Improving Quality of Care Based on CMS Guidelines

Volume 8, Issue 2
Free CE Inside!

Influenza:
Prevention
Guidelines

Survivors
Share Their
Stories

TAKE THE
PINK GLOVE
SURVEY
Page 80 The Dance
Goes On:
How to Prepare for PINK GLOVE
Emergencies & Disasters DANCE SEQUEL
 HEALTHY SKIN
Join the team! CDC CLINICAL REMINDER

Use of Fingerstick Devices on More than One Person Poses

Risk for Transmitting Bloodborne Pathogens
Summary: The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the
risks for transmitting hepatitis B virus (HBV) and other bloodborne pathogens to persons undergoing fingerstick
procedures for blood sampling -- for instance, persons with diabetes who require assistance monitoring their blood
1,2,3
glucose levels. Reports of HBV infection outbreaks linked to diabetes care have been increasing . This notice
serves as a reminder that fingerstick devices should never be used for more than one person.

Background

Fingerstick devices are devices that are used to prick the skin and obtain drops of blood for testing. There are two
main types of fingerstick devices: those that are designed for reuse on a single person and those that are
disposable and for single-use.

When it comes to hot
topics in long-term care,
you’re the experts!
You, our readers, are on the front lines of everything that
happens in the healthcare industry – and we want to hear
from you! Have you ever wished you could write an
article that would be published in a large-circulation
magazine? Nowʼs your chance. Healthy Skin is looking
Reusable Devices: These devices often resemble a pen and have the
means to remove and replace the lancet after each use, allowing the device
to be used more than once (see Figure 1). Due to difficulties with cleaning
and disinfection after use and their link to numerous outbreaks, CDC
recommends that these devices never be used for more than one person. If
these devices are used, it should only be by individual persons using these
devices for self-monitoring of blood glucose.
Single-use, auto-disabling fingerstick
devices: These are devices that are
for writers and contributors. Whether youʼd like to try your disposable and prevent reuse through an
hand at writing or offer suggestions for future articles, we auto-disabling feature (see Figure 2). In
want to hear what you have to say! You never know – the settings where assisted monitoring of blood
next time you open an issue of Healthy Skin, it might be
glucose is performed, single-use, auto-
to read your own article!
disabling fingerstick devices should be used.

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

Figure 1: Reusable
fingerstick devices* Figure 2: Single-use, disposable
fingerstick devices*

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
The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such
as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk
for transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons
are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier this
year, dozens of attendees were potentially exposed to bloodborne pathogens when fingerstick devices were
reused to conduct diabetes screening.

Weʼve tried to include content that clarifies the initiatives or gives you ideas and tools for implement-
ing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion (DHQP)
 HEALTHY SKIN
Improving Quality of Care Based on CMS Guidelines

36 CDC, FDA, CMS Issue Infection Control Guidance

Survey Readiness

Sue MacInnes, RD, LD

66 Emergencies & Disasters: Preparedness Planning for Long-term
Editor

Care Facilities
Margaret Falconio-West, BSN, RN,
Clinical Editor

APN/CNS, CWOCN, DAPWCA

39 Save Those Heels! Effective Techniques to Help Avoid Heel
Prevention

Pressure Ulcers
Alecia Cooper, RN, BS, MBA, CNOR 50 Implementing Medlineʼs Pressure Ulcer Prevention Program at Page 32
Managing Editor

Lacombe Nursing Centre

Carla Esser Lake 58 Influenza: Prevention Guidelines and Recommendations
Senior Writer

11 MDS 3.0: Revised Guidelines for Pressure Ulcer Risk Assessment

Treatment
Mike Gotti
Creative Director

and Staging
Clinical Team
20 Adult Obesity in the United States: A Growing Epidemic
Clay Collins, BSN, RN, CWOCN, CFCN, 32 Feeding Dementia Patients with Dignity
CWS, DAPWCA
46 Foot, Skin and Wound Care from the Other Side of the Bed Rail Page 39
Lorri Downs, BSN, RN, MS, CIC
54 Case Study: Use of Porcine Urinary Bladder in a Dehisced Wound
Cynthia Fleck, BSN,MBA, RN, CWS, DNC,
CFCN, DAPWCA, FCCWS
Joyce Norman, BSN, RN, CWOCN,
13 Wound Care Nurses Win Case Study Abstract Award at 2010
Special Features
DAPWCA
WOCN Conference
Kim Kehoe, BSN, RN, CWOCN, DAPWCA
14 Third Annual Prevention Above All Conference
Elizabeth OʼConnell-Gifford, BSN, MBA, RN,
62 Control Measures for Influenza
CWOCN, DAPWCA
79 CDC Forms New Advisory Committee on Breast Cancer in
Jackie Todd, RN, CWCN, DAPWCA
Young Women
Connie Yuska, RN, MS, CORLN Page 46
80 Take the Pink Glove Survey!
86 The Dance Goes On: Pink Glove Dance Sequel
88 Sharing Stories
Wound Care Advisory Board
Zemira M. Cerny, BS, RN, CWS
Patricia Coutts, RN
Cindy Felty, MSN, RN, CNP, CWS 74 Fail-Safe Strategies to Deal with Difficult People
Caring for Yourself

Evonne Fowler, MSN, RN, CNS, CWOCN 84 Breast Health Tips

Lynne Grant, MS, RN, CWOCN 92 Taste the Fountain of Youth
Diane Krasner, PhD, RN, CWCN, CWS, 94 Healthy Eating: Tuscan Tomato Soup
BCLNC, FAAN
Page 66
Dea J. Kent, MSN, RN, NP-C, CWOCN
96 Announcing New Online Skin & Risk Assessment Competency
Forms & Tools
Andrea McIntosh, BSN, RN, APN, CWOCN
Linda Neiswender, BSN, RN, CPN, CWOCN 98 SKINSAVERS Initiative: A Pressure Ulcer Prevention Tool
Laurie Sparks, BSN, RN,CWOCN 103 Impact of Healthcare Reform on Home Health
Lynne Whitney-Caglia, MSN, RN, CNS, 105 Patient Handout: Medicare and the New Health Care Law –
CWOCN What it Means for You
Laurel Wiersema-Bryant, RN, ANP, BC 109 A National Framework and Preferred Practices for Palliative and
Linda Woodward, BSN, RN, OCN, CWOCN Hospice Care Quality
Deborah Zaricor, RN, CWOCN 111 Ten Tips for Cleaning and Disinfecting Shared Medical Equipment
Page 86
114 Some Things Should Not be Reused
115 CDC Clinical Reminder: Use of Fingerstick Devices

Meeting the highest level of national and international quality standards, Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more is FDA QSR compliant and ISO 13485 certified. Medline serves on major
About Medline

than 100,000 products to hospitals, extended care facilities, surgery centers, industry quality committees to develop guidelines and standards for medical
home care dealers and agencies and other markets. Medline has more than 800 product use including the FDA Midwest Steering Committee, AAMI Steriliza-
dedicated sales representatives nationwide to support its broad product line and tion and Packaging Committee and various ASTM committees. For more
cost management services. information on Medline, visit our Web site, www.medline.com.

©2010 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Improving Quality of Care Based on CMS Guidelines 3

 HEALTHY SKIN Letter from the Editor
Dear Reader,
September 17th Medline launched the Pink Glove
Dance Sequel. If you haven’t seen it, I highly recom-
mend you to go to pinkglovedance.com and take
a look.
The first video, launched in November 2009, now has
over 11.5 million hits on YouTube. It has been all over
the globe. When it hit the Netherlands and the com-
ments were in Dutch, my daughter and I were so
excited. Emily Somers, you see, is the choreographer,
and this year she has been super busy traveling for
the making of the Pink Glove Dance Sequel. Shortly
after the video release last year, both St. Vincent’s
Hospital in Portland, Ore., and Medline began receiv-
ing countless phone calls and e-mails about people’s
experiences with breast cancer.
One daughter wrote, my mom has not smiled nor has
she gotten off the couch since she was diagnosed.
Once she saw the video, she smiled for the first time
in months. Another woman said she was getting treat-
ments for stage 4 breast cancer, and the video was so
uplifting. Several hospitals and nursing homes asked
if we would do a pink glove dance at their facility.
So, September 17, 2010, Medline launched the Pink
Glove Dance Sequel. Starting at St. Vincent’s in Port-
land, you will see healthcare workers from 10 hospi-
tals and 3 nursing homes in North America dance,
and as a special note of appreciation, you will see
breast cancer survivors from coast to coast dance in
appreciation of their healthcare workers—caregivers
and survivors coming together celebrating. More than
4 Healthy Skin
4,000 people participated. We are thrilled, honored
and filled with the hope that this sequel will spur more
people to talk about breast cancer, support each
other through tough times, and give everyone hope.
With so many participants in the film it was hard to
condense hours of footage into four short minutes. In
order to give everyone a chance to dance, we will be
launching an additional video for every hospital that
participated, a video for the nursing homes and a
“
video of all of the breast cancer survivors. These will
be released the first week of October, to see the I want to extend
schedule go to pinkglovedance.com. It is our goal to a heartfelt thank
spread the word to as many people as possible about you to the health-
saving lives and early detection. care workers who
show compassion
On behalf of all the breast cancer survivors and their and care to those
families, I want to extend a heartfelt thank you to the diagnosed and
healthcare workers who continue to show compas-
sion and care for those diagnosed and their families.
You are spectacular!
”
their families.
Enjoy this edition of Healthy Skin! And, take a moment
to reflect on all the good you do. Watch the video,
share it with friends and spread the cheer.
My deepest thanks to all of you,
Sue MacInnes, RD, LD
Editor
 Improving Quality of Care Based on CMS Guidelines

Introducing
Volume 8, Issue 2
Free CE Inside!

Influenza:
Prevention
Guidelines

25th
Deb!
Survivors
Share Their
Stories

TAKE THE
PINK GLOVE
SURVEY

Anniversary
Page 80 The Dance
Goes On:
How to Prepare for PINK GLOVE
Emergencies & Disasters DANCE SEQUEL

of Breast Cancer Awareness Month

Starring in “The Pink Glove Dance”
Some historical facts

2010 In her Generation Pink™

marks the 25th anniversary of Breast Cancer Gloves, pink bouffant cap
Awareness Month, whose purpose is to remind and scrubs, Deb danced
women about the value of early detection and in the Pink Glove Video
mammograms. Sequel. To watch the
video, go to

1993 www.pinkglovedance.com.

To order your own

Evelyn Lauder, senior corporate vice president Deb doll, visit
of the Estee Lauder Companies founded the www.medline.com/dolls.
Breast Cancer Research foundation and began
distributing pink ribbons to symbolize breast
cancer awareness.

1985
Breast Cancer Awareness Month was created
in October 1985 as a collaborative effort among
the American Academy of Physicians, Cancer-
Care Inc. and various other sponsors.

Pink
was chosen as the breast cancer ribbon color
because it symbolizes health and femininity.

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

QIO Utilization and Quality Control Peer Review Organization

1 9th Round Statement of Work

The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “Ninth
Scope of Work” plan became effective August 1, 2008 and is a three-year work plan.
Origin:

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

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

prevent illness, decrease harm to patients and reduce waste in health care.
Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare,
support the adoption and use of health information technology and reduce health disparities in their communities.
Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national
network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.

The official Executive Summaries for the 9th SOW Theme are available at:
Quality Improvement Organization Program’s 9th Scope of Work Theme

http://providers.ipro.org/index/9SOW_summaries

2 Advancing Excellence in America’s Nursing Homes

A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home
residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an
Origin:

additional 2 years (until September 26, 2010).

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

surveys into continuing quality improvements and increase staff retention to allow for better, more consistent
care for nursing home residents.

Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal and
one operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goals
for the next two-year campaign.

The coalition is meeting to consider the following additions for the next two-year campaign:
Advancing Excellence

1. Improving immunizations as a clinical goal

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

6 Healthy Skin
The 9th Scope of Work Content Themes

Theme #1: Beneficiary Protection Activities will focus on Theme #4: Prevention Activities will focus on nine Tasks:
nine Tasks: 1. Recruiting participating practices
1. Case reviews 2. Identifying the pool of non-participating practices
2. Quality improvement activities (QIAs) 3. Promoting care management processes for preventive services
3. Alternative dispute resolution (ADR) using EHRs
4. Sanction activities 4. Completing assessments of care processes
5. Physician acknowledgement monitoring 5. Assisting with data submissions
6. Collaboration with other CMS contractors 6. Monitoring statewide rates (mammograms, CRC screens, influenza
7. Promoting transparency through reporting and pneumococcal immunizations)
8. Quality data reporting 7. Administering an assessment of care practices
9. Communication (education and information) 8. Producing an annual report of statewide trends, showing baseline
and rates
Theme #2: Patient Pathways/Care Transitions Activities 9. Submitting plans to optimize performance at 18 months
will focus on three Tasks:
1. Community and provider selection and recruitment There will be two periods of evaluation under the 9th SOW. The first
2. Interventions evaluation will focus on the QIO's work in three Theme areas (Care
3. Monitoring Transitions, Patient Safety and Prevention) and will occur at the end of
18 months. The second evaluation will examine the QIO's performance
Theme #3: Patient Safety Activities will focus on six on Tasks within all Theme areas (Beneficiary Protection, Care Tran-
primary Topics: sitions, Patient Safety and Prevention). The second evaluation will take
1. Reducing rates of health care-associated methicillin-resistant place at the end of the 28th month of the contract term and will be
Staphylococcus aureus (MRSA) infections based on the most recent data available to CMS. The performance
2. Reducing rates of pressure ulcers in nursing homes and hospitals results of the evaluation at both time periods will be used to determine
3. Reducing rates of physical restraints in nursing homes the performance on the overall contract.
4. Improving inpatient surgical safety and heart failure treatment
in hospitals Focus for the 9th Scope of Work
5. Improving drug safety – Move away from projects that are “siloed” in specific care settings
6. Providing quality improvement technical assistance to nursing – Focused activities for providers most in need
homes in need – New emphasis on senior leadership (CEOs, BODs) involvement
in facility quality improvement programs

Clinical and Operational/Process Goals

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

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

Trends in Goal Selection

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

Participating nursing homes: 7,481

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

Improving Quality of Care Based on CMS Guidelines 7

 MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

Each package is a 2-Minute Course

in Advanced Wound Care ™

Medline’s Educational Packaging offers all the information you need, step by step,
short and sweet, to help the Medline dressing do its job of healing.

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

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 BREAKING NEWS

What to Expect This Flu Season
Flu season is here, and the Food and Drug Administration has
approved eight vaccines made by six companies. One of the
eight is a new high-dose version meant for people 65 and older.1
The 2010-2011 vaccine contains killed or weakened
forms of three viruses:1
1. Swine flu (technically known as A/California/7/09 (H1N1)
2009 influenza
2. A/Perth/16/2009 (H3N2)-like virus
3. B/Brisbane/60/2008-like virus
FLU FACTS2
• The Centers for Disease Control and Prevention
(CDC) announced on June 22, 2010 that it would
not be endorsing mandatory influenza vaccinations
for healthcare workers this flu season.
• The CDC now recommends that
healthcare workers wear surgical
face masks instead of N-95
respirators when working with
influenza patients.
HHS Grants $159.1 Million to Train Healthcare Workers3
The Department of Health and Human Services (HHS) has
awarded $159.1 million in grant money to support healthcare
worker training to be targeted to nursing and geriatric-targeted
programs, as well as Centers of Excellence programs for minor-
ity students. The funding is made possible through the Ameri-
can Recovery and Reinvestment Act and Patient Protection
and Affordable Care Act. A state-by-state chart of grant
award recipients is available at www.hhs.org.
Health Care Spending Among Obese Adults
Increases 30 Percent Over 20 Years4
Health care spending per adult grew rapidly among obese
patients between 1987 and 2007, according to an analysis
recently released by the Congressional Budget Office. Spending
per capita for obese adults exceeded spending for adults of
normal weight by about eight percent in 1987 and by about 38
percent in 2007. If recent trends continue, the adult obesity rate
would rise from 28 percent in 2007 to 37 percent in 2020. Per
capita spending on health care for adults would increase by
about 3 percent more than it would if the obesity rate were
unchanged, CBO estimates.

