benches
These devices can aid in resident transfer. OSHA recommends
placing clothing or material between the residentʼs skin and the
board to help reduce friction and skin tears.5 For added resident
comfort, choose models with padded seats or back support.
Universally accessible sinks
Making bathroom sinks accessible to all residents helps them
remain independent in their grooming.1 Residents in wheelchairs
can easily access sinks that have space under the bowl or that are
accessible from the side.1 While youʼre at it, you might want to take
a look at the faucets on your sinks. Single-control faucets can prove
problematic for residents with poor grasping ability. Instead, choose
blade handles.1 Adjustments should also be made so that residents
in wheelchairs can see the mirrors placed above bathroom sinks.
References
1 Maben PA. Designing a better bathroom: making bathrooms and toilet rooms safer
and more comfortable. Nursing Homes. 2003 March.
2 National Institute on Aging. AgePage: Falls and Fractures. Available at:
http://www.nia.nih.gov/HealthInformation/Publications/falls.htm. Accessed August 20,
2008.
3 National Center for Health Statistics. Health, United States, 2005. Hyattsville, Md:
National Center for Health Statistics; 2005.
4 Rubenstein LZ, Robbins AS, Schulman BL, Rosado J, Osterweil D, Josephson KR.
Falls and instability in the elderly. Journal of the American Geriatrics Society.
1988;36:266-78.
5 Occupational Safety & Health Administration. Ergonomics: Guidelines for Nursing
Homes. Available at:
http://www.osha.gov/ergonomics/guidelines/nursinghome/final_nh_guidelines.html.
Accessed August 20, 2008.
 How to Thrive in
a Tough Economy
Unless you are on another planet, it is likely that your organization has already gone
through several “downsizings” or “rightsizings,” as your boss might like to call them.
Time to get depressed, right? Wrong!

By Wolf J. Rinke, PhD, RD, CSP

64 Healthy Skin

Time to put yourself in the driverʼs seat of your career by
developing new skills that will enable you to take advantage
of the opportunities that are unfolding before your very
eyes – opportunities that will enable you to not only survive,
but thrive in this tough economy.
Think projects
Old organizations were organized by departments and
position titles. Today, projects accomplish most work. To
thrive in a project environment, recognize that work gets
done primarily by three distinct specialties. First, there are
the resource providers. These are the folks who develop
and supply talent or money. Your human resource manager
Improving Quality of Care Based on CMS Guidelines 65
Special Feature
and financial officer would fit into this category. Next are the
project managers. They are responsible for making sure
that the talent and resources are organized in such a way
that the project gets done. Next is the talent. These are the
people who have the skills to get the job done, such as
nurses, OR techs and other front-line healthcare profes-
sionals. To thrive in this tough economy, it is important that
you master “winning management” skills so that you can
perform equally well in the project manager or resource
provider role. (For details read my Winning Management:
6 Fail-Safe Strategies for Building High-Performance
Organizations book.)
Think global
Globalization is accelerating at a nanosecond pace. To take
advantage of globalization, you must dramatically increase
your cultural awareness. If you are now employed in a
primarily “homogeneous” organization and are not at least
90 percent satisfied, seek employment in a multicultural
organization. Donʼt know where to start? Get a copy of
Fortuneʼs latest issue of either 100 Best Companies to Work
For (typically published in February) or Americaʼs Most
Admired Companies (typically issued in March of every
year) and apply to any of the companies listed. Want to stay
in health care? Not a problem, there are many on either list.
For example, Methodist Hospital System is in the number
10 spot on the 2008 100 Best Companies to Work For and
Manor Care is in the number one spot for the Healthcare
Medical Facilities Group in the 2008 Americaʼs Most
Admired Companies.
Equally important, learn a foreign language. If youʼre not
fluent in at least one foreign language, you will be in trouble
 IN THIS TOUGH ECONOMY
real soon. And put your language you can simply no longer expect to be Think of yourself
to work by traveling to a country compensated for time, only for results as self-employed
that speaks the language of in- Seeing yourself working for
terest to you. Youʼll really learn to and problems solved. one company for the rest of
speak it, become culturally sen- your career is, to say it gently,
sitive whether you want to or not crazy! Itʼs just not going to
and will bring back a ton of great ideas to accelerate your happen! In this tough economy, itʼs important that you see
success curve dramatically. yourself as “self-employed,” or “renting” your services out
to someone else (your employer). To get started, pretend
Become an effective team player and leader that you are an entrepreneur or a consultant who is selling
Like it or not, teams are the way lots of work is being services to a client (your employer). To make this realistic,
accomplished in todayʼs organizations. Being effective in compute your daily compensation. Be sure to add about 30
this environment requires that you learn how to empower percent for benefits. Then get in the habit of asking yourself
others and master leadership and winning management “Have I created value today that exceeded my daily com-
skills, and be equally comfortable and effective in a pensation?” Repeat that question every day you are at
supportive role as in a leadership role. (For more, read my work. You may even find it helpful to place a nice-looking
Donʼt Oil the Squeaky Wheel and 19 Other Contrarian Ways sign on your work station that asks “How are you creating
to Improve Your Leadership Effectiveness book.) $_____ of value today?”