• Flu vaccination rates increased References

by an average of eight percent 1. Grady D. Flu vaccines are approved and urged for most. The New York Times.
during the 2009-2010 flu season. July 30, 2010. Available at: http://www.nytimes.com/2010/07/31/health/policy/31-
flu.html?_r=1&ref=health. Accessed August 9, 2010.
2. Bartlett JG. Need-to-know news about influenza. From Medscape Infectious
Diseases. Available at: http://www.medscape.com/viewarticle/725532.
Accessed August 4, 2010.
3. Costello MA. HHS awards $159.1 million in heath care workforce grants. AHA
News Today. August 6, 2010.
4. How does obesity in adults affect spending on health care? Congressional Budget
Office web site. September 8, 2010. Available at: http://www.cbo.gov/doc.cfm?
index=11810. Accessed September 10, 2010.

Improving Quality of Care Based on CMS Guidelines 9

What you see...
...is because of what you don't see
Happy residents, healthy skin and fewer pressure ulcers
are what you want to see in your facility. That's why you
should take a look at PUP -- the Pressure Ulcer Preven-
tion program from Medline.
One glance shows that this program is comprehensive.
It includes:
• Curriculum for you to help train your staff: RNs,
LPNs, CNAs, MDs
• Practical tools to help reduce the incidence of
pressure ulcers
• Innovative products supported by evidence-based
information that results in better patient care
acquired pressure ulcers. By April 2010 they had only six
facility-acquired pressure ulcers -- that's an 89 percent
reduction in nine months.The number of pressure ulcers
decreased another 67 percent by June 2010 after staff
completed their PUP education program.1
For more information on the Pressure Ulcer
Prevention Program, contact your Medline
representative, call 1-800-MEDLINE or visit
www.medline.com/pupp-webinar to register
for a free informational webinar.

When Tewksbury State Hospital, a 250-bed facility in

Massachusetts, began using Medline's Remedy and
Ultrasorbs products in June 2009, there were 55 facility-

1. Medline Industries, Inc. Data on file.

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 MDS 3.0
Revised Guidelines for Pressure Ulcer Risk Assessment and Staging
The Centers for Medicare & Medicaid Services implemented
the Minimum Data Set (MDS) 3.0 on October 1, 2010. MDS
3.0 includes revisions to Section M: Skin Conditions, which
changes how wounds are tracked and recorded in Medicare-
certified skilled nursing facilities. MDS 3.0 presents pressure
ulcer risk in a more sophisticated, thorough and clinically
relevant way that requires greater collaboration between
caregivers and physicians or primary care providers. The net
result is an assessment tool that is more in keeping with
residents’ needs.1 The following is a summary of the
major changes that apply to pressure ulcer risk assessment
and staging.
Reverse staging no longer allowed
MDS 3.0 illustrates a change in philosophy based on the
National Pressure Ulcer Advisory Panel’s (NPUAP) conclusions
that applying the pressure ulcer staging system in reverse
order is erroneous and can lead to inappropriate wound care
and reimbursement. For example, if an ulcer reaches Stage
IV and then granulates and epithelializes, it may appear
clinically shallow like a Stage II, but it still must be
documented as a healing Stage IV.1
(M0300B-G) Now included! Present on admission
(POA)/reentry data
MDS 3.0 includes new coding for pressure ulcers that are
present on admission or upon reentry to the nursing facility.
POA ulcers that worsen during the resident’s stay at the
nursing facility are then coded at the higher stage and are no
longer considered POA. Also, if a pressure ulcer is unstageable
at admission, but then becomes visible and stageable, it must
then be coded as POA.1
Improving Quality of Care Based on CMS Guidelines 11
M0610) Now included! Measurement of largest
pressure ulcer
If the resident has one or more unhealed (non-epithelialized)
Stage III or IV pressure ulcers or an unstageable pressure
ulcer due to slough or eschar, you must identify the pressure
ulcer with the largest surface area (length × width) and record
it in centimeters.2
(M0800, M0900) Now included! Tracking of
changes in pressure ulcers over time
These items document whether overall skin status has
worsened since the last assessment. To track increasing skin
damage, this item documents the number of new pressure
ulcers and whether any pressure ulcers have worsened to a
higher (deeper) stage since the last assessment. Most Stage
II pressure ulcers should heal in a reasonable timeframe. Full
thickness Stage III and IV pressure ulcers may require longer
healing times.2
(M0300G) Pressure ulcer blisters associated with
signs/symptoms of suspected deep tissue injury
(sDTI) must be coded as unstageable sDTIs
As of June 2010, MDS 3.0 instructed clinicians to code all
blisters related to pressure as Stage II pressure ulcers. These
instructions changed in August 2010. Upon consultation with
clinicians it was decided to further clarify coding related to
pressure ulcer related blisters and sDTIs to emphasize the
assessment findings of the wound and the surrounding
tissue, rather than the color of the fluid in the blister. The
emphasis is on complete and comprehensive assessment of
the resident and the type of skin injury rather than just solely
on the type of fluid in the blister.3
 \ Cy∙an∙o∙a∙cry∙late \
MDS 3.0 A fast-acting adhesive that bonds with the skin
to create a barrier against moisture and friction.

Deep tissue injury may precede the development of a Stage

III or IV pressure ulcer even with optimal treatment. Quality
health care begins with prevention and risk assessment, and
care planning begins with prevention. Appropriate care
planning is essential in optimizing a resident’s ability to avoid,
as well as recover from, pressure (as well as all) wounds.
Deep tissue injuries may sometimes indicate severe damage.
Problem: Peristomal Irritation
Identification and management of suspected deep tissue
injury (sDTI) is imperative.2 Solution: Marathon® Cyanoacrylate Liquid
Skin Protectant
Further understanding of MDS 3.0 Peristomal irritation can lead to decreased wear time, pain
For a more in-depth look at MDS 3.0 Section M: Skin and embarrassment about leakage. So it only makes
Conditions, visit http://journals.lww.com/aswcjournal/pages sense to do everything you can to protect the peristomal
and search for the articles referenced below. area. Marathon Liquid Skin Protectant helps protect
against irritation and maceration by creating a barrier
To locate a complete copy of MDS 3.0 and related training against moisture and chemical assault.
materials, go to http://www.cms.hhs.gov/NursingHome-
Marathon, a cyanoacrylate, bonds to the skin surface,
QualityInits/01_Overview.asp#TopOfPage. Section M:
integrating with the epidermis on a molecular level to
Skin Conditions is located in Chapter 3 of the MDS 3.0 seal in moisture. While other skin protectants may flake
RAI Manual. off, Marathon stays in place, offering robust protection
and increased wafer wear time.
The information presented here was current when this article
was published in mid-September 2010.

References
1. Levine JM, Roberson S, Ayello EA. Essentials of MDS 3.0 Section M: Skin Conditions. Ad-
vances in Skin & Wound Care. 2010;23(6):273-283.
2. MDS 3.0 RAI Manual August 2010. Centers for Medicare & Medicaid Services. Available at:
http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOf-
Stoma site before Same stoma site after
Page. Accessed September 10, 2010.
treatment with Marathon.1 treatment with Marathon.1
3. Ayello EA & Levine JM. CMS updates on MDS 3.0 Section M: Skin Conditions—change in
coding of blister pressure ulcers. Advances in Skin & Wound Care. 2010;23(9):394-397.

To learn more, visit

www.medline.com/skincare.

1. Data on file

12 Healthy Skin © 2010 Medline Industries, Inc. Medline and Marathon are registered
trademarks of Medline Industries, Inc.
 Special Feature

Wound Care Nurses Win

Case Study Abstract Award
at 2010 WOCN Conference

Left to right: Tricia Corvino,

MSN, RN, CWOCN,
co-author; Phyllis Bonham,
PhD, MSN, RN, WOCN,
DPNAP, president, Wound,
Ostomy and Continence
Nurses Society; Amparo
Cano, MSN, RN, CWOCN,
co-author; and Margaret
Falconio-West, BSN, RN,
APN/CNS, CWOCN,
DAPWCA, senior vice
president, clinical education,
Medline Industries, Inc.

Wound care nurses Tricia Corvino and Amparo Cano won a

merit award for their case study, “Use of a Porcine Urinary Bladder
Matrix (UBM) in a Dehisced Wound Between Stomas Promoted
Closure Facilitating Regular Pouch Changes in a Premature
Neonate,” which they presented at the 42nd Annual Wound,
Ostomy and Continence Nurses Society Conference June 12-16,
2010, in Phoenix, Ariz. Turn to page 54 to review the study.

Improving Quality of Care Based on CMS Guidelines 13

 Third Annual Prevention Above All Conference
Strategies for Thriving in the
New Era of Healthcare Reform
The heat is on in health care like never before. Error
prevention, efficiency and cost containment have been
top priorities for a very long time, but now, with the
introduction of healthcare reform, they are absolutely
critical for survival, according to Joint Commission
President Mark Chassin, MD, MPP, MPH.
What to expect from healthcare reform
Dr. Chassin delivered the keynote address at Medline’s 3rd
Annual Prevention Above All Conference devoted to sharing
new strategies for delivering cost-effective, high-quality, evi-
dence-based health care. An audience of more than 100 hos-
pital CEOs, chief nursing officers and other executives attended
the meeting August 16 and 17, 2010, in New York City.
“Today’s message is clear,” Dr. Chassin said. “Solve safety and
quality problems. Don’t say you’re trying; just solve them. Take
care of 30-plus million more people in your organizations. Be-
come or participate in an accountable care organization. Figure
out bundled payments. Adopt electronic medical records
quickly. And one more thing. You can’t have any more money.”
Overall, Dr. Chassin explained, healthcare reform increases
coverage while experimenting with some new payment and
14 Healthy Skin
care delivery ideas. Reform will increase federal costs, and
there is only one vehicle for cost containment: limiting payment
to providers.
Dr. Chassin cautioned, “You will never be paid better than you
are being paid now. This was true six months ago, it’s true now,
and it will be true tomorrow and next week.”
So how do healthcare providers control costs and avoid major
payment cuts and benefit reductions while also maintaining
quality? Dr. Chassin outlined several keys to survival in today’s
era of healthcare reform.
Employ a quality-driven strategy to eliminate overuse of health
services. Examples include discontinuing wasteful practices
such as prescribing antibiotics for colds and inducing labor ear-
lier than 39 weeks.
“This is one part of health policy that has not received any at-
tention,” Dr. Chassin explained. “It’s been overlooked for
decades in the research community. We must come together
to do this.” Two more keys to survival are eliminating the waste
inherent in needlessly complex care delivery processes and
putting an end to preventable complications.
 Special Feature

Deborah Adler, Trent Haywood,

Mark Chassin and Mikel Gray
answer questions from the
audience at the Third Annual
Prevention Above All Conference
held at the Hudson Theatre in
New York City.

Improving Quality of Care Based on CMS Guidelines 15

 A look into the future
Speaking from his experience as CEO of New York City’s Mount
Sinai Hospital, one of the nation’s largest and busiest hospitals,
Wayne Keathley provided a firsthand look at what he predicts
will be the norm for the average U.S. hospital amidst the new
era of healthcare reform—having to do a lot more with a lot less Left: Keynote speaker
at average capacity levels of 95 percent. Joint Commission President
Mark Chassin, MD, MPP, MPH.

“A fair number of you probably don’t recognize the kind of con-

gestion, overcrowding and difficulties with flow that I’m about
to describe,” Keathley said. “I would ask you to indulge in a lit-
tle suspension of disbelief and assume for a minute that as
health reform evolves, possibly because of a whole new group
of patients who will come to you for care … and more likely
because the economics will require you to rethink capacity and
the way you manage it — that the situation I’m going to
describe for us, in fact has some meaning for you.”

Mount Sinai is operating at 95 percent capacity, and they are

currently working with GE Healthcare to implement new
systems to accommodate this level of activity.

Keathley advocates improvement through fixing systems, Above (left to right): Medline
not by adding more resources. For example, whereas hospi- President Andy Mills, Deborah
tals often rely on intuition and personal judgment when man- Adler, Medline Chief Marketing
Officer, Sue MacInnes, RD, LD,
aging patient flow and locating empty beds, Keathley suggests Atul Gawande, MD, MPH,
that studying capacity patterns and related data leads to Medline COO Jim Abrams.
more efficient use of resources. He also encourages collabo-
ration among departments, viewing the hospital as a whole
rather than operating as individual silos.

“If money were no object, we would add more beds, add more
operating rooms, hire more nurses, and we could drive
occupancy back down to the ideal 85 percent,” Keathley Right: The Third Annual
said. “But I am telling you, that fantasy doesn’t exist.” Prevention Above All Conference
took place at the historic Hudson
Theatre in New York City.
Prevention Above All
Another solution to meeting the challenges of healthcare reform
lies in preventing costly medical errors and infections that are
indeed preventable. Sue MacInnes, Medline’s Chief Marketing Urinary Tract Infection (CAUTI) Foley Catheter Management
Officer and host of the Prevention Above All Conference, System to help prevent CAUTIs.
reviewed Medline’s growing offering of preventive strategies
for healthcare providers: These six strategies are targeted, focused and achievable evi-
dence-based solutions that are also practical. They fit with
The Gold Standard Surgical Safety Program to help prevent everyday processes and systems currently in place at most
operating room errors, the Hand Hygiene Compliance Pro- healthcare facilities.
gram, the Pressure Ulcer Prevention Program, Educational
Packaging, the ClearCount Surgical System to help prevent MacInnes emphasized, “Sometimes the simplest solutions
sponges from being left behind and the Catheter-Associated make the biggest difference.”

16 Healthy Skin
What the Experts Are Saying ...
Caroline Fife, MD and Kevin W. Yankowsky, JD
Lawsuits, Technology and Wound Care: How Electronic
Health Records Change Your Legal Risks
“Any time a lawsuit is filed, you and your facility and your
practitioners lose. The only question is the question
of degree ... I would suggest and recommend that you
take a moment to focus on how, in addition to improving
your clinical care, you can take steps to absolutely mini-
mize your risk of ever being involved in the legal system; of
ever being sued in the first place.” - Kevin W. Yankowsky
Fife Yankowsky

Trent T. Haywood, MD, JD

Social Practice: Observation
for Understanding and Improving
“One of the key things people have taught us in anything
that has to do with practice improvement is not really what
you don’t know; it’s what you think you know that ain’t so.”

Dale Bratzler, DO, MPH

Healthcare-Associated Infections
and Public Accountability
Haywood Bratzler “Clearly, if there is a single practice that we can do better
that will dramatically reduce healthcare-associated infec-
tions, it would be hand hygiene.”

Mikel Gray, PhD, FNP, CUNP, CCCN, FAANP, FAAN

Evolution of Evidence: New Models
for Demonstrating Effectiveness
“Insufficient evidence remains the primary challenge
of evidence-based practice; demystification of the
research process is urgently needed.”

Gray Gawande Abdul Gawande, MD, MPH

For video clips of the speakers’ presentations from
the 3rd Annual Prevention Above All Conference,
visit www.medline.com/media-room. Or contact
your Medline representative for a free set of DVDs.
Author, The Checklist Manifesto
“What we have today, though, is a volume and complex-
ity of medical discovery that has now exceeded our ability
as individual specialized artisans to be able to deliver that
care to the right person, the right way, at the right time
without waste of resources,” Dr. Gawande said.