Focus on delivering exceptional quality service
Delivering exceptional quality service is not an option, but
rather a survival strategy. We must be absolutely clear
about who provides us with our paycheck. No, itʼs not your
boss or even your organization. It is the person you serve –
an external or internal “customer.” As a litmus test of how
customer-focused you are, look back at your calendar for
the last week to find our how much actual time youʼve spent
with your external or internal customers. If you are not
spending at least one third of your time with your “cus-
tomers,” you are messing up.
The other side of the coin is to keep asking “How have I
ʻgrownʼ in my job today?” To make this happen, think of
going to work each day with a “briefcase” of skills and com-
petencies. At the end of the day, check your briefcase to see
if there is more in it than at the beginning of the day. If, day
after day, what you bring to work is the same as what
you take home, itʼs is time to move on to a more challeng-
ing “assignment.”
Get in the habit of asking yourself,

Become a problem solver

One of the best ways to position yourself for advancement
or pay increases is to become a problem solver. In this
tough economy, you can simply no longer expect to be com-
pensated for time, only for results and problems solved. So
actively look for a problem that impacts negatively on the
bottom line then put a team together and solve it. Then, let
others know (especially the powers-that-be) what a great
job your team did and how much your team improved the
profitability of your organization. If you do that consistently,
you will be ready to be promoted or negotiate for an
increase in pay. (If youʼd like help with that, devour my
Win-Win Negotiation CPE program.)
“Have I created value today that
exceeded my daily compensation?”
Become an expert networker
One of the most powerful skills you can develop is to
become a highly effective networker, both inside and outside
of your organization. When it comes time to find a new
assignment, your network, more than anything else, will
determine how fast youʼll find your next dream job. To test
your networking effectiveness, 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 net-
working opportunities. Get in the habit of eating lunch with

66 Healthy Skin
different people three out of five days a week, to sit with people
you donʼt know at meetings and to attend conferences that
are sponsored by groups other than yours.

Check yourself
To assess how well you are achieving a competitive advantage
in this tough economy, ask yourself the following diagnostic
questions:
ASK YOURSELF...
Am I learning?
If you are not constantly learning new things, your value in
• Am I learning?
the marketplace is diminishing rapidly. • Am I being taken advantage of?
Am I being taken advantage of?
• If my job was open today,
Your employer is taking advantage of you if you consistently would I get it?
sacrifice your long-term development to put out short-term
“fires.” Donʼt let your ego get the better of you when you are
• Am I adding value?
being told that you are so critical to the organization that “we • Am I good at selling?
canʼt do without you.” Hogwash! No one is indispensable.
Never, ever get caught in persistent short-term traps at the
• Am I energized by change?
expense of your long-term development. • Does my résumé focus
If my job was open today, would I get it?
on contributions?
Itʼs important that you “benchmark” your skills all of the time.
Continued on Page 69

Improving Quality of Care Based on CMS Guidelines 67

Bringing it home to you
More than 1 million Americans receive home health care For your free cost-savings analysis, contact your
services every year. Just as every patient is unique, so is
1
sales representative or call 1-800-678-7852.
every home health care agency.