Improving Quality of Care Based on CMS Guidelines 17


Practicing Advanced Medicine
Within Outdated Systems
Atul Gawande, MD, a Harvard professor and author of several
books, including his most recent, The Checklist Manifesto,
addressed the challenges of delivering highly advanced medical
care within outdated systems.
He pointed out that we’ve entered a complex medical world in
which we have 13,600 different diagnoses, 6,000 prescription
medications and more than 4,000 medical and surgical
procedures.
Compounding matters, we’ve inherited a structure from 50
years ago that didn’t have nearly so many diagnoses, drugs
and procedures. At that time, the doctor was considered an
artisan, and all you really needed was the physician’s brain,
along with an operating room, a few simple tools and some
skills behind that.
“What we have today, though, is a volume and complexity of
medical discovery that has now exceeded our ability as
individual specialized artisans to be able to deliver that care to
the right person, the right way, at the right time without waste
of resources,” Dr. Gawande said.
The Checklist Manifesto: How to Get Things Right
Atul Gawande, MD, MPH
We live in a world of great and
increasing complexity, where even
the most expert professionals strug-
gle to master the tasks they face.
Longer training, ever more advanced
technologies — neither seems to pre-
vent grievous errors. But in a hopeful
turn, acclaimed surgeon and writer
Atul Gawande finds a remedy in the
humblest and simplest of techniques:
the checklist.
18 Healthy Skin
Bedside Clinicians as Researchers
Mikel Gray, PhD, FNP, CUNP, CCCN, FAANP, FAAN,
editor-in-chief of the Journal of Wound, Ostomy and
Continence Nursing, described the research process,
focusing on randomized controlled trials, which are con-
sidered the gold standard for establishing the efficacy
of an intervention.
According to Dr. Gray, the primary challenge of evi-
dence-based practice is an overall lack of research. He
feels that doctoral prepared researchers from universi-
ties are not the only ones qualified to perform meaning-
ful clinical research. And as a way to generate more
research, he believes there is an urgent need to
demystify the research process to encourage bedside
clinicians to conduct studies based on their every-
day practice.
“Bedside clinicians can and do perform meaningful
research if provided proper support, mentoring from
sympathetic researchers and adequate resources,” he said.
Dr. Gray shared an example of
one such clinician, Dea J. Kent,
MSN, RN, NP-C, CWOCN, man-
ager of the Wound Ostomy Clinic
at Riverview Hospital in Noblesville,
IN, who compared the effects of
educational materials for wound
dressing application that were
attached to dressing packag-
ing versus traditional wound care education.
The study showed that none of the 139 nurses who
used traditional dressing packaging were able to apply
the wound dressing correctly. On the other hand, 88
percent of the nurses who used the package with the
educational guide attached to it were able to apply the
dressing correctly. The study will be published in the No-
vember 2010 issue of the Journal of Wound, Ostomy
and Continence Nursing.
To download a free copy of Kent’s study, “Effects of a
Just-in-Time Educational Intervention Placed on Wound
Dressing Packages” visit http://journals.lww.com/jwoc-
nonline/pages/default.aspx.
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• Adjunctive Therapies
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• Tools for Wound Healing
• Discharge Planning and Grant Writing
Join us on Twitter
• Developing a Certified Wound Care Team
Be the first to know when we add new courses and content.
• Preventing Pressure Ulcers
• Legal Issues in Wound Care

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

* Courses approved for continuing education by the Florida Board

of Nursing and the California Board of Reigistered Nursing.
 Treatment

Adult Obesity in the United States

A GROWING EPIDEMIC

by Cathy S. Birn, RN, MA, CGRN, CNOR

We all intend to eat right and exercise, but life intervenes. We’re too rushed for a real
meal and grab something from the vending machine. After a 12-hour shift or a long
commute, we crave sleep and comfort food instead of exercise and veggies.
The pounds creep up on us despite our best intentions.

As nurses, we are used to educating patients about health
problems, including excess weight. But for many nurses it’s
time for a refresher course on the science behind weight gain
and loss. The pounds we shed can bring us added energy and
better health — and the pride of accomplishing something
important for our own well-being. Losing weight is certainly a
hard task, with the inevitable setbacks and frustrations, but a
worthwhile one.
Anyone who is overweight has lots of company these days.
Obesity as a major public health issue has moved to the fore-
front and for good reason. Obesity among U.S. adults has
become epidemic in proportion. Progressively increasing in
recent years, American obesity rates are the highest in the
world, with 68 percent of adults categorized as overweight,
one-third of whom are clinically obese.1,2
expended through activities of daily living plus physical exer-
cise. However, obesity is an expansive and complex health
issue that also results from a combination of factors, among
them genetics, metabolism, behavior, environment, culture and
socioeconomic status.3
Body mass index, also known as the Quetelet index, defines
body mass in relation to both height and weight. (BMI is based
upon metric measurements, dividing weight in kilograms by
height in meters; BMI = weight/height2.) A strong relationship
exists between BMI and mortality in adults.4 The most widely
accepted obesity scale, the World Health Organization obesity
criteria, is based upon BMI and calculates that a BMI of
between 25 and 29.9 kg/m2 is overweight, a BMI of between
30 kg/m2 and 39.9 kg/m2 is obese, and a BMI over 40 kg/m2
is severely or morbidly obese.5

Factors that increase the risk of obesity include genetics
(affecting the amount and areas of body fat storage), family
history (having two obese parents increases the chances of
being obese, due to the influence of genetics and learned pat-
terns of behavior) and age (which increases inactivity).
A variety of other factors contribute to obesity. At a basic level,
obesity is an issue of energy imbalance. Excess weight is the
result of the intake of more calories from food than are
The body requires some body fat for insulation and to provide
shock absorption and store energy for potential use later. How-
ever, along with the cosmetic concerns, too much body fat
can have serious health implications, among them the propen-
sity for hypertension, diabetes and cardiac disease. The med-
ical costs directly attributable to obesity are estimated at $147
billion per year.6 Combined with smoking, alcohol use and high
levels of stress, excessive weight can have seriously detri-
mental effects upon the body.

Improving Quality of Care Based on CMS Guidelines 21

 I Came, I Saw, I Ate
Obviously, diets that include large portions of high-calorie foods
contribute to weight gain. Foods high in fat can be heavy in
caloric content since fat has more calories per gram than carbo-
hydrate or protein. Foods and beverages such as soft drinks,
candy and desserts have not only a high sugar content, but also
a high caloric content.

Sedentary people are more likely to gain weight since they are
not burning calories through physical activity. Some people gain
weight when they quit smoking. Nicotine raises the body’s meta-
bolic rate, resulting in more calories burned. In addition, food typ-
ically tastes and smells better after one stops smoking, and
eating a natural stopgap for hands and mouths no longer filled
with a cigarette.10 In addition, many women find it difficult to lose
Where’s the Beef?
pregnancy weight after giving birth, contributing to the develop-
In the United States, society facilitates obesity. Food is readily
ment of obesity.
available and often comes in “super-sized” portions. Passive
entertainment has become the norm as the bulk of the popula-
Also of note is the distribution of body fat as it can have an impact
tion has morphed into a modern cliché, the “couch potato.” Stud-
on illnesses that are directly attributable to obesity. Excessive body
ies have shown that only a small fraction of the population
fat in the abdominal area significantly increases the probability of
achieves the minimally recommended exercise goals.7
diabetes mellitus, hypertension and hypercholesteremia.11

Environment and lifestyle play a significant role in the develop-

ment of obesity. Obesity is not only a product of our eating habits Distribution of Body Fat
and exercise patterns, but also a manifestation of our modern Women typically collect fat in
lifestyle. More people choose to drive around the block than to the hips and buttocks, giving
walk, to eat in restaurants or order take-out than to cook and to them a “pear-shaped” look.
snack on high-caloric vending machine selections than to con- Men typically develop more women
centrate on healthier alternatives.7 “pear” men
of an “apple” shape, generally shape “apple”
accumulating fat around the shape
Cultural background also affects weight. Foods specific to certain abdomen. Women with a
cultures may be high in salt and fat. Family gatherings often prof- waist measurement of more
fer large quantities of food, along with an excellent excuse not than 35 inches and men with
only to socialize, but to overindulge.7 a waist measurement of more
than 40 inches run a higher risk of
Certain preexisting conditions and illnesses can lead to a propen- developing weight-related complications
sity for overweight and obesity. Hypothyroidism lowers the body’s related to the distribution of body fat.12
metabolic rate, resulting in a slower and reduced expenditure of
energy. Cushing’s disease, a hormonal disorder, commonly People who are obese are more likely to develop a number of
causes upper-body obesity and increased fat around the neck. significantly serious and chronic diseases. Among these are
Increasing evidence exists that insufficient sleep may lead to hypertension; elevated cholesterol levels; diabetes; coronary
weight gain over time as does polycystic ovarian syndrome artery disease; stroke; osteoarthritis, sleep apnea and respiratory
(which is characterized by high levels of male hormone), irregular difficulties; some cancers (endometrial, breast and colon); nonal-
or missed menstrual cycles and multiple, small cysts in the coholic fatty liver disease; endocrine problems; gallbladder dis-
ovaries. Certain drugs — such as steroids, some antidepressants ease; and fertility and pregnancy complications. The greater the
and medications used to treat psychiatric illnesses and seizure weight, the more likely a chronic health problem will develop.
disorders — may cause weight gain by slowing the metabolic A reduction of body weight by as little as 5 to 10 percent can sig-
rate, stimulating the appetite or causing water retention.9 nificantly improve overall health status.13

22 Healthy Skin
It’s Not a Diet — It’s a Lifestyle
The goal of any weight loss program is to achieve and main-
tain a healthy weight. The treatment of choice depends upon
the level of obesity and a person’s overall health and readi-
ness to devote the effort to a weight loss plan. Any weight loss
regimen should begin with dietary and lifestyle modifications.
Weight loss will result primarily from a decrease in overall food
intake, which will decrease calorie intake. (A calorie is a unit of
energy that is supplied by food.) An excess of about 3,500
calories results in the accumulation of one pound of body fat.
Simply by reducing caloric intake by as little as 250 calories
per day, a person can loose a half a pound per week.
Decreasing intake by 500 to 1,000 calories a day will produce
a weight loss of about one to two pounds per week. This can
be accomplished by replacing high-calorie food of low nutri-
tional value, typically highly processed foods with a high sugar
and solid fat content, with nutritious, low-calorie foods, such
as fruits, vegetables and whole grains.14
Physical activity in conjunction with a modified dietary intake
plays an important role in preventing overweight and obesity.
Although the body burns a certain amount of calories natu-
rally as it cycles through its daily functions of breathing,
digestion and activities of daily living, most people still ingest
more calories than they expend. To remain in balance, the
calories consumed from food must equal the calories
expended in physical activity. Too many calories will cause
weight gain while too few will lead to a weight loss. Physical
activity provides both direct and indirect benefits. While
increasing energy expenditure and reducing the risk of car-
diovascular disease, it also helps preserve muscle mass at
the same time it is decreasing body fat. Physical activity can
be in the form of walking, running, dancing, gardening or par-
ticipating in sports. A person should engage in some form of
physical activity to achieve an optimally healthy lifestyle.
Adults should take part in at least two and a half hours of
moderate exercise or one hour and 15 minutes of vigorous,
aerobically beneficial exercise every week.15
Crash diets are never recommended, because they can com-
pound existing health issues by creating vitamin deficiencies.
People can shed weight quickly with very low calorie diets,
which consist of 800 calories per day (most adults consume
2,000 to 2,500 calories daily), but they generally regain the
weight quickly when they resume a regular diet.14
A successful weight loss program requires changes in
behavior and more than just the reduction of caloric intake in
isolation. A solid weight loss plan consists of alterations in
physical activity, as well as a thorough examination of eating
habits and realistic and achievable goals. Goals set too high
too quickly will result only in failure. Obesity does not have to
become a chronic disease. A healthy diet, daily exercise and
a strong commitment to a healthy lifestyle can derail obesity
and its health complications.
Continued on page 25
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The Drug’s the Thing
The most therapeutic weight loss approach involves a solid diet,
exercise plan and behavior modification system set up, ideally, in con-
junction with a physician and a nutritional counselor. However, peo-
ple who have found this approach to be unsuccessful, have a BMI
greater than 30 and have developed obesity-related medical com-
plications can explore additional regimens of weight loss. The phar-
macological management of obesity has gained attention as a
greater portion of the population strives to lose weight. Weight-loss
medications should be considered only in conjunction with a diet and
exercise plan, and only if lifestyle modifications have not proved to
be effective.
Medications to treat obesity can be divided into three categories:
those that reduce food intake, those that alter metabolism and
those that increase energy expenditures. Many medications are
sold over-the-counter or by prescription to enhance weight loss
in individuals who are obese. Although most weight-loss med-
ications are approved for short-term use only, two that have been
approved by the FDA for long-term use are sibutramine (Meridia)
and orlistat (Xenical). Sibutramine alters the brain chemistry in the
appetite center of the brain by extending the amount of time that
serotonin and noradrenaline are free to work. The increased rate
of activity of these combined chemicals results in appetite sup-
pression. While its most common adverse effect is hypertension,
sibutramine can also cause tachycardia, headaches, dry mouth,
constipation and insomnia.17 It should not be used by a person
with or at a high risk for cardiovascular disease.
Improving Quality of Care Based on CMS Guidelines 25
Orlistat, on the other hand, prevents absorption of fat in the
intestines; fat is eliminated in the stool instead of being absorbed
and becoming fat itself. By keeping the body from absorbing
dietary fat, orlistat reduces the total amount of energy from calories
absorbed by the body and, taken as directed, can block up to 30
percent of ingested fat.18 The adverse effects include oily and fre-
quent bowel movements and diarrhea, as well as a reduction in
absorption of essential fat-soluble vitamins and nutrients. Orlistat
must be taken with vitamin and nutrient supplements.18
Most FDA-approved weight-loss medications are appetite sup-
pressants not suggested for use for more than 12 weeks.
Examples include phentermine (Fastin) and diethylpropion (Ten-
uate). Other medication classifications that cause weight loss as
a side effect include the diabetic medication metformin HCl (Glu-
cophage), antidepressive medications including bupropion (Well-
butrin) and antiseizure medications that include topiramate
(Topomax) and zonisamide (Zonegran). Researchers are studying
these drugs for their unequivocal usefulness in treating obesity.19
Research is ongoing on the long-term effects of medications pre-
scribed specifically for weight loss. Currently, except for orlistat
(released in 2007 in an over-the-counter variety), all weight loss
medications are controlled substances because of the potential
for abuse and development of dependency. Many people on
weight-loss medication are nonadherent with diet and exercise
programs because they believe the medication will control their
weight for them. However, although many of the adverse effects

Patients should
use caution when
considering the
many OTC products
advertised for
weight loss
of these medications are mild, rare, serious and even fatal
outcomes can and do occur. In addition, when people stop
taking these drugs, weight gain tends to reoccur.20
Patients should use caution when considering the many OTC
products advertised for weight loss. The FDA issued warn-
ings against more than 70 “tainted weight-loss products” that
contained undocumented or dangerous pharmaceutical in-
gredients. Many contained prescription drugs in amounts that
exceeded maximum recommended doses or contained
undeclared and dangerous chemical components.21
26 Healthy Skin
Big Eyes, Small Stomach
Weight-loss surgery, known as bariatric surgery, bypass sur-
gery or gastric banding, is recommended for people who
have clinically severe obesity (once called “morbid obesity”)
and have failed to lose weight through diet and exercise.
Weight-loss surgery is suggested for people with a BMI of 40
or greater, men who are 100 pounds or more overweight and
women who are 80 pounds or more overweight.22 Surgical
intervention provides a medically sustained weight loss for
more than five years in most patients.23 However, it is not a
miracle cure and still requires a life-long commitment to a
healthy lifestyle consisting of a low-calorie diet and a healthy
exercise program.
Gastric bypass surgeries limit the amount of food a person can
consume and digest by surgically altering the anatomy of the
GI tract. There are different types of bypass surgeries, and their
use depends on surgeon preference and patient requirements.
The Roux-en-Y gastric bypass is the most common weight-
loss surgery in the United States. A surgery that combines the
principles of “restriction” and “malabsorption,” it consists of the
stapling of a portion of the stomach together to form a smaller
pouch that cannot contain a large amount of food at any one
time. This limits food intake. In addition, a Y-shaped section of
the small intestine is attached to the pouch, which causes food
to bypass both the duodenum and the first portion of the
jejunum, leading to reduced caloric and nutrient absorption.24
Continued on page 28
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A more extensive and complicated gastric bypass surgery is the
biliopancreatic diversion. It involves removing the lower portion of
the stomach and attaching the small pouch remaining directly to
the small intestine, bypassing the entire duodenum and jejunum.
Although successful as a weight-loss surgery, it is not extensively
performed as it carries a high risk for nutritional deficiencies since
so much of the area of the small intestine is not absorbing poten-
tially essential nutrients.25
Sleeve gastrectomy is another example of a “restrictive” bariatric
surgery. Typically considered a surgical option for patients who
have a BMI of 60 or greater, sleeve gastrectomy involves creat-
ing a sleeve-shaped stomach pouch about the size of a banana,
larger than the pouch created during a Roux-en-Y bypass sur-
gery. Sleeve gastrectomy is usually the first of a two-part surgi-
cal treatment plan that is completed with the performance of a
gastric bypass surgery.26
28 Healthy Skin
Gastric banding is a “restrictive” surgical procedure. An
adjustable silicone band is placed around the upper portion of
the stomach, molding it into two separate but connected cham-
bers. Saline is added or removed from the band through an
injection port attached to the abdominal wall underneath the skin
and connected to the band with soft, thin tubing. Adding saline
to the band through the port increases restriction and limits
intake, helping patients feel full sooner with less food. Potential
benefits of this procedure include an improved quality of life,
improved physical function, improved social and economic
opportunities, and improvement of obesity-related comorbidities,
including diabetes, hypertension and high cholesterol. The down
side is that although the procedure restricts the amount of food
that can be ingested at any one time, it doesn’t eliminate the
desire to eat. Diet, an exercise plan and behavior modification
must still be a definitive part of any surgical resolution of obesity.27
As miraculous as the results of these surgeries may be, they are
not without risks and complications. Pneumonia, blood clots and
infection can occur after any surgical procedure. Rapid weight
lose can predispose a person to gallstones. The gastric bypass
itself can cause “dumping syndrome,” which occurs when the
contents of the stomach move through the intestines too quickly,
resulting in nausea, vomiting, diarrhea, dizziness and sweating.28
Weight-loss surgeries can produce dramatic and startling effects
not only on a person’s weight, but on his or her overall health sta-
tus and quality of life. Within the first two years postprocedure,
people can shed 50 to 60 percent of their excess weight.12 Ded-
icated maintenance of a healthy lifestyle will ensure that weight
loss is permanent.29
The Invisible Man
Obesity carries a negative connotation in numerous societies.
Many cultures judge beauty by weight. (Consider the saying “You
can never be too rich or too thin.”) Many people view the over-
weight as slothful, gluttonous and lazy. People who are over-
weight are often overlooked and ignored. As a result, obesity can
have serious psychological, social and economic consequences.
Society’s weight bias leaves people who are obese vulnerable to
depression, anxiety, lowered self-image and, in some instances,
suicidal ideation.
The stigma of obesity affects all areas of a person’s life.30
Under the umbrella of weight bias are employees who are
treated poorly by their coworkers and obese students who
are ridiculed by their peers. It is no wonder that depression
and feelings of inadequacy can result. Unhealthy coping
mechanisms can emerge, and people may react to negative
stimuli by overindulging on comfort food, isolating themselves
or responding negatively to others and refusing to diet. Pos-
itive coping mechanisms can include stress management,
stimulus control, cognitive restructuring and the cultivation of
a strong and supportive social network. A positive self-image
that includes developing self-love and acceptance, dieting,
refusing to hide and educating others about the very real
dilemma of weight bias can go a long way in alleviating the
burden of prejudice.31
The Long and Winding Road
Weight loss and maintenance are life-long. Management
includes the reduction of excessive weight in combination
with the maintenance of weight loss and control of any obe-
sity-related comorbidities. It is as much a state of mind as a
way of life. Weight loss and maintenance of a healthy weight
involve a healthy diet low in fat and high in carbohydrates and
a plan for regular physical activity. Successes should be
rewarded, but not with food. A person can adjust to smaller
portions by eating more slowly and taking smaller bites of
food at a time. Weight loss can be charted, and successes
can be documented and celebrated. The conscientious mon-
itoring of progress increases motivation.32
Improving Quality of Care Based on CMS Guidelines 29
Weight loss not only helps control diseases exacerbated by
obesity and related to increased mortality rates, but also
decreases the likelihood of developing such diseases in the
first place. There is no rule of thumb for the treatment of
weight loss. Basic principles of obesity therapy and treatment
are a “pyramid” with a base of diet, exercise and behavior
modification. The next level is pharmacological intervention
and, at the top, surgery if necessary. Noninvasive interven-
tions include acupuncture, hypnosis and herbal remedies and
supplements. In the end, weight loss and control is a jour-
ney, not just a destination, with the goal a comprehensive
improvement in overall health.
Weight Management and Obesity Resource List
• The Obesity Society: www.obesity.org
• Obesity Action Coalition: http://obesityaction.org/
home/index.php
• CDC resources: www.cdc.gov/obesity/
resources.html
About the author
Cathy S. Birn, RN, MA, GRN, CNOR practices endoscopy at
memorial Sloan-Kettering Cancer Center in New York, NY; is
the cochair woman of the education committee of The Soci-
ety of Gastroenterology Nurses and Associates and is a for-
mer member of the board of directors of the Gastroenterology
Nursing Journal.
Copyright [2010]. Nursing Spectrum Nurse Wire
(www.nurse.com). All rights reserved. Used with permission.
 References
1 Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity
among U.S. adults, 1999-2008. JAMA 303(3):235-241, 2010.
2. AOA fact sheets: obesity in the U.S. American Obesity Association Web site.
http://www.obesity.org/information/factsheets.asp. Accessed July 8, 2010.
3. Adams KF, Schatzkin A, Harris TB, et al. Overweight, obesity, and mortality in a
large prospective cohort of persons 50 to 71 years old. N. Engl J Med. 2006
355(8):763-778.
4. About BMI for adults. CDC Web site. http://www.cdc.gov/healthyweight/assess-
ing/bmi/adult_bmi/index.html. Accessed July 9, 2010.
5. Obesity and overweight for professionals: data and statistics. CDC Web site.
http://www.cdc.gov/obesity/data/trends.html. Accessed July 9, 2010.
6. Obesity and overweight for professionals: economic consequences. CDC Web site.
http://www.cdc.gov/obesity/causes/economics.html. Accessed July 9, 2010.
7. Caprio S, Daniels SR, Drewnowski A, et al. Influence of race, ethnicity, and culture
on childhood obesity: implications or prevention and treatment: a consensus
statement of Shaping America; Health and the Obesity Society. Diabetes Care.
2008;(11):2211-2221.
8. Chaput JP, Despres JP, Bouchard C, Tremblay A. The association between sleep
duration and weight gain in adults: A six-year prospective study from the Quebec
family study. Sleep. 2008;31(4):517-523.
9. Reutsch O, Viala A, Bardou H, Martin P, Vacheron MN. Psychotropic drugs in-
duced weight gain: s review of the literature concerning epidemiological data,
mechanisms, and management. Encephale. 2005:507-516,
10. Lerman C, Berrettini W, Pinto A, et al. Changes in food reward following smoking
cessation: a pharmacogenetic investigation. Psychopharmacology. 2004;174:571-577.
11. Bessesen DH. Update on obesity. J Clin Endocrinol Metab. 2008;93(6):2027-2034.
12. Guh D, Zhang W, Bansback N, Amarai Z, Birmingham C, Anis A. The incidence of
co-morbidities related to obesity and overweight: a systematic review and meta-
analysis. MC Public Health Web site. http://www.biomedcentral.com/1471-
2458/9/88. Published March 25, 2009. Accessed July 9, 2010.
13. Shai I, Stampfer MJ. Weight-loss diet: can you keep it off? Am J Clinical Nutrition.
2008;88 (5):1185-1186.
14. Gorin AA, Phelan S, Wing RR, et al. Promoting long-term weight control: does
dieting consistency matter? Int J Obes Relat Metab Disord. 2004;28(2):278-281.
15. Physical activity for everyone. Department of Health and Human Services Web
site. http://www.cdc.gov/physicalactivity/everyone/guidelines/
adults.html. Accessed July 9, 2010.
16. Bray GA. Lifestyle and pharmacological approaches to weight loss: Efficacy and
safety. J Clin Endocrinol Metab. 2008;93(11 Suppl 1):S81-S88.
30 Healthy Skin
17. Wooltorton E. Obesity drug sibutramine (Meridia): hypertension and cardiac
arrhythmias. CMAJ. 2002;166(10):1307-1308.
18. Genentech USA Inc. Xenical (orlistal) product information. Xenical Web site.
http://www.xenical.com/hcp/3_productinfo.asp. Accessed July 9, 2010.
19. Boss, Olivier; Karl G. Hofbauer. Pharmacotherapy of Obesity: Options and
Alternatives. Boca Raton, FL: CRC Press. 2004.
20. Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005;
82(1 Suppl):2225-2255.
21. FDA uncovers additional tainted weight loss products. FDA Web site.
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/-
ucm149547.htm. Updated March 20, 2009. Accessed July 9, 2010.
22. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med.
2007:356(21):2176-2183.
23. Echols J. Obesity weight management and bariatric surgery case management
programs: A review of literature. Prof Case Management. 2010;15(1):17-26.
24. Buchwald H, Olen DM. Metabolic/bariatric surgery worldwide 2008. Weightloss
Surgery Vitagarten Web site. Published 2009. Accessed July 9, 2010.
25. Piazza L, Pulvirentil A, Ferrara F, et al. Laparoscopic biliopancreatic diversion: our
preliminary experience with 201 consecutive cases. Chir Ital. 2009;61(2):143-148.
26. Sammour T, Hill AG, Singh P, Ranasinghe A, Babor R, Rahman H. Laparoscopic
sleeve gastrectomy as a single-stage bariatric procedure. SpringerLink Web site.
http://www.springerlink.com/content/3145284114518783. Accessed July 9, 2010.
27. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or by
pass? A systematic review comparing the two most popular bariatric procedures.
Am J Med. 2008;(10):885-893.
28. Apovian CM, Cummings S, Anderson W, et al. Best practice updates for multi-
disciplinary care in weight loss surgery. Obesity. 2009;17(5):871-879.
29. Farrell TM, Haggerty SP, Overby DW, Kohn GP, Richardson WS, Fanelli RD.
Clinical application of laparoscopic bariatric surgery: an evidence-based review.
SpringerLink Web site. http://www.springerlink.com/content/
121234v000452321. Accessed July 9, 2010.
30. Puhl RM, Heuer CA. Obesity stigma: important consideration for public health.
Am J Public Health. 2010;100(6):1019-1028.
31. Wardle J, Cook L. The impact of obesity on psychological well being. Best Pract
Res Clin Endocrinol Metab. 2005;19(3):421-440.
32. Butryn ML, Phelan S, Hill JO, et al. Consistent self-monitoring of weight: a key
component of successful weight loss maintenance. Obesity. 2007;15 (12):3091-3096.
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32 Healthy Skin
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Feeding Dementia
Patients With
DIGNITY
By Roni Caryn Rabin
She would chew away at her food, coughing and sput-
tering and spitting up but swallowing very little, said her
daughter, Cyndy Viveiros. And like many relatives caring
for patients with advanced dementia, Ms. Viveiros had to
decide whether or not to have a gastric feeding tube
inserted.
This quandary — which usually arises near the end, when
Alzheimer’s begins to destroy the part of the brain that
controls eating — is often presented as a stark choice
between providing nourishment and withholding it.
But social workers advising Ms. Viveiros suggested
another option: continuing to have her mother carefully
fed by hand, giving her only as much as she wanted and
stopping if she started choking or became agitated.
“I had this realization — wow — that no matter what we
did, Mom was never going to get better,” Ms. Viveiros
said. “We were just prolonging the inevitable, and poten-
tially causing more suffering.
“Mom was already dying. Alzheimer’s is a terminal disease.
There’s no stopping it,” she said.
Mrs. DeFelice, of Providence, R.I., died about eight months
later.
Improving Quality of Care Based on CMS Guidelines 33
Treatment
Doctors are calling this new option in palliative care “com-
fort feeding only.” In a recent paper in The Journal of the
American Geriatrics Society, the authors argue that feed-
ing tubes do not necessarily prolong life in patients with
advanced dementia, and that surveys indicate that a vast
majority of nursing home residents say they would rather
die than live with a feeding tube.
But medical orders like “no artificial hydration and
nutrition” — used to indicate that the patient should not
be given a feeding tube — are often interpreted as “do not
feed.” And few people can tolerate the idea that a loved
one may be starving to death.
Comfort feeding offers another alternative.
“We believe careful hand-feeding is a much more humane
way of taking care of these people, and preserves the
patient’s dignity,” said an author of the paper, Dr. Joan
Teno, a professor of community health at Brown Univer-
sity’s medical school. “They can still have that human
interaction and intimate contact that comes with being fed.
“Just imagine someone interacting with the patient, talking
to them, cueing them into eating,” Dr. Teno said, “as
opposed to someone walking to the bedside and pouring
a bottle of Ensure down the feeding tube.”