That’s why Medline HomeCare is proud to offer innovative

solutions for every segment of your business, designed to
fit your specific needs. We provide:
• Supply management
• Clinical support
• Increased productivity
• Back office connectivity
• Documented cost savings

To learn more about Medline HomeCare, call us at

1-800-678-7852.

Reference
1 The Centers for Disease Control and Prevention. Home Health Care Patients:

www.medline.com
Data from the 2000 National Home and Hospice Care Survey. Available at:
www.cdc.gov/nchs/pressroom/04facts/patients.htm. Accessed April 12, 2008.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
One way to do that is to look at the want ads to find out what liberate and empower you. Action will get you to grow,
the marketplace is looking for. If you do not possess the change and adapt. Action will provide you with virtual job
skills that the marketplace is looking for, itʼs time to invest security, will enable you to achieve the competitive advan-
more in yourself. tage and assure that you thrive in this tough economy.

Am I adding value?
How long does it take you to answer this question? If you
are unable to answer it immediately, in fewer than two or
three sentences, you can assume that no one else knows
how you contribute value either. In that case, you are a likely
target during the next downsizing.

Am I good at selling?
Many healthcare professionals see no need to become
excellent at selling. The reality is that you sell all the time.
You sell your patient on getting better, you sell your boss on
a raise and you sell your team members on an idea. In
addition, you do the same at home with your spouse, children
and even your pets. Since it is something you do all of
the time, I recommend that you get good at it. No, wait, I
recommend you get great at it! So start looking for a quality
sales program and attend it this year!
Am I energized by change?
If you are still fighting or resisting change, you are in trouble.
All indications are that change will continue to accelerate at
“hyper speed,” so you might as well start welcoming it.
About the author
Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar
leader, management consultant, executive coach and editor of
the free electronic newsletters Make It a Winning Life and
The Winning Manager. To subscribe, go to www.Wolf Rinke.com.
He is the author of numerous books, CDs and DVDs including
Winning Management: 6 Fail-Safe Strategies for Building High-
Performance Organizations and Donʼt Oil the Squeaky Wheel
and 19 Other Contrarian Ways to Improve Your Leadership
Effectiveness, available at www.WolfRinke.com. His company
also produces 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.

Does my résumé focus on contributions?

Finally, to check how focused you are on contributions, get
out your résumé and check for specific outcomes, specific
impact on the organization and variety and content of work,
projects and leadership experiences. Are you impressed?
Would you hire this person? If so, congratulations!

The most important concept

of all time: Take action
There is one more skill that you need to master. This one is
more important than all the others. Itʼs the one skill that,
when all else fails, will determine whether you will thrive in
this tough economy. The skill is to take action! Action lets
you know whether what youʼve tried works. If it does, do
more of it. If it does not, try something else and start the
same process all over again. Soon youʼll find yourself suc-
ceeding faster than you have ever thought possible. And
whatever you do, avoid fretting about having failed – there
is no such thing, unless you make the same mistake over
and over again. Action gets you away from bemoaning
change and mourning the lack of job security. Action will

Improving Quality of Care Based on CMS Guidelines 69

 Tw
employe
of comm
the de
fa

All information is
important, but different
disciplines value and prioritize
it in different ways.

70 Healthy Skin
 Special Feature

Why Can’t We All

wo out of three
ees feel that the flow Just Get Along?
Improving relationships between
munication between

healthcare organizations
epartments of their
acility is poor.

By Dayna Lowe, Clinical Instructor

Does your facility have a failure to communicate?

If it does, youʼre not alone. Surveys show that two out of three employees
feel that the flow of communication between the departments of their facility
is poor.2

First and foremost, healthcare providers, no matter what their discipline,

want to give their patients the best possible care. If this is true, why are
there so many problems? It all comes down to communication.

Nursing homes often say that hospitals transfer all of their complex prob-
lems to them. Hospitals claim that nursing homes never seem to send the
right paperwork with their patients. Certainly it is not always this bad, but we
are all guilty of similar thoughts from time to time.2

Although important, communication takes time – time that many people

simply do not feel they have.

Healthcare facilities are only getting bigger. Many hospitals are part of a
larger system that not only includes acute care facilities but outpatient serv-
ices, doctorsʼ offices, rehabilitation centers and long-term care facilities.
Departments that need to communicate many be a floor away from each
other or miles apart in different buildings. Even with email and phones so
readily available, important information still gets forgotten.2

How can you help your own facility?

So what can you do? There is no one simple solution for breaking down the
barriers of communication between healthcare providers of different
organizations. Improvements need to be tailored to the needs of each
facility. However, there are some basic guidelines that we can all follow.

First of all, the information that is truly important and necessary needs to be
identified. So often, time is wasted sifting through documents and repeating
the same piece of information over and over. All information is important,
but different disciplines value and prioritize it in different ways. Communi-

Improving Quality of Care Based on CMS Guidelines 71

 cation checklists for different departments could be devel- another. They must communicate in an efficient and proper
oped so that only necessary information is shared and manner. Last but not least, they need to ensure that the best
nothing is missed. They would ensure the sharing of “need to possible communication tools are available and that their staff
know” rather then “nice to know” information.2 has adequate training on their use. Staff must learn to work
with new technology and with each other. They must
Properly conducted team-building remember that this is all done for the
exercises can dramatically improve how good of the patient.
well department heads and staff mem-
bers work with each other. Typically, this Communication checklists References

requires the use of an outside profes-

sional with experience getting fellow
employees to unite as a team. Part of
for different departments
could be developed so
1 Plsek P. Interdepartmental communication in a
large hospital. Available at: http://www.plexusinsti-
tute.org/ edgeware/archive/think/main_tales9.html.
Accessed September 2, 2008.

these exercises could also include staff

that only necessary
2 Katcher BL. How to improve interdepartmental
communication. Available at: www.discovery-
rotating to other facilities to see “how the
information is shared
surveys.com/articles/itw-017.html.
other half lives.” Not only does this give
and nothing is missed.
Accessed September 2, 2008.
everyone a better understanding of what 3 Spring Valley Hospital Medical Center. High marks
for prompt ER care. Available at: http://valleyhealth.
other facilities do, it also gives employ- uhspublications. com/winter2007/story2.html.
ees a more rounded perspective of how Accessed September 2, 2008.
the work of the organization is con-
ducted and the importance of sharing
information between departments. It About the author
is also a great way fo different organ- Dayna Lowe has been a surgical tech-
nologist for six years. She currently
izations to get to know one another.2
works at a hospital in Florida and as an
Instructor of Surgical Technology at
Facilities need to look into available com-
Central Florida Institute.
munication technology and train their
staff how to use communication tools
properly. Without adequate education,
these tools can be used incorrectly,
causing more problems then they solve.

As we plunge headlong into the 21st

century, health care will only continue to
get bigger and more complex. Staff will
be expected to provide skilled services faster then ever
before. Administrators and managers of these organizations
must set good examples for their staff. They must be able
to put aside any personal differences and work with one

72 Healthy Skin
 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 be forced to stay in • Crutches (650 lb capacity)
bed because he or she didn’t have a wheelchair or walking • Bath benches (550 lb capacity)
aid to use. You also don’t want to risk patient or staff injury by • Transfer benches (550 lb capacity)
using equipment not rated for bariatric use. • Commodes (up to 850 lb capacity)