Nancy Berlinger, a bioethics research scholar at the
Hastings Center, a research institute in Garrison, N.Y.,
said the feeding-tube dilemma was “not a choice peo-
ple tend to want to face with reference to their mother,
who probably fed them at an earlier age.”
Eating is a pleasurable activity, and feeding is associ-
ated with love and nurturing, Dr. Berlinger went on, so
the question “Should we put a feeding tube in, or do
you want to stop feeding her?” is almost like asking, “Do
you love your mother or not?”
Feeding tubes are used in about a third of all nursing
home residents with advanced dementia, in part
because the homes worry they could face regulatory
scrutiny if their patients are losing weight. Hand-feeding
can also be time-consuming and labor-intensive. In
addition, the United States Conference of Catholic Bishops
issued a directive last year stating that Catholic health
facilities have “an obligation to provide patients with
food and water, including medically assisted nutrition
and hydration for those who cannot take food orally.”
Yet studies suggest that the tubes do not necessarily
prolong survival. Nor do they always prevent aspiration
in people who have trouble swallowing, since they are at
risk of aspirating their own saliva.
Moreover, the tubes can be very uncomfortable, and
people with dementia must often be physically
restrained or sedated to prevent them from yanking the
tubes out.
From The New York Times, © August 3, 2010 The New York Times All rights reserved. Used by permission and protected by the Copyright Laws of the
United States. The printing, copying, redistribution, or retransmission of the Material without express written permission is prohibited.
Photos published here did not run with the original New York Times article.
34 Healthy Skin
Photo from Shutterstock
As many as 5.1 million Americans have Alzheimer’s
disease, the most common cause of dementia, and the
number is expected to rise as the baby boom genera-
tion ages. The disease is progressive and terminal,
though it may take years to run its course; it is the sixth
leading cause of death in the United States, killing more
than 71,000 a year, a figure many experts think is
understated.
Sometimes the ability to eat is lost in the early stages of
Alzheimer’s, not toward the end. Seymour Geffner says
it was one of the first signs that something was wrong
with Blossom, his wife of 63 years.
He started feeding her four years ago, while she went
through a series of tests to figure out what was wrong.
Now that she lives at Schervier Nursing Care Center in
Riverdale, in the Bronx, he spends every day there,
hand-feeding her lunch and dinner.
Each feeding takes 45 minutes to an hour, said Mr.
Geffner, 86.
“Some days are better than others,” he said. “The food
is puréed, and she doesn’t eat a full meal. But I always
give her at least half a banana every day, and strawberries
in season.”
“The bottom line is she doesn’t go hungry,” he said.
“She looks good.”
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 Survey Readiness
CDC, FDA, CMS ISSUE
INFECTION CONTROL GUIDANCE
Point of care testing in healthcare settings
The Centers for Disease Control and Prevention (CDC) recently
released new guidelines regarding blood glucose monitoring and
insulin administration when people are assisting others, (i.e., in
healthcare settings). Not all of the CDC information is new; how-
ever, it clarifies how to prevent infection when using a glucose
monitor. Some of this information has been available from the
CDC since 2005. The latest language states:
CDC is alerting all persons who assist others with blood glucose
monitoring and/or insulin administration of the following infec-
tion control requirements:
• Fingerstick devices should never be used for more than
one person
• Whenever possible, blood glucose meters should not
be shared. If they must be shared, the device should
be cleaned and disinfected after every use, per the
manufacturer’s instructions. If the manufacturer does
not specify how the device should be cleaned and
disinfected, then is should not be shared.
• Insulin pens and other medication cartridges and syringes
are for single patient use only and should never be used
for more than one person.
An underappreciated risk of blood glucose testing is the opportunity
for exposure to bloodborne viruses, such as hepatitis B virus
(HBV), hepatitis C virus and HIV through contaminated equip-
ment and supplies if devices used for testing and/or insulin
administration are shared. Examples of these devices include
blood glucose meters, fingerstick devices and insulin pens.
Outbreaks of HBV infection associated with blood glucose mon-
itoring have been identified with increasing regularity, particularly
in long-term care settings, where residents often require assis-
tance with monitoring of blood glucose levels and/or adminis-
36 Healthy Skin
tration. In the last 10 years alone, there have been at least 15
outbreaks of HBV infection associated with providers failing to
follow basic principles of infection control when assisting with
blood glucose monitoring. Due to under-reporting and under
recognition of acute infection, the number of outbreaks due to
unsafe diabetes care practices identified to date are likely to be
underestimated.
Although the majority of these outbreaks have been reported in
long-term care settings, the risk of infection is present in any
setting where blood glucose monitoring equipment is shared
or when those assisting with blood glucose monitoring and/or
insulin administration fail to follow basic principles of infection
control.
For example, at a health fair in New Mexico in 2010, dozens of
attendees were potentially exposed to bloodborne viruses when
fingerstick devices were inappropriately reused for multiple persons
to conduct diabetes screening. In addition, at a hospital in Texas
in 2009, more than 2,000 persons were notified and recom-
mended to undergo testing for bloodborne viruses after individ-
ual insulin pens were used for multiple persons.
Fingerstick devices should never
be used for more than one person.
Full guidelines can be found at http://www.cdc.gov/injection-
safety/blood-glucose-monitoring.html.
The Food and Drug Administration (FDA) recently posted a
Safety Alert on reusable fingerstick devices and point of care
testing devices. They stated that fingerstick devices should
never be used for more than one person. When possible, POC
blood testing devices, such as blood glucose meters and
PT/INR anticoagulation meters, should be used only on one
patient and not shared. If dedicating POC blood testing devices
to a single patient is not possible, the devices should be prop-
erly cleaned and disinfected after every use as described in the
device labeling.
PERIOPERATIVE PRESSURE
The full alert can be found at: http://www.fda.gov/Safety/Med- ULCER EDUCATION.
Watch/SafetyInformation/SafetyAlertsforHumanMedicalProd-
MORE IMPORTANT
ucts/ucm224135.htm?sms_ss=email
THAN EVER BEFORE
If shared, blood glucose meters
should be cleaned and disinfected
after every use.
Similar to the CDC and FDA, the Centers for Medicare & Medi-
caid Services (CMS) issued a memo in late August 2010
regarding infection control standards for nursing homes. The
memo is a reminder:
“ I have seen an increase in
the number of legal issues
linking facility-acquired pressure
ulcers to post-surgical patients.
A pressure ulcer program for the
OR is more critical than ever.”
Diane Krasner, PhD, RN, CWCN,
• not to reuse fingerstick devices for more than one resident CWS, BCLNC, FAAN
• not to use a blood glucose meter or other point-of-care device
for more than one resident without cleaning and disinfecting Medline’s Pressure Ulcer Prevention Program
it after each use now has a component designed specifically for the
perioperative services. The easy-to-use interactive
Also, if the manufacturer does not specify instructions for clean- CD addresses the following:
ing and disinfection between uses of a point-of-care device, • Hospital-acquired conditions
then the device should not be used for more than one resident. • CMS reimbursement changes
• Best practices for pressure ulcer prevention
CMS also clarifies that reuse of fingerstick devices for more than
• Perioperative assessment tools
one resident should be treated as immediate jeopardy. Failure to
• Critical patient and equipment risk factors
clean and disinfect blood glucose meters used for more than
one resident is a deficiency in infection control that warrants
corrective action; however, it may not constitute immediate
To learn more about Medline’s
jeopardy.
Pressure Ulcer Prevention Programs
for long-term care, acute care and
A copy of the CMS memo to state survey agency directors is
perioperative services, call your
located at www.cms.gov/surveycertificationgeninfo/downloads-
Medline representative or visit
/SCLetter10_28.pdf.
www.medline.com/pupp-webinar.

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©2010 Medline Industries, Inc.
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Continuing Education Article Prevention

VE
EFFECTI S
UE
TECHNIQ OID
AV
TO HELP SURE
ES
HEEL PR S
ULCER

by Alecia Cooper, RN, BS, MBA, CNOR
With their drier skin and bony prominences, the heels are par-
ticularly vulnerable to injury. People with medical conditions
requiring them to spend long periods of time in bed are espe-
cially susceptible to heel injuries – particularly pressure ulcers
– in the absence of proper prevention strategies. In addition,
the soles of the feet have no sebaceous glands, resulting in a
lack of skin lubrication. This makes the heels vulnerable to dry-
ness and damage from friction, another precursor to pressure
ulcers.1
SAVE
THOSE
HEELS!
Complex heel pressure ulcers represent one of the most costly
complications in the elderly.2 They are the most common
facility-acquired pressure ulcers in long-term care facilities and
the second most common among all healthcare settings. In
fact, long-term care facilities have reported pressure ulcer
prevalence rates as high as 27.3 percent, with 23.6 percent of
the ulcers occurring on the heels. In acute care and mixed
acute care/long-term care settings, heel pressure ulcers
account for approximately one third of all pressure ulcers.

Improving Quality of Care Based on CMS Guidelines 39

 They can be physically debilitating and painful, possibly lead-
ing to serious complications, including infection, cellulitis,
osteomyelitis, septicemia, limb amputation, and even death.3
Risk assessment
To avoid these complications, it is best to prevent heel pres-
sure ulcers altogether. And with appropriate preventive care,
most heel pressure ulcers can be avoided.3 Prevention begins
with a thorough assessment to determine which individuals
are at greatest risk. The most effective assessment of pressure
ulcer risk blends the results of general screening tools, knowl-
edge of common risk factors and nursing judgment.4
The Braden Scale is a widely used risk assessment tool that
screens for the individual’s degree of sensory perception,
exposure to moisture (usually caused by incontinence),
amount of activity, degree of mobility, nutrition level and
amount of exposure to friction and shear. Each of these areas
is scored numerically, with lower numbers indicating greater
risk. A copy of the Braden Scale is available online at
www.bradenscale.com/images/bradenscale.pdf.
Preventive interventions should focus on specific Braden
categories in which the patient has a low score. For example,
if a patient scores low under exposure to friction and shear,
interventions should focus on ways to minimize friction and
shear. Preventive measures also should be pursued in patients
whose total score indicates they are at risk.5 A total score
of 18 or less indicates a person at risk for developing pres-
sure ulcers.
40 Healthy Skin
Risk factors
Certain physical conditions also increase the risk for pressure
ulcers, including:6
• Decreased circulation and low blood pressure
• Being obese or underweight
• Advanced age
• Specific illnesses
• Medications
Decreased circulation and low blood pressure. Blood
supplies the body’s tissues with oxygen and nutrients, so
when blood flow is blocked or reduced, the tissues can liter-
ally starve. The result is the death of skin cells, which can lead
to the development of pressure ulcers.
People with diabetes often experience decreased circulation,
particularly in the legs and feet, making it more difficult for
a sore or infection to heal. Proper foot care is essential for
these individuals and necessary to prevent foot ulcers and in-
fection. Preventive measures include inspecting feet daily for
any cuts, sores, blisters or calluses. Feet should be washed in
warm water and dried thoroughly.7
Being obese or underweight. Two body types are at in-
creased risk for pressure ulcer development: people who are
obese and those who are extremely underweight. Obesity
causes higher risk because blood circulation to fatty tissue is
not as good as circulation to leaner muscular tissue. The poor
circulation means less oxygen and fewer nutrients, which can
lead to pressure ulcers. Very thin people are at risk as well be-
 “ Heel pressure ulcers are the most common
pressure ulcers in long-term care facilities.
cause they have less fatty tissue to cushion bony promi-
nences.
Advanced age. Age is an uncontrollable risk factor for pres-
sure ulcers. Older skin tends to be drier and thinner. It also
breaks down more easily and forms new cells more slowly.
Specific illnesses. Specific medical conditions also put indi-
viduals at greater risk for heel pressure ulcers. The following
groups of patients have the highest risk:8
• Those who cannot move their legs because of fractured
hips, joint replacement surgery, spinal cord injury, Guillain-
barre syndrome, stroke or another medical condition.
• People with diabetes and peripheral neuropathy,
which lessens the feeling of pressure or pain in the feet.
• Individuals with dementia who are confused and dis-
traught may inadvertently rub their heels on the bed,
causing heel abrasions from shear and friction.
These abrasions can result in pressure ulcers.
Medications. The side effects of certain medications can also
put individuals at increased risk for pressure ulcers. For ex-
ample, long-time use of steroids for the treatment of asthma
and other chronic respiratory disorders have a tendency to
thin the skin.
Once you have identified an individual at risk for heel pressure
ulcers, the next step is to create a personalized prevention
plan, including a thorough skin assessment with results doc-
umented in the chart. When assessing heels, a normal heel
may be defined as clean and dry with intact skin. An abnor-
Improving Quality of Care Based on CMS Guidelines 41
”
mal heel could be one that is pink, red, blistered or containing
an existing pressure ulcer.9
Tools for prevention
In addition to basic pressure ulcer prevention techniques, such
as regular turning and making sure the patient is well-nourished
and hydrated, there are several products that can aid in
preventing pressure ulcers on the heels. Preventive devices
should be selected on the basis of effectiveness, ease of use,
and cost. For preventing heel pressure ulcers, the best products
achieve the following:5
• Reduce pressure, friction and shear
• Separate and protect the ankles
• Maintain heel suspension
• Prevent foot drop
In patients at risk, the primary goal is to reduce pressure, fric-
tion and shear on the heels. Several types of products are
available to achieve one or more of these objectives. Some
examples include: pillows, heel offloading devices, padding
devices, moisturizers and pressure-relieving mattresses.
Pillows. The National Pressure Ulcer Advisory Panel (NPUAP)
recommends the use of pillows as an effective, convenient
and cost-effective way to elevate the legs of cooperative indi-
viduals for short periods of time. Raising the heel off the bed
with pillows is best achieved when the pillow is placed longi-
tudinally underneath the calf with the heel suspended in air.3
Pillows are not recommended, however, for individuals who
are at risk for moving the leg off the pillow or in cases when the
leg(s) must be elevated longer than 24 hours. For these
Continued on page 43
Relieve Pressure on Vulnerable Heels
HEELMEDIX™ Heel Protector
Pressure relief and skin protection all in one

The heels are the most common site for facility-acquired pressure ulcers in long-term
care, and the second most common site in all healthcare settings.1 According to clinical
experts, the most effective aspect of pressure ulcer prevention for heels is pressure relief,
also known as offloading.1,2 Offloading is achieved with the use of pillows or heel protection
devices that relieve pressure by elevating the heel off the bed or other surface.
Open back provides
maximum ventilation The HEELMEDIX Heel Protector is designed to help eliminate pressure, friction and
shear on the skin by elevating the heel. Made of soft, suede-like material on the inside
and easy-to-clean nylon on the outside. Adjustable straps are soft against vulnerable
skin. Includes a mesh laundry bag with patient ID label to simplify washing and sorting.

Mention this ad to receive a 10 percent discount on your first order.

Contact your Medline sales representative or call 1-800-MEDLINE.

1
Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing
heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48.
2
Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers:
stand guard. Advances in Skin & Wound Care. 2008;21(6):282-292.

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
patients, it’s best to use a product that stays on the foot during
movement – perhaps in the form of a heel offloading device.4

Heel offloading devices. The type of product most often

used to elevate the foot and keep it in place is called a
heel offloading device. Heel offloading devices can be more
efficient than pillows because they can remain in place around
the clock.3 Look for a device that is comfortable for the patient,
easy for the caregiver to use and permits repositioning with-
out increasing pressure in other areas. Most are shaped like a
large boot, surrounding the foot and ankle on all sides, but
also allowing open spaces for needed air flow. The advantage
of these devices is that they both relieve pressure and greatly
reduce friction and shear on the skin. They also separate and
protect the ankles and prevent foot drop. One area of cau-
tion: remember to remove protective boots routinely (i.e.,
every shift) to inspect the individual’s skin for redness.

To help determine the effectiveness of heel offloading devices

as a way to prevent heel pressure ulcers, Meyers studied
53 sedated ICU patients at high risk for pressure ulcers. All 53
wore a heel offloading device. As a result, none of the patients
developed a hospital-acquired heel pressure ulcer.9
Padding devices. Padding devices such as sheep skin and
“bunny boots” protect the heels from friction and shear but
do not remove pressure.
Moisturizers. Moisturizers also minimize friction. In addition,
they may contain topical nutrients to nourish the skin and/or
ingredients such as dimethicone, which adds a layer of
protection on top of the skin. Moisturizers do not, however,
provide any protection from excessive pressure.5
Pressure-reducing mattresses. Air fluidized beds consis-
tently reduce heel pressure below minimal capillary pressure.
However, some benefit may be lost if the head of the bed is
elevated to 30 degrees – a technique recommended to pre-
vent pressure ulcers on the upper body.5 Also, make sure the
mattress is positioned properly. Many pressure-reducing mat-
tresses have a definitive head and foot. Placing the mattress
upside down on the bed, so that the individual’s feet are rest-
ing on the head portion, can lead to heel problems.
Conclusion
With heel pressure ulcers being the most common type of
pressure ulcer in long-term care and the second most com-
mon in all healthcare settings, there is still much to be learned
about prevention. Overall, information on the prevention of
heel pressure ulcers is lacking; however, medical needs are
changing. Higher patient acuity and the growing elderly pop-
ulation will continue to keep this issue in the forefront.10 Further
studies are needed to document the effectiveness of existing
interventions and develop new ones.
References
1. Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure
ulcers: stand guard. Advances in Skin & Wound Care. 2008;21(6):282-292.
2. Walsh JS. Keeping heels intact: using a nursing professional practice model
can improve outcomes. Advance for Nurses. 2010; 8(24):25.
3. Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for
preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10).
Available at www.o-wm.com/content/practice-recommendations-preventing-
heel-pressure-ulcers. Accessed August 25, 2010.
4. Cuddigan JE, Ayello EA, Black J. Saving heels in critically ill patients.
WCET Journal; 28(2):2-8.
5. FAQs: Preventing heel pressure ulcers in immobilized patients. Advances in
Skin & Wound Care; 18(1):22.
6. Pressure Ulcer Prevention Program Nurse Workbook. 2nd edition. Medline
Industries: Mundelein, IL. 2010.
7. Saccomano SJ. Handle with care: proper foot and skin care are necessary
to prevent complications in diabetic residents. Advance for Long-Term Care
Management. July/August 2010:24-26.
8. Black J. Preventing heel pressure ulcers. Nursing. 2004; 34(11):17.
9. Meyers TR. Preventing heel pressure ulcers and plantar flexion contractures
in high-risk sedated patients. Journal of Wound, Ostomy and Continence
Nursing. 2010; 37(4):372-378.

Improving Quality of Care Based on CMS Guidelines 43

 CE TEST

SAVE THOSE HEELS!

Effective Techniques to Help Avoid Heel Pressure Ulcers

True/False Multiple Choice (cont)

1. People who spend long periods of time 8. Which of the following devices protect heels from
in bed are more susceptible to heel friction and shear but do NOT remove pressure?
pressure ulcers. T F a. Sheep skin
b. Heel offloading devices
2. Obesity increases an individual’s risk for c. Moisturizers
developing pressure ulcers. T F d. Both a and c

3. Heel pressure ulcers are the most 9. Heels are more prone to pressure ulcers than
common facility-acquired pressure ulcers other parts of the body because
in long-term care. T F a. They have bony prominences
b. The skin lacks sebaceous glands and tends to
4. Heel pressure ulcers account for approximately be dry
one half of all pressure ulcers in acute care and c. They are usually covered with shoes and socks
mixed acute care/long-term care settings. T F d. Both a and b

5. People with diabetes often experience decreased 10. Heel pressure ulcers are the second most
circulation, especially in the legs and feet. T F common type of pressure ulcers among
a. All healthcare settings
Multiple Choice b. Home health care
6. A low score on the Braden Scale means the c. Hospitals
individual is d. Day care centers
a. At lower risk for pressure ulcers
b. At higher risk for pressure ulcers
c. Anemic
d. None of the above

7. Which of the following is NOT a common risk

factor for developing heel pressure ulcers?
a. Guillain-Barre syndrome
b. Joint replacement surgery
c. Dementia
d. Urinary tract infection

Submit your answers at

www.medlineuniversity.com
and receive 1 FREE CE credit

Courses approved for continuing education by the Florida Board of Nursing and the California Board of Reigistered Nursing.

44 Healthy Skin
Snug-fitting sheets
for healthier skin.
SoftSpan sheets with spandex fit snugly
on the bed to comfort and protect the skin.
A patented blend of cotton, polyester and spandex
provides softness and a non-abrasive surface, along Call your Medline representative or 1-800-MEDLINE
with better air circulation for skin health. to trial two dozen SoftSpan fitted sheets for the
same price you’re paying for your current sheets.
Independent laboratory studies1 showed that SoftSpan
fitted sheets had 260% stretch in the width and 98%
stretch in the length, compared to a regular knit sheet,
which has 104% stretch in the width and 45% in the
length. Regular woven sheets have no stretch at all.
References
1. Diversified Testing Laboratories, Inc. ASTM D 6614-07, “Standard Test
More stretch means a tighter, smoother fit, and no Method for Stretch Properties of Textile Fabrics – CRE Method.” July 29,
wrinkles. Mayo Clinic and other healthcare experts 2009. Data on file.
2. Mayo Clinic. Bed sores (pressure sores). Available at http://www.may-
recommend keeping the bottom sheet pulled tight oclinic.com/health/bedsores/DS00570. Accessed on February 5, 2010.
to prevent wrinkles and bunching, which can cause 3. Oregon Department of Human Services. Pressure Sores: A Self-Study
Course. 2008. Available at: http://www.oregon.gov/DHS/spd/provtools/nurs
pressure that contributes to skin breakdown.2,3

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 Treatment

by Cynthia Ann Fleck

RN, BSN, MBA, CWS, DNC, CFCN

In January, I had what I like to describe as

Extreme Makeover — Foot Edition. While my
show didn’t include Ty Pennington’s yelling from
his megaphone, rebuilding homes for deserving
folks on a Sunday night, I couldn’t take the agony
of da feet any more and needed more than just my
custom orthotics. I needed something drastic to
alleviate the years of pain and suffering my poor
peds had endured.

I was a ballerina growing up, then spent my teenage and young-

adult years as a competitive long-distance runner. This, coupled
with some genetics from my maternal grandmother Florence, left
me with some motor changes in my feet and pain that became
increasingly worse — to the point that walking through an airport
or standing to give a presentation in anything other than sneakers
became excruciating! Reprinted with permission
from AAWC News.
www.aawconline.org

46 Healthy Skin
Improving Quality of Care Based on CMS Guidelines 47
 Looking back at my grandmother’s things when she passed
and helping clean out her home, I found all sorts of concoc-
tions, bunion pads, foot creams, etc. It was all-too reminis-
cent of the 2 x 2 hydrocolloids and special skin creams
always in my handbag, medicine cabinet, and suitcase when
I need to pad the many hot spots on my feet.
So, I finally took the plunge and had my foot deformities surgi-
cally corrected (on my right foot) by my friend, Larry Huels,
DPM, a foot and ankle surgeon (see Figure 1). Five surgeries on
one foot (see Figure 2) meant I was on the OR table almost 4
hours. A tough recovery brought along nausea, vomiting, pain,
immobility, 4 weeks non-weight-bearing, and 12 weeks in a
walking cast (see Figure 3). My husband Joe was a saint — I fell
several times and was quite a handful, I’m sure. I was back out
on the road traveling, flying, and working after only 4 weeks.
I’m still in the midst of 9 months of using my bone-growth
stimulator daily. On the whole, my foot feels and works great
now. I am back in normal shoes — with my orthotics, of
course. And I was back to speed walking on the treadmill
after only a few months. The only complaint: Some inflexibil-
ity remains due to hardware in several toes. Can’t wait until
January to get the other foot done (ugh!), but all good things
come with pain and sacrifice, right?
Enough about that. This is a story about taking care of feet,
wounds, and skin from the patient’s perspective. For me,
nothing was more important as a patient than having a total
experience that let me be independent, moving about, taking
Figure 1. Dr. Larry and Cynthia’s foot. Figure 2. Cynthia’s edematous post-op foot.
48 Healthy Skin
a shower, working, and relieving my pain. I will share some
insight into what worked. Sometimes it’s not just about evi-
dence-based medicine, nursing, and outcomes — but rather
about patient choice, consumer satisfaction, and overall
experience. Isn’t that what life is about, anyway: the experience?
So, here’s what we did. I had three osteotomies, some hard-
ware, an implanted xenograft, and five incisions, so infection
was a concern. Right out of surgery, a silver transparent film
was applied to reduce my chances of succumbing to a sur-
gical site infection (see Figure 4). The remarkable thing
about the silver transparent film is that it liberated ionic silver
to all my sites, and I was able to shower the next day. The
dressing didn’t have to be removed for 7 days, which dra-
matically decreased my pain since there was no manipulation
of the tender incision sites. Keep in mind, the most frequent
time patients experience wound pain is at dressing change.1
One of the best parts is that the silver transparent film let me
and my surgeon view the incision lines without removing the
dressings. A plus for nurses is that it’s often a nursing decision
to use such a dressing.
When my dressing and sutures were removed, I immediately
moved to a cyanoacrylate monomer protectant that remained
in place an average of 5 to 7 days (see Figure 5). This cousin
of Dermabond ® has 510(k) approval as a device so it’s
another nurse-mediated dressing. The nurse pinches the little,
glow-stick-like device to activate it, then paints it directly on
and around the wounds and incisions. I simply reapplied
when I no longer could see the lavender color. It chemically
Figure 3. Cynthia on a tricycle offloader.
bonded to my incisions, protecting them and allowing them
to gain strength. Another key advantage was that it reduced
pain from socks and hosiery, the water from the shower, etc.
The protectant is removed only by epidermal turnover.
I’ve progressed greatly at the 6-month mark and am now
cleansing, moisturizing and protecting daily with a nutritional
skin care line that is free of soap and surfactants, and contains
antioxidants and breathable silicones. The products also have
ingredients that offer topical nutrition via amino acids, vitamins,
and a proprietary blend of methylsulphonmethane to reduce
stinging and pain. As a result, my scars are fading beautifully
(see Figure 6).
Maybe it’s due to having gone soap-free. Perhaps it’s the
antioxidants and nutritional blend that are helping the scars
fade. It could also be the breathable blend of silicones that
decrease transepidermal water loss. These are some of the
same products that facilities nationwide are using to reduce
pressure ulcers and skin tears. Post-op skin needs the same
nutrition and coddling, however.
Was my surgery a success? Absolutely! I’m happy with the
result. And, further, my experience was as positive as feasi-
ble because my satisfaction, comfort, and choice were
important to my surgeon, who acted additionally as my
cooperative partner.
Gallup World Poll researchers have found that happiness is
likely to be associated with how well one's psychological and
Figure 4. Nurse Shelly changes Arglaes® Figure 5. Marathon® skin sealant protects
silver transparent dressing. the new incision lines on Cynthia’s foot.
Dermabond is a registered trademark of Johnson & Johnson Company. Marathon and Remedy are registered trademarks of Medline Industries, Inc.
Improving Quality of Care Based on CMS Guidelines 49
Arglaes is a registered trademark of Giltech Limited Corporation
“ Being a patient made me think about
the experience of each and every
person I treat. I hope that, as a result,
”
I’m a better caregiver.
social needs are being met.2 In other words, it’s all about the
experience.
Why not consider making every patient experience as opti-
mistic, pain-free, and supportive as possible? Think beyond
your chronic wounds to your post-op patients like me. After
all, people remember the experience. Of course, kindness,
respect, and gentle, reassuring care didn’t hurt. Patients
return for care and refer future business when you use prod-
ucts that offer a satisfying and atraumatic experience. Plus,
it’s the right thing to do.
This positive experience tied a big bow on an already-beau-
tifully wrapped package: my brand new, now-pain-free foot!
Here’s to life on the other side of the bed rail, treatment table,
podiatric chair, or OR table. Being a patient made me think
about the experience of each and every person I treat. I hope
that, as a result, I’m a better caregiver.
References
1. European Wound Management Society Position Document: Pain at Wound
Dressing Changes. London, UK: Medical Education Partnership Ltd., 2002:2,8.
Available at www.aawconline.org (accessed July 19, 2010).
2. Levy F. The World's Happiest Countries. Forbes. Available at
http://travel.yahoo.com/pinterests-35010143 (accessed July 19, 2010).
Figure 6. Remedy® Skin Repair Cream is
applied to nourish the skin and smooth
the scars.
 Treatment

Implementing Medline’s Pressure

Ulcer Prevention (PUP) Program
at Lacombe Nursing Centre

Lacombe Nursing Centre is a 98-bed family-owned long-

term care and rehabilitation facility in Louisiana. Rehabilitation Lacombe PUP Program Test Scores
represents the fastest growing segment of the care they pro- Compared to National Averages
vide. The facility employs 26 registered nurses and 38 certi-
fied nursing assistants (CNAs). They also have a treatment CNAs and nurses at LaCombe scored higher than the na-
tional averages on the PUP program pre- and post-tests.1
nurse. Staff members completed Medline’s Pressure Ulcer
Prevention (PUP) program in May 2010 and celebrated their PUP Post-
newfound knowledge with the awarding of certificates Pre-Test % test %
and pins. Certified Nursing Assistant (NA) Average 58 80
Lancombe CNA Average 71 90
The Pressure Ulcer Prevention Program includes a strategic
Nurse Average 78 88
product bundle consisting of skin care products and incon- Lancombe Nurse Average 82 90
tinence garments to assist in reducing or preventing pres-
sure ulcers and incontinence-associated skin conditions.

50 Healthy Skin
 Prevention

WHEN PREVENTION BUNDLES

(toolkits) are employed, pressure
ulcers are reduced.2

The program also packages education and training tools to-

gether with the products to allow healthcare teams to imple-
ment an effective pressure ulcer prevention program and
immediately begin reducing the incidence of healthcare-ac-
quired pressure ulcers. Training may be completed on a self-
study basis or conducted classroom style by staff at the
facility. Included are workbooks, patient and family educa- Lacombe nurses proudly display their PUP certificates.
tion brochures, a CD with printable electronic forms and
tools, and a staff rewards program.

In addition, the MD Education DVD includes everything the

physician needs to recognize, assess and document pres-
ent–on–admission (POA) indicators for Stage III and IV pres-
sure ulcers. There is also a separate version of the PUP
program specifically for home care and hospice.

Lacombe was uncertain at first about trying the program,

mainly because purchasing the Remedy® Skin Repair Cream
would add significantly to their supply costs. Once they
moved forward, however, they learned that the product cost
was not even a factor because of the savings achieved by no
longer having to treat as many pressure ulcers or buy addi-
tional wound care products.
50 percent reduction in pressure ulcers
Within 90 days of implementing the PUP educational program
and product bundle, Lacombe saw a 50 percent reduction in
pressure ulcer incidence. Residents were selected to partic-
ipate in the program based on particular medical factors,
including diabetes, peripheral vascular disease, history of skin
tears, poor nutrition status and/or low Braden Scale scores.
Residents experienced increased skin integrity and also ben-
efited from one-on-one social interaction with the nurses as
Graduates of the PUP program celebrate with cake.
CONTINUOUS PROFESSIONAL
development trains staff members on
an ongoing basis in their work setting
and results in confirming current practice,
changing current practice or causing
the learner to seek more information.2
they applied the Remedy Skin Repair Cream. Staff said res-
idents enjoy spending those 20 minutes talking and sharing
with the nurse as they feel the soothing touch and breathe in
the aromatic citrus fragrance of the cream. In addition, resi-
dents with diabetes showed significant improvement in red-
ness and scaling on their legs.

Improving Quality of Care Based on CMS Guidelines 51

 CNA pride and accomplishment
For the education portion of the PUP program, registered
nurses at Lacombe studied the workbook and completed
the course on their own, and Assistant Director of Nursing
Sheila Smith conducted classroom style sessions for the
CNAs. The CNAs especially praised the program for its focus
on topics that were not covered as part of their professional
training. They liked the PUP class so much that they
encouraged each other to sign up.
“You should have seen the smiles on the faces of our CNAs
when they received their PUP pins,” Smith said. “They were
so proud.”
CLOSE TO 40 PERCENT
of the facilities participating in the PUP
program are nursing homes or LTCs.1
Left to right: Gwen B. Aucoin, Administrator; Shiela Smith, Assistant
Director of Nursing; Mona Soileau, Medline Wound Care Representa-
tive; Chrystal Wust, LPN Restorative Nursing.
52 Healthy Skin
CLINICIAN TRAINING AND
education is an ideal opportunity for the
wound care community to partner with
associations or industry to develop
appropriate programs and materials
that can be implemented quickly.2
Each nurse and CNA who completes the PUP program re-
ceives a personalized certificate and a paw print (“PUP”) lapel
pin from Medline. They display their pins on their ID badges.
Good patient care
Overall, the administrators at Lacombe said they believe in
the PUP program because it represents good patient care.
Developing pressure ulcers limits residents’ ability to socialize
and participate in activities, affects their appetite and
increases their physical pain.
“Anything we can do to minimize poor outcomes and enhance
residents’ enjoyment of life is a good thing,” said Lacombe
Administrator Gwen Aucoin. “Not only does the PUP program
contribute to good patient care, it is also valuable for staff
development. So there’s a double reason to participate in PUP
because it’s good for patients and it’s good for staff.”
References
1 Medline Industries Inc. Pressure Ulcer Prevention (PUP) program. Data on file.
2 Armstrong DG, Ayello EA, Capitulo KL, et al. Opportunities to improve pressure
ulcer prevention and treatment: implications of the CMS inpatient hospital care
present on admission (POA) indicators/hospital acquired conditions (HAC) pol-
icy. Adv Skin Wound Care. 2008;21(10):469-78.
Remedy is a registered trademark of Medline Industries, Inc.
 ®
Medline Remedy

Serious care.
Serious results.

Nosocomial pressure Nosocomial pressure Estimated cost

ulcers reduced by ulcers reduced to zero savings of $6,677.11
50% after 3 months1 after 8 months1 per patient1

Independent outcomes research1 was conducted in an acute care facility where,

after implementation of a prevention program, the only additional change during the
reduction period was the focus of improving skin care by using Medline Remedy
products exclusively, as part of a formal skin care regimen. The results were amazing!

To receive a FREE TRIAL of our effective Remedy skincare

products, contact your Medline representative.