Call your Medline rep or go to www.medline.com to

find out more. And check out Medline’s other bariatric
products, including patient lifts, pressure-reducing
mattresses, briefs, furniture and more.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 Caring for Yourself
By Brian Tracy
The greatest obstacle to success
The fear of failure is the single greatest obstacle to success in
adult life. Taken to its extreme, we become totally preoccupied
with not making a mistake, with seeking for security above all
other considerations. The experience of the fear of failure is in
the words of “I canʼt,” “I canʼt.” We feel it in the front of the body,
starting at the solar plexus and moving up to the rapid beating of
the heart, rapid breathing and a tight throat. We also experience
this fear in the bladder and in the irresistible need to run to the
bathroom.
The fear of rejection holds you back
The second major fear that interferes with performance and
inhibits expression is the fear of rejection. We learn this when our
parents make their love conditional upon our behavior. If we do
what pleases them, they give us love and approval. If we do some-
thing they donʼt like, they withdraw their love and approval –
which we interpret as rejection.
The roots of a Type A behavior
As adults, people raised with conditional love become preoc-
cupied with the opinions of others. Many men develop Type
A behavior that is characterized by hostility, suspicion and an
obsession with performance to some undetermined high stan-
dard. This is expressed in the attitude of “I have to,”
“I have to,” and is associated with the
feeling that “I have to work harder and
accomplish more in order to please
the boss” who has become
a surrogate parent.
74 Healthy Skin
The most common trap
More than 99 percent of adults experience both these fears of
failure and rejection. They are caught in the trap of feeling,
“I canʼt,” but “I have to,” “I have to,” but “I canʼt.”
The key to peak performance
The antidote to these fears is the development of courage,
character and self-esteem. The opposite of fear is actually love,
self-love and self-respect. Acting with courage in a fearful situa-
tion is simply a technique that boosts our regard for ourselves to
such a degree that our fears subside and lose their ability to
affect our behavior and our decisions.
Action exercises
Here are two things you can do to increase your self-esteem and
self-confidence and overcome your fears.
First, realize and accept that you can do anything you put your
mind to. Repeat the words, “I can do it! I can do it!” whenever you
feel afraid for any reason.
Second, continually think of yourself as a valuable and important
person and remember that temporary failure is the way you learn
how to succeed.
Reprinted with permission from www.mercola.com.
 Medline Supports Breast Cancer
Awareness 365 Days a Year
Together We Can Save Lives Through
Early Detection Breast Cancer Campaign
Every three minutes a woman in the United States is
diagnosed with breast cancer. The chance of developing
invasive breast cancer at some time in a woman's life is
about 1 in 8.¹ These are startling statistics, but behind these
numbers are people — sisters, daughters, mothers, grand-
mothers, neighbors and friends. Any one of the 182,460
women who will be diagnosed with invasive breast cancer
this year could be someone we love. Although mammo-
grams are among the best forms of early detection, more
than 13 million American women over the age of 40 have
never had one.2 The Centers for Disease Control recommend
that women begin having yearly mammograms at age 40.
These facts form the foundation of Medlineʼs “Together We
Can Save Lives through Early Detection” campaign. Medline
is on a mission to change the future by taking action now.
2008 marks the third year that Medline has partnered with
the National Breast Cancer Foundation (NBCF), which
provides grants to hospitals and healthcare organizations
that offer free mammograms for underprivileged women. To
date, Medline has donated $350,000 to the NBCF to give
back to customers and their communities, help promote
early detection of breast cancer and ultimately save lives.
Spreading the word
To keep early detection on everyoneʼs minds, Medline
sponsors a number of outreach projects throughout the
year and distributes several products and programs to
promote awareness.
AORN breakfast forum
In March, Medline hosted a breakfast forum for 900 periop-
erative nurses at the annual meeting of the Association of
periOperative Registered Nurses (AORN) in Anaheim, Calif.
Featured speaker, Dr. Marla Shapiro, author of Life in the
Balance: My Journey with Breast Cancer and renowned
Canadian on-air medical expert, delivered a dynamic pres-
entation on coping with stress, balancing life and battling
breast cancer. Visit www.medline.com/aorn/2008 to learn
more about the event.
Improving Quality of Care Based on CMS Guidelines 75
Beyond the Shock® DVD
Medline, in partnership with the NBCF, distributes free
copies of the DVD “Beyond the Shock,” a step-by-step guide
to understanding the diagnosis of breast cancer. More than
70 leading oncologists contributed to the content. To request
a copy, contact Jennifer Freedman at (847) 643-4358 or
jfreedman@medline.com.
Angel doll
Angel, the second-born in Medlineʼs family of nurse dolls,
promotes infection prevention and she also sports pink
scrubs and a pink ribbon to support breast cancer awareness.
The Angel doll is distributed by Medline at trade shows and
large customer events.
Pink ribbon products
Medline sells several pink ribbon products, including a
Breast Cancer Awareness Rollator and bath bench, a pink
ribbon lab coat and special scrubs available on
scrubs123.com. A customerʼs purchase of these products
supports Medlineʼs partnership with the NBCF. Visit
medline.com or scrubs123.com or contact your Medline
sales representative for more information.
For more information on Medlineʼs breast cancer
awareness campaign, visit www.medline.com/bca
or contact Jennifer Freedman at 847-643-4358 or
jfreedman@medline.com
References:
1. American Cancer Society. Cancer Reference Information. “What Are the Key
Statistics for Breast Cancer?” Available at: http://www.cancer.org/docroot/
CRI/content/CRI_2_4_ 1X_What_are_the_key_statistics_for_breast_cancer_ 5.asp.
Accessed July 15, 2008.
2. The Breast Cancer Site. About Breast Cancer page. Available at:
http://www.thebreastcancersite.com/clickToGive/boutbreastcancer.faces?siteId
=2&link=ctg_bcs_aboutbreastcancer_from_home_maincolumn.
 Healthy Eating