1. Shannon RJ, Coombs M, et al. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associated
skincare regimen. Adv Skin Wound Care, 2009;22:461-7.
©2010 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.
 CASE STUDY
Use of Porcine Urinary Bladder Matrix (UBM)* in a Dehisced
Wound Between Stomas Promoted Closure Facilitating Regular
Pouch Changes in a Premature Neonate
PROBLEM
Maintaining pouch adherence over neonates’ stomas after
laparotomy for Necrotizing Enterocolitis (NEC) challenges the
NICU staff. The likelihood of achieving a seal decreases when
the pouching surface is an open wound. A typical case of a
NEC patient is LG, who is a five week old female born at the
gestational age of 29 weeks, 4 days with a birth weight 690
gm. At 36 days of age, a laparotomy was performed and the
wound dehisced eight days later. The dehisced abdominal
wound, located between the ileostomy and the mucus fistula,
measured 1.5 cm by 2.5 cm, and was approximately 20
percent of the total abdominal surface area. The goal was to
close the wound as quickly as possible in order to provide a flat
pouching surface. This led to a search for a dressing that
promoted wound closure.
9-2-2009
9-24-2009 9-28-2009
54 Healthy Skin
PAST MANAGEMENT
Two other patients with NEC (Patient A and Patient B) born
at 30 weeks and 32 weeks 2 days, respectively, experi-
enced dehisced wounds similar to LG’s wound described
above. The dehisced wounds of both were treated with a
Hyrdofiber® dressing and hydrocolloid dressing or tape
strips followed by pouch application. Although both
patients’ wounds closed completely, the dressing often
failed to contain effluent and resulted in skin irritation and
wound contamination, necessitating daily or more frequent
pouch and dressing changes. Average closure time was
23.5 days.
CURRENT APPROACH
Porcine UBM was selected because of its ability to man-
age wounds, and its composition that contains collagen,
elastin, glyscosamionglycans and other materials associ-
ated with wound closure. Wound management consisted
of application of porcine UBM covered with a perforated
silicone sheet that was cut to circumscribe the stoma,
followed by the pouch application. The dressing was
changed twice a week, except for one time when the
dressing had to be changed one day ahead of schedule.
OUTCOMES
Complete wound closure was achieved in 17 days of
implementation of porcine UBM. Additionally, the perforated
silicone sheet helped to increase pouch adherence over the
open wound, decreasing the number of pouch changes.
9-30-2009
Amparo Cano, MSN, RN, CWOCN
Patricia Corvino, MSN, RN, CWOCN
Broward General Medical Center
and the Chris Evert Children’s Hospital
Fort Lauderdale, FL

CONCLUSIONS AND DISCUSSION ACKNOWLEDGEMENT

Wound closure was achieved with the use of porcine UBM,
allowing better pouch adhesion and increased wear time in
this premature neonate. Although the study sample size
was small, it is worth noting that the patient who was
treated with UBM was gestationally the youngest, had the
lowest birth weight and the largest open wound, yet the
closure was the most rapid of this group. This type of
advanced material, UBM, is widely used for management
of chronic wounds; however we believe that this is the first
instance where the use of this material in the management
of an acute wound in neonates has been reported. It is pos-
sible that LG had better results due to reduced pouch
change related disturbance of the wound site, coupled with
the use of the advanced UBM material. Clinical trials with
greater sample sizes are recommended.
The authors would like to acknowledge the NICU Nursing and
Medical staff at Broward General Medical Center and the
Chris Evert Children’s Hospital for their care of this and all
neonates and for their contributions to this poster.
REFERENCES
1. Angel, C., Daw, S., Phillipe, P, et al. (1992). Pig in a pouch:
A technique for the management of complete wound dehiscence
after Laparotomy for neonatal necrotizing Enterocolitis. Journal
of Pediatric Surgery, 27(1), 67-69.
2. Brown B, Lindberg K, Reing J, Stolz D.B., Badylak S.F. The
basement membrane component of biologic scaffolds derived
from extracellular matrix. Tissue Eng., 12(3):519-526.
3. Hocevar, B., (2005). Home care management of an ostomy
within a dehisced abdominal wound. Journal of WOCN, 32(3),
202-204.
4. WOCN. Best practice: Troubleshooting pediatric Ostomies.
http://www.wocncenter.com/uploaded_documents/pdf/Ped.-
Trouble.Shooting.9.10.08.pdf. Accessed October 28, 2009,

* Urinary Bladder Matrix (UBM), MatriStem

Patient A Patient B LG is a Registered Trademark of ACell,
Columbia, MD. MatriStem is distributed
Gestational Age 30 weeks 32 weeks, 2 days 29 weeks, 4 days by Medline Industries, Inc. Mundelein, IL.
Date of Birth 11-12-07 5-15-09 8-8-09
+Hydrofiber. Aquacel is a Registered
Birth Weight 1400 gm 1030 gm 690 gm Trademark of E. R. Squibb & Sons, L.L.C.
Laparotomy Date 12-7-07 6-9-09 9-13-09
3w, 4d after birth 3w, 4d after birth 5w, 1d after birth
Dehiscence Date 12-13-07 6-16-09 9-21-09
6 days post op 7 days post op 8 days post op
Measurements 0.9 x 1.5 cm 2 x 1 cm 1.5 x 2.5 cm
Date Closed 1-3-08 7-12-09 10-8-09
3 weeks 3 weeks, 5 days 2 weeks, 3 days
Dressing Used Hydrofiber+ Hydrofiber+ UBM*

10-5-2009 10-8-2009 10-29-2009

Improving Quality of Care Based on CMS Guidelines 55

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ci
Ex

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 Prevention

Influenza:
Prevention Guidelines
and Recommendations
Infection Control Measures for Prevent-
ing and Controlling Influenza Transmis-
sion in Long-Term Care Facilities
Influenza is a contagious respiratory disease that
can cause substantial illness and death among
long-term care facility residents and illness
among personnel in long-term care facilities.
Influenza vaccination of health care personnel
and long-term care facility residents combined
with basic infection control practices can help
prevent transmission of influenza. Every effort
should be made to ensure compliance with
influenza vaccination recommendations each
season. However, because influenza outbreaks
can still occur among highly vaccinated long-
term care residents, long-term care facility per-
sonnel should be prepared to monitor personnel
and residents each year for influenza and
promptly initiate measures to control the spread
of influenza within facilities when outbreaks are
detected. This document provides general guid-
ance for prevention and control of influenza
transmission in long-term care facilities.

58 Healthy Skin
[Transmission]
Influenza is primarily transmitted from person to person
via large virus-laden droplets that are generated when infected
persons cough or sneeze; these large droplets can then
settle on the mucosal surfaces of the upper respiratory tracts of
susceptible persons who are near (e.g., within about 6 feet) in-
fected persons. Three feet has often been used by infection
control professionals to define close contact and is based on
studies of respiratory infections; however, for practical
purposes, this distance may range up to 6 feet. The World
Health Organization defines close contact as “approximately
1 meter”; the U.S. Occupational Safety and Health
Prevention and Control Measures
Strategies for the prevention and control of influenza in long-term care facilities include the following:
1 Annual influenza vaccination of all residents
and healthcare personnel
2 Implementation of Standard and Droplet
Precautions when a person is suspected or
confirmed to have influenza
3 Active surveillance and influenza testing for
new illness cases
Improving Quality of Care Based on CMS Guidelines 59
Administration uses “within 6 feet.” For consistency with these
estimates, this document defines close contact as a distance of
up to approximately 6 feet. Transmission may also occur
through direct contact or indirect contact with respiratory
secretions, such as touching surfaces contaminated with
influenza virus and then touching the eyes, nose or mouth.
Adults may be able to spread influenza to others from 1 day
before getting symptoms to approximately 5 days after
symptoms start. Young children and persons with weakened
immune systems may be infectious for 10 or more days after
onset of symptoms.
4 Restriction of ill visitors and personnel from
entering the facility
5 Administration of influenza antiviral medications
for prophylaxis and treatment when influenza is
detected in the facility
6 Other prevention strategies, such as respiratory
hygiene/cough etiquette programs
[Vaccination]
Health care personnel (e.g., all paid and unpaid workers
who have contact with residents and visitors, including vol-
unteer workers) and persons at high risk for complications
from influenza, including all residents of long-term care
facilities, are recommended to receive annual influenza vac-
cination according to current national recommendations.

Vaccination is the primary measure to prevent influenza,

limit transmission, and prevent complications from influenza
in long-term care facilities.
Vaccination of persons 65 years and older does not pre-
vent 100 percent of influenza infection, but can reduce
serious complications from influenza in this population.
Vaccination rates of 80 percent and higher among resi-
dents have been shown to decrease influenza outbreaks in
long-term care facilities.
The following persons
NOT receive LAIV...
should
■ Persons with a history of hypersensitivity, including ana-
phylaxis, to any of the components of LAIV or to eggs
■ Persons aged 2-4 years who have recurrent
wheezing and healthy persons 50 years and older

Inactivated influenza vaccine or live attenuated influenza
vaccine may be used to vaccinate most healthcare person-
nel. Inactivated influenza vaccine (LAIV) may be given to
healthcare personnel younger than 50 years who do not
have contraindications to receiving this intranasal vaccine.
Healthcare personnel who may receive LAIV include those
who care for immunocompromised patients who do not
require care in a protective environment. Healthcare work-
ers who care for patients with severely weakened immune
systems (i.e., patients who have recently had a hematopoietic
stem cell transplant and require a protected environment)
and who receive LAIV should refrain from contact with
severely immunosuppressed patients for 7 days after LAIV
vaccination.
Source: Centers for Disease Control and Prevention
■ Persons with asthma, reactive airways disease,
or other chronic disorders of the pulmonary or
cardiovascular systems
■ Persons with other underlying medical conditions,
including metabolic diseases such as diabetes, renal
dysfunction, and hemoglobinopathies; or persons with
known or suspected immunodeficiency diseases or
who are receiving immunosuppressive therapies
■ Children or adolescents receiving aspirin or other
salicylates (because of the association of Reye’s
syndrome with wild-type influenza infection)
■ Persons with a history of Guillain-Barré Syndrome
■ Pregnant women

■ Administration of LAIV should be postponed among

persons with a fever or significant nasal congestion that
may interfere with delivery of the LAIV although persons

60 Healthy Skin
with mild respiratory illness can receive LAIV
Patient Safety is in Your Hands
Epi-clenz™ Gel Instant Hand Sanitizers contain
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For a FREE case of our 16 oz. Epi-clenz

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©2010 Medline Industries, Inc. Medline and Epi-clenz are registered trademarks of Medline Industries, Inc.
 Special Feature

Control
Measures
for Influenza
In addition to influenza vaccination,
the following infection control measures
are recommended to prevent person-to-person
transmission of influenza and to control influenza
outbreaks in long-term care facilities.

2. Standard Precautions
During the care of any resident with symptoms of
a
respiratory infection, healthcare personnel should
adhere
to Standard Precautions:

a. Wear gloves.
b. Wear a gown.
c. Change gloves and gowns after each resident
encounter and perform hand hygiene.
d. Decontaminate hands before and after contact
1. Educatio
Educate per
n with a sick resident.
e. Wash visibly soiled or contaminated hands with
sonnel abou
of vaccinatio t the import
n, signs and ance soap (either plain or antimicrobial) and water.
influenza, co symptoms o
ntrol measu f f. If hands are not visibly soiled, use an alcohol-ba
res and indic sed
tions for obta a- hand rub for routinely decontaminating hands.
ining influen
za testing.

62 Healthy Skin
 p ir a t o r y H ygiene/ [Other Considerations]
3. R e s
t iq u e t t e P r og rams never resid-
Cough E ene/cough et
iquette whe
t
A. If influenza is suspected in any resident,
spiratory hygi iratory infectio
n to preven influenza testing should be done promptly.
Implement re om s of re sp
have sympt -term care Confine symptomatic residents with
ents or visitors ry tr ac t in fe ctions in long
irato e: suspected or confirmed influenza and
on of all resp grams includ
the transmissi en e/ co ug h etiquette pro their exposed roommates to their rooms
piratory hygi
facilities. Res rsons who or on one unit for 5 days following the
st ru ct in g re sidents and pe
sual alerts in ey have onset of symptoms. Personnel should
a. Posting vi he al th ca re personnel if th
em to inform ging those w
ho work on only one unit, if possible.
accompany th ct io n and discoura
respirato ry in fe B. Patients receiving antiviral treatment for
symptoms of y. influenza should continue to be confined
ting the facilit tors who are
are ill from visi to re si dents and visi until treatment is completed because
as ks outh and
tissues or m cover their m
b. Providing at th ey ca n patients may still be infectious and rarely
eezing so th
coughing or sn may be shedding antiviral resistant viruses.
on
nose. rubs in comm
an d al co ho l-based hand
tissues
c. Providing
ting rooms. e available w
here
areas and wai r ha ndwashing ar
s fo
d. Ensuring th
at su pp lie alcoho ased
l-b
d pr ov id in g dispensers of
ted an
sinks are loca .
other locations t at least 3
hand rubs in ar e coughing to si
s w ho
ng person ith symptoms
of
e. Encouragi he rs . Residents w
et fro m ot us in g
to about 6 fe ouraged from
ry in fe ct io n should be disc
respirato le.
s where feasib
common area

ns for Ill
5. Restrictio H e alth care
s a n d I ll
Visitor n Inf luenza
o n n e l w h e
Pers r r ing in the
y is O c c u
Activit ommunity
r o u n d in g C
4. Droplet Precautions Sur via posted no
tices) that
rs (e.g.,
a. Notify visito s should not
Health-care workers should adhere to Droplet Precautions ts w ith re sp iratory symptom
adul d children with
during the care of a resident with suspected or confirmed y for 5 days an
visit the facilit the onset
influenza for 5 days after the onset of illness: om s fo r 10 days following
sym pt
of illness. ould not com
e
a. Place resident in a private room. If a private room is not
oy ee s w ith symptoms sh
b. Em pl
available, place suspected influenza residents
to work. ize and
with other residents suspected of having influenza; e re si de nt s' ability to social
n th g
c. To maintai rtunities durin
residents with confirmed influenza with other residents
ce ss to re ha bilitation oppo
have ac ely
ions are unlik
confirmed to have influenza.
ds w he n influenza infect
pe rio confirm , ed
b. Wear a surgical or procedure mask upon entering the
flu en za is suspected or
and no in infections
resident’s room. Remove the mask when leaving the sy m pt om s of respiratory
residents with in group mea
ls
resident’s room and dispose of the mask in a waste rm itt ed to participate
can be pe to about 6
container. if th ey ca n be placed 3
and activities n adhere to
c. If resident movement or transport is necessary, have the
m ot he r re si dents and ca
feet fro etiquette.
resident wear a surgical or procedure mask, if possible.
sp ira to ry hy giene/cough
re
tion
rol and Preven
ers fo r Disease Cont
Source: Cent

Improving Quality of Care Based on CMS Guidelines 63

 [Control of Influenza Outbreaks
in Long-term care Facilities ] activities and serve all meals in patient rooms. If patients
Definitions
Cluster: Three or more cases of acute febrile respiratory
illness (AFRI) occurring within 48 to 72 hours, in residents
who are in close proximity to each other (e.g., in the same
area of the facility).
Outbreak: A sudden increase of AFRI cases over the normal
background rate or when any resident tests positive for
influenza. One case of confirmed influenza by any testing
method in a long-term care facility resident is an outbreak.
The outbreak control measures described below should
be promptly implemented in the event of any clustering
or an outbreak of AFRI, or any case of laboratory confirmed
influenza:
• Inform local and state health department officials within
24 hours of outbreak recognition. Determine if the health
department wants clinical specimens or viral isolates.
• Implement daily active surveillance for respiratory
illness among all residents and healthcare personnel
until at least 1 week after the last confirmed influenza
case occurred.
• Identify influenza virus as the causative agent early in the
outbreak by performing rapid influenza virus testing of
residents with recent onset of symptoms suggestive of
influenza. In addition, obtain viral cultures from a subset
of residents to confirm rapid test results (both positive
and negative) and to determine the influenza virus
type and influenza A subtype. Ensure that the laboratory
performing the tests notifies the facility of tests
results promptly.
• Implement Droplet Precautions for all residents with
suspected or confirmed influenza.
• Confine the first symptomatic resident and exposed
roommate to their room, restrict them from common
activities, and serve meals in their rooms.
64 Healthy Skin
• If other patients become symptomatic, cancel common
are ill on specific wards, do not move patients or
personnel to other wards, or admit new patients to the
wards with symptomatic patients.
• Limit visitation, exclude ill visitors, consider restricting
visitation of children via posted notices.
• Monitor personnel absenteeism due to respiratory
symptoms and exclude those with influenza-like
symptoms from patient care for 5 days following onset of
symptoms, when possible.
• Restrict personnel movement from areas of the facility
having outbreaks to areas without patients with influenza.
• Limit new admissions.
• Administer the current season’s influenza vaccine to
unvaccinated residents and health care personnel as per
current vaccination recommendations for nasal and
intramuscular influenza vaccines.
• Administer influenza antiviral chemoprophylaxis and
treatment to residents and health care personnel
according to current recommendations.
• Consider antiviral chemoprophylaxis for all health care
personnel, regardless of their vaccination status, if the
health department has announced that the outbreak is
caused by a variant of influenza virus that is a sub-
optimal match with the vaccine.
[Additional Resources]
The following resources provide information about prevent-
ing the spread of influenza in health care facilities:
Sneller VP, Izurieta H, Bridges C, Bolyard E, Johnson D, Hoyt
M, Winquist A. Prevention and control of vaccine-pre-
ventable diseases in long-term care facilities. JAMDA
2000;Sept-Oct:S1-S37.
Bradley SF. Prevention of influenza in long-term-care facili-
ties. Long-Term Care Committee of the Society for Health-
care Epidemiology of America. Infect Control Hosp Epidemiol
1999;20:629-37.
THE
CHOICE
IS YOURS.
Medline’s comprehensive line of face masks
was designed to meet a variety of needs and
preferences, but all of our masks are united
by a common trait — quality. Every mask we
manufacture — from our fluid-resistant masks
to our spearmint-scented masks — is backed
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• Fluid resistant
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• Chamber style
• Isolation
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• Face shield
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©2010 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.
 Survey Readiness

66 Healthy Skin
Emergencies
& Disasters
Preparedness Planning
for Long-Term Care Facilities

By Guy Robertson, MLS

Long-term care facilities need to have a

formal working plan to handle emergencies
and disasters before they take place. The
following article was originally published by
the Long Term Care Association of Ontario
and gives an overview of risk factors for
facilities to review and have practical con-
tingency plans for.