Holy Guacamole!
You can make this avocado salad smooth
or chunky depending on your preference.

Nutritional Information
Prep time 10 minutes Servings Per Recipe: 4
Guacamole (4 servings)

Ready in 10 minutes Amount Per Serving

Calories: 264
3 avocados - peeled, pitted and mashed Total Fat: 23.3g
1 lime, juiced Cholesterol: 0mg
1 teaspoon salt Sodium: 601mg
1/2 cup diced onion Total Carbs: 16.4g
3 tablespoons chopped fresh cilantro Dietary Fiber: 8.8g
2 roma (plum) tomatoes, diced Protein: 3.7g
1 teaspoon minced garlic
1 pinch ground cayenne pepper (optional)
www.allrecipes.com
In a medium bowl, mash together the avocados, lime juice
and salt. Mix in onion, cilantro, tomatoes and garlic. Stir in
cayenne pepper. Refrigerate 1 hour for best flavor, or serve
immediately.

76 Healthy Skin
 FORMS & TOOLS

The following pages contain practical tools for implementing

patient-focused care practices at your facility.

Pressure Ulcer Prevention

Policy and Procedure ..................................79
Predicting Pressure Ulcer Risk ....................84

Infection Control Activities and Their

Infection Control

Relevance to Pneumonia in LTC ..................86

Improving Quality of Care Based on CMS Guidelines 77

Join the program
to reduce pressure ulcers.
Medline’s Pressure Ulcer Prevention Program The Pressure Ulcer Prevention Program from Medline will help
you in your efforts to reduce pressure ulcers in your facility.
Systematic efforts at education, heightened awareness and specific
interventions by interdisciplinary healthcare teams have demon-
The program includes:
strated that a high incidence of pressure ulcers can be reduced.1
• Education for professional staff and nurse technicians
• Teaching materials for you to help train your staff
The main challenges to having an effective pressure ulcer prevention
• Practical tools to help reduce the incidence of pressure ulcers
program are lack of resources, lack of staff education, behavioral
• Innovative products supported by evidence-based information
challenges and lack of patient and family education.2
that results in better patient care

Medline’s comprehensive Pressure Ulcer Prevention Program offers

To join the fight against pressure ulcers and for more
solutions to these challenges to promote the reduction of pressure
information on the Pressure Ulcer Prevention Program,
ulcers with clinical and educational resources, assessment tools
please contact your Medline sales representative of
and a complete compatible product line designed to work alone
call 1-800-MEDLINE.
or complement your existing program.

The Pressure Ulcer Prevention

Program. Pressure ulcer
prevention made easy.

References
1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.
2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. www.medline.com
Pressure Ulcer Prevention Policy and Procedure Forms & Tools

Pressure Ulcer Prevention

Personnel: All accountable for patient care
Patient outcomes:
1. Maintenance of intact skin in the patient who is at risk for breakdown.
2. Patient/caregivers verbalize knowledge of pressure ulcer risk factors, assessment,
prevention and early treatment.

High Risk Diagnoses: Factors That Contribute To Pressure

Ulcer Development

Peripheral Vascular Disease
Age greater than 75

Myocardial Infarction
Existing pressure ulcer

Stroke
Immobility

Multiple Trauma
Those having a procedure

Musculoskeletal which immobilizes them for
disorders/Fractures greater than one hour

GI Bleed
Bed linen

Spinal Cord Injury
Devices (e.g., oxygen tubing,

Paraplegia splints, TEDs stockings)

Neurological disorders (e.g.,
Sedation
Guillain Barré, multiple
Sensory deficits
sclerosis)
Nutritional deficits/Weight loss

Those with unstable and/or
Excessive exposure to
chronic medical conditions (e.g., moisture (e.g., incontinence,
diabetes, renal disease, cancer) excessive perspiration, wound

History of previous pressure drainage)
ulcer
Those exposed to friction and

Preterm neonates shearing

Early and ongoing assessment of patients at risk for skin breakdown is essential.
Prevention involves not only identification of patients at risk but also a detailed plan
of interventions which address and minimize the effects of each risk factor.

Improving Quality of Care Based on CMS Guidelines 79

 Forms & Tools Pressure Ulcer Prevention Policy and Procedure
Nursing Diagnosis
Asessement/evaluation
1. Identify patients at risk for developing a
pressure ulcer upon admission and daily for
at-risk patients or with any change in condition.
2. Assess specific vulnerable pressure points.
A. Supine: occiput, sacrum, heels
B. Sitting: ischial tuberosities, coccyx
C. Side-lying position: trochanters
D. Reddened areas which do not fade within
30 minutes
E. Dusky or cyanotic areas
F. Under devices (i.e., TEDs, pneumoboots,
splints, collars, tubing)
3. Assess skin for exposure to moisture from
intervals incontinence, wound drainage
perspiration.
80 Healthy Skin
Interventions/key points
1. Determine an adult patient's risk for
developing a pressure ulcer by using the
Braden Risk Assessment.
A patient is considered at risk if their
Braden score is:
15-18 = Mild risk
13-14 = Moderate risk
10-12 = High risk
9 or below = Very high risk
2. Advance your patient to the next risk level in
the presence of:
A. Age over 75
B. Chronic illness
C. Hemodynamic instability (e.g., diastolic
blood pressure less than 60 mmHg).
3. Utilize the Nursing Care Plan to individualize
specific prevention interventions.
4. Initiate Pressure Ulcer Treatment Protocol at
the first sign of skin breakdown.
5. Consult WOC nurse when current plan of
care does not meet the needs of the patient.
2. Inspect the skin at least every 8 hours.
A. Avoid vigorous massage over bony
prominences.
B. Patients with dark pigmentation will
demonstrate a cyanotic area, warmth or
complain of pain over the bony prominence.
3. Cleanse and dry skin at routine intervals or
and at the time of soiling, using a low residue soap.
A. Initiate the Incontinence Protocol in the
incontinent patient.
B. Moisturize dry skin with lotion.
Pressure Ulcer Prevention Policy and Procedure
Nursing Diagnosis
4. A. Assess mobility and activity status.
B. Identify sitting status.
5. Assess nutritional status.
6. Identify factors that increase shearing, fric-
tion and/or pressure.
A. Shearing: Tissue layers sliding against each
other; e.g., sliding down in bed.
B. Friction: Skin rubbing against other sur-
faces; e.g., elbows and heels rubbing against
sheets.
C. Pressure/friction: e.g., heels resting on mat-
tress, devices such as oxygen tubing, cervical
collars, casts.
Improving Quality of Care Based on CMS Guidelines 81
Forms & Tools
4. A. 1. Maintain or increase patient's level of
activity, mobility and range of motion unless
contraindicated.
2. Schedule regular and frequent turning and
repositioning at least every 2 hours (e.g.,
alternating supine, left lateral and right lateral
positions).
3. Individualize to the patient's needs based
on risk and level of mobility.
B. For sitting position in bed (head of bed
greater than 30°), cardiac chair or wheelchair:
1. Assist/instruct patient to shift weight at
least every 15 minutes.
2. Reposition at least every 30 minutes if
patient cannot independently perform
pressure relief exercises every 15 minutes.
3. Consult PT/OT for assistance in seating,
positioning and wheelchair cushion options.
5. Due to increased protein needs for healing,
consult Nutrition Services for a nutritional
assessment and plan at the earliest sign of
skin breakdown.
6. A. 1. Keep head of bed less than 30° unless
contraindicated.
2. Promote proper positioning, transferring and
turning techniques.
B. 1. Use reusable underpad, trapeze or lift
sheet to lift, not drag, patient.
2. Utilize pillows or positioning devices to
prevent skin surfaces from rubbing together.
C. 1. The immobilized patient should have heels
suspended off bed by using pillows or heel
suspension boots.
2. Heel and elbow protectors are best used for
reducing friction and should not be used for
pressure reduction.
3. Pad devices when it is not contraindicated.
 Forms & Tools Pressure Ulcer Prevention Policy and Procedure

Nursing Diagnosis
7. Assess patient/family knowledge of pressure
ulcer prevention, risk factors and early treatment.
7. A. Teach patient/family about the causes and
risk factors for pressure ulcer development and
ways to minimize risk.
B. The patient or caregiver, or both, should
understand the importance of the following:
1. Conduct regular inspection of skin over bony
prominences. (Individuals can use a mirror if
necessary to inspect their own skin.)
2. Follow appropriate skincare regimens.
3. Use measures to reduce friction/shearing.
4. Avoid vigorous massage of bony prominences
or reddened area.
5. Include routine turning, repositioning and the
use of pressure-reducing devices if patient is
confined to bed and/or chair.
6. Avoid use of donut-type devices.
7. Maintain adequate nutrition and fluid intake
and monitoring for weight loss, poor appetite or
gastrointestinal changes that interfere with eating.
8. Program for bowel and bladder management.
9. Promptly report healthcare changes and
nutritional problems to healthcare providers.

Adapted from North Memorial Health Care’s Pressure Ulcer Prevention Protocol.

References
Bryant R. Acute and Chronic Wounds. 2nd ed. St. Louis: Mosby; 2000.
Frantz RA. Evidence-based protocol: Prevention of pressure ulcers. Journal of Gerontological Nursing. 2004;30(2):4-11.
Hobbs BK. (2004). Reducing the incidence of pressure ulcers: Implementation of a turn-team nursing program. Journal of
Gerontological Nursing. 2004;30(11):46-51.
Makelbust J, Sieggreen M. Pressure Ulcers: Guidelines for Prevention and Management. 3rd ed. Pennsylvania:
Springhouse; 2001.
Wound, Ostomy and Continence Nurses Society. Guidelines for the Prevention and Management of Pressure Ulcers.
Glenview, Ill; 2003.
U.S. Department of Health and Human Services. Pressure ulcers in adults: Prediction and prevention clinical practice
guideline. 1992.

82 Healthy Skin
 Is This a Four-Star Hotel?
Nope – it’s a nursing home!
Medline, the company that knows health care, brings you
luxury you can depend on.
Our Feels Like Home™ line of textiles includes everything from
soft and cozy towels to 100 percent terry robes and 310 thread
count reverse sateen sheeting. All of Medline’s Feels Like Home
products provide the same comfort and quality that your residents
expect in their own homes.

Feels Like Home products don’t stop at luxury – they’re practical,

too. All of these products were designed with nursing input to
ensure that they meet the needs of patient-centered care. They’re
also incredibly durable and have been tested to withstand the
wear and tear of commercial laundering.

To learn more about the Feels Like Home line, please

call 1-800-MEDLINE, visit www.medline.com or speak
to your Medline sales representative

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. www.medline.com
 Forms & Tools Predicting Pressure Ulcer Risk

84 Healthy Skin
Predicting Pressure Ulcer Risk Forms & Tools

Improving Quality of Care Based on CMS Guidelines 85

 Forms & Tools Infection Control

Infection Control Activities and Their Relevance to Pneumonia in LTC

86 Healthy Skin
 Infection Control Forms & Tools

Reprinted with permission from the Texas Department of Aging and Disability Services

Improving Quality of Care Based on CMS Guidelines 87

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©2008 Medline Industries, Inc. MKT208244/LIT265R/15M/JBK5

Medline is a registered trademark of Medline Industries, Inc.