Improving Quality of Care Based on CMS Guidelines 67

 Have A Plan
Assume that 20 minutes from now, a fire breaks out in a building down the street from your facility. Flames
burst from the windows while black smoke shrouds the neighborhood. A firefighter appears at your reception
desk and says that he might ask you to evacuate your staff and residents shortly, “depending on the toxic fume hazard.” Are
you prepared for such an event? Many long-term care facilities aren’t, despite occasional fire drills and binders crammed
with instructions from emergency response agencies.
Check List
! What risks threaten your facility?
Best ways to mitigate them.


Emergency Response Plan.
Many organizations rely on business
resumption (or continuity) plans to resume
and restore your administrative operations
A good emergency plan starts with a summary of the risks
that prevail at your facility. Every region has its natural risks,
from high winds and winter storms to flooding to earthquakes.
Heat waves and freak storms are increasingly common across
North America. Any of these risks can lead to property dam-
age, power outages and supply problems for care facilities.
Technological risks include computer failures and data loss,
toxic spills, electrical fires and explosions. Contrary to popu-
lar opinion, these risks prevail just as often in less populated
rural regions as in cities and towns. Technological problems
often result from human error. Somebody pushes the wrong
button or forgets to push the right one, and the lights go out
all over town. Somebody else trips over a cable in the server
room, disables an entire network and you lose access to your
electronic files, including those pertaining to essential resi-
dent care.
68 Healthy Skin
While human error is unintentional, some harmful actions are
purposeful. These are security risks: theft, sabotage, vandal-
ism and fraud. A thief could steal cash, drugs and residents’
valuables. A prankster might leave a bomb threat on your
voice mail or hack into your website and tamper with its con-
tents. Crooks have been known to get vulnerable long term-
care facility residents involved in different kinds of bogus
financial schemes. While some neighborhoods are more
secure than others, security risks prevail wherever there
are people.
Make a list. What risks threaten your facility?
! Remember that risks at nearby sites can threaten
you directly. For example, an accident on an
adjacent roadway could isolate your facility for hours. A fuel
spill at the local gas station could lead to an explosion that
cuts your power. And then there’s the fire in the building down
the street that’s making your eyes water. Some of your residents
are starting to cough. Nearby threats are called proximity
risks, and every property manager should be aware of them.
Once you’ve determined the risks to your facility,
consider the best ways to mitigate them. There are
always means of dealing with a risk so that it’s less
likely to disrupt your operations. For example, high winds and
severe winter weather may be unavoidable, but if your build-
ing has a good preventative maintenance program in place,
you’ll experience fewer problems from roof leaks and heating
problems. If you’re concerned about power failures, investi-
gate the feasibility of a backup generator. Ask your staff and
residents to report any facility problems promptly. You should
be able to mitigate most of your risks to the point where they
no longer pose serious threats to your facility.


But occasionally risks turn into emergencies. You
need an emergency response plan to deal with the
real thing. You don’t need a huge binder to tell you
 Natural Disasters
how to evacuate your building or restore your power. Often
a small brochure containing the standard procedures is
more useful than a binder that only a few of your staff mem-
bers have studied carefully. Besides, you don’t want to start
leafing through a binder when a fire threatens your facility
and the smoke gets in your eyes. As for reviewing emer-
Cyclones, typhoons, hurricanes, tornadoes,
Meteorological Disasters
gency response procedures during a power outage, forget
it. You’ll have other uses for those flashlights — if you can hailstorms, snowstorms and droughts
find them.

Land slides, avalanches, mud flows and floods

Topological Disasters
You can create a small brochure on your office workstation
and reproduce your fire department’s advice to meet the

Earthquakes, volcanic eruptions and tsunamis

Disasters that Originate Underground
specific needs of your facility. You can print separate
brochures for staff and residents. You can include handy (seismic sea waves, also known as tidal waves)
reminders and space for notes and personal information,

Communicable disease epidemics and insect

including room numbers, addresses, family contacts and the Biological Disasters

swarms (locusts)
locations of refuge areas and safe gathering sites. Brochures
can be designed to fit in a wallet, coin purse or pocket.
When they’re attractively laid out and contain concise, prac-

Man-made Disasters
tical response measures, brochures are ideal tools for emer-
gency orientation and procedural training. They’re also much
less expensive than those binders.

Conventional warfare (bombardment, blockade and siege)

After an emergency, how can you resume adequate levels of Warfare

Non-conventional warfare (nuclear, chemical and biological)

service and restore your administrative operations? Many
organizations rely on business resumption (or continuity)
plans, which contain solutions to problems that arise after Civil Disasters
Riots and demonstrations, strikes
the storm has died down or the fire has been extinguished.
Often a resumption plan begins with a damage assessment

Bomb threat/incident; nuclear, chemical, or biological

checklist, which guides you through your facility and points Criminal/Terrorist Action

attack; hostage incident

out those areas where different kinds of damage can occur.
Has a storm damaged your roof? Here’s what to look for:
cracks, pools of water, debris from trees and neighboring

Transportation (planes, trucks, automobiles, trains and ships)

structures, broken wires, leaky skylights. Even if you’re not Accidents

Structural collapse (buildings, dams, bridges, mines,

a trained property manager, your damage assessment
checklist will help you to make a record of any damage to a
Explosions, fires, chemical (toxic waste and pollution)
and other structures)
roof or any other part of your facility’s structure.
Biological (sanitation)
A key component for any care facility’s resumption plan is a
strategic alliance program. After an emergency, you might
have difficulty obtaining supplies that in normal circum-
stances you would take for granted. What if severe weather
puts your usual delivery service out of action for a few days?
Fortunately, you’ve organized an alliance with a local taxi
firm, which will pick up medications, groceries and office

Improving Quality of Care Based on CMS Guidelines 69

 equipment from suppliers and deliver them to you as soon as
possible. Taxis can also serve as couriers and help staff
members get to and from your facility if the roads are closed.
Benefits Of A Great
Taxi companies use radio communications to receive infor-
mation regarding road closures and other lifeline problems,
Work Environment
and are often better prepared to travel in disaster areas than By Greg Smith
local police and firefighters.
Businesses can improve retention and make their organization
Your residents might be frightened or disoriented by an the good place to work by following the five-step PRIDE model:
emergency. To restore their good morale, you should include
normalization guidelines in your resumption plan. Getting P – Provide a positive working environment
residents to talk about their experience during an emergency R – Recognize, reinforce, and reward individual efforts
is one way to ease their anxiety. Another is to hold a “closure
I – Involve and engage everyone
party,” during which staff and residents are served refresh-
D – Develop the potential of your workforce
ments and given a chance to celebrate the conclusion of
E – Evaluate and hold managers accountable
events relating to the emergency. Sometimes facilities bring
in trauma counselors to address individual concerns or Source: http://workz.com/content/view_content.html?
ongoing fears. But residents are not always disturbed by section_id=531&content_id=6965
emergencies. After a fire near a Vancouver care facility that
resulted in an evacuation, some residents told their care-
givers that they enjoyed the excitement. “It was a nice break
from the usual TV game show,” one resident said.
Medline Named One of Becker’s
Your resumption plan can contain advice concerning alter-
native sites for residents, a list of post-emergency service
priorities, a summary of emergency team activities and
100 Best Places to
advice regarding the auditing and testing of the plan. Since
each care facility is unique, each should have an emergency
Work in Healthcare
plan customized to meet its specific needs. A template plan
will not necessarily give you the most effective guidance. It’s Becker’s recognizes company for
up to you to ensure that your facility has a plan that takes “Excellence in Promoting Teamwork,
into account characteristics that make it different from a
Professional Development”
facility in a different part of the country, city or neighborhood.
You have only three minutes until that fire breaks out down
the street and you hear the wail of the sirens. Fortunately this Medline Industries, Inc. has been named one of the “100 Best
is only an imaginary scenario. But next time it might be the Places to Work in Healthcare” for 2010 by Becker's ASC Review
real thing. Isn’t it time that you developed a real emergency and Becker's Hospital Review, well respected industry publications.
plan for your facility?
According to Becker’s, the list was developed “through nomina-
tions, recommendations and research, and the organizations were
About the author
Guy Robertson, MLS, is an emergency management consultant
selected for their demonstrated excellence in creating a work envi-
based in Vancouver, British Columbia, Canada. He has over 20 ronment promoting teamwork, professional development and qual-
years of experience working with financial institutions (e.g. credit ity patient care.”
unions), insurance companies, hospitals, libraries, and private and
public archives. He regularly writes for various professional associ-
ations’ journals and magazines. His knowledge is often presented
with humor and anecdotal examples, making him a sought-after
public speaker. To contact him, send an e-mail to
guy_robertson@telus.net.

70 Healthy Skin
“ How do we improve
our resident and family-
centered quality of care
and prepare for QIS?

We use abaqis.”
Sherri Dahle, RN, DNS
Director of Nursing
Central Healthcare
LeCenter, MN

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

®
abaqis is the only quality assessment and reporting
system for nursing homes that is tied directly to the QIS,
and its quality assessment modules reproduce the same
forms, analysis and thresholds used by State Agency
surveyors. Rich reporting capabilities on 30 care areas
guide you to what surveyors will be targeting in your facility.

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
“ Oh
Yeah!
“
New learning opportunities for CNAs

For the first time ever,

Medline University introduces
online CNA courses at
www.medlineuniversity.com.

Visit today to learn more about:

• Diabetes
• Hand hygiene
• Incontinence
• Indwelling urinary catheters
• Skin care
• Skin tears
• QIS

Access
courses
on your
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ME DLINE

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UNIVERSITY
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©2010 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.
 “
“Excellent.
NAB-approved courses now
available at Medline University.
Visit www.medlineuniversity.com for
an all-new way to earn nursing home
administrator certification credits —
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QIS topics:
• Understanding the Survey
• The Seven Mandatory Facility-Level Tasks
• The Five Triggered Tasks
• Activities of Daily Living and Range of Motion
• Critical Elements for Activities
• Critical Elements for Pain Management
• Federal Tag 441 – Infection Prevention
and Control

Plus,
• Diabetes Education for Long-Term Care
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Medline is a registered trademark of Medline Industries, Inc.
 Caring for Yourself

Fail-Safe Strategies to Deal with

DIFFICULT PEOPLE
By Dr. Wolf J. Rinke, RD, CSP

Let’s face it. Certain people just like to make your life difficult. Maybe it’s a
patient who seems to get his jollies from making you miserable. Or a team member
who refuses to perform at an acceptable level. Or what about your colleagues who
drive you nuts? Any of these can be a huge challenge and cause you a great deal
of difficulty and stress. But don’t despair. There are specific steps you can take to
deal more effectively with these kinds of people.

74 Healthy Skin
The Most Powerful Stress Control System of All Time
But first let me share with you what I consider the most powerful
stress control system of all time. It’s very simple—only three steps,
but if you can master it, your ability to deal with all types of stress
and conflict, not just difficult people, will be significantly enhanced.
Here they are:

1. Change the Changeable.

Don’t like something? Change it! Don’t fret, complain or whine …
just do it! (I know you’ve heard that before.) Remember, you don’t
have to do anything you don’t want to do. Alright, you caught me.
There is one thing you have to do—die. No choice—not yet. Every-
thing else is a choice. And no matter how badly other people
behave, you always are able to control your response to their
behavior. Notice I said you can control your response, but you cannot
control them or their behavior, so quit wasting time trying to do
the impossible.

2. Remove Yourself from the Unacceptable

Find something or someone unacceptable? Get out of the way.
Sitting with someone who is bitching and griping? Get up and sit
somewhere else. Working for a toxic boss? Start shopping for a
new one. About to be sucked into another conversation with an
employee who is always complaining about his team members?
Tell him you are busy and that you prefer that he talk to the other
party directly instead of coming to you. Can’t remove yourself? Min-
imize the time you are exposed to unacceptable people. Whatever
you do, just do it without fretting and whining … I know you’re
catching on!

Improving Quality of Care Based on CMS Guidelines 75

 3. Accept the Unchangeable
There are lots of things beyond your control, such as your
parents. No matter how much you would like them to be
different, they won’t be. So love them the way they are, not
the way they ought to be. (By the way, that is a great pre-
scription for getting along with all people!) Bad weather?
Get a grip. Deal with it. Learn to associate any type of bad
weather with prior positive events in your life. For example,
when it is rainy, misty or foggy, I’ve taught myself to think
back to my days in Germany. When it is freezing cold, I think
of cuddling in front of a toasty warm, roaring fireplace with
Superwoman – my wife and lover of 42 years.
Getting older? Accept it. You are beautiful just the way you
are! A wise person once remarked, “God doesn’t make
junk.” In fact, evaluating both my physical and emotional
health, I have never felt better in my life as I do right now.
(I’m 66—thanks for asking.) One reason is that I have never
been as content and at peace as I am right now. So don’t
sweat your chronological age—something you can’t
change. Instead, take care of your body … that’s something
you can have a positive impact on right now.
Difficult people? Accept that some people like to be miserable.
Just don’t try to take it away from them. (I hope you are
smiling. Otherwise you are taking this much too seriously.)
Accept them just the way they are, and minimize the time
you spend with them. If they report to you make sure that
you do not place them in patient sensitive positions, and do
your best to get them out of your team or organization as
soon as possible.
76 Healthy Skin
10
Ten Fail-Safe Strategies to Deal with Difficult People
After you have mastered these three biggies, let’s take a
look at what other strategies you can use to make your life
less aggravating:
1. Change your response to the other person.
As I mentioned earlier, you are the only one you can change.
(And most of us have lots of difficulty achieving that!) In deal-
ing with difficult people, don’t try to change the other per-
son; you will only get into a power struggle, cause
defensiveness, invite criticism or otherwise make things
worse. It also makes you a more difficult person to deal with.
On the other hand you can always control your response to
the other person. So don’t let negative people live in your
head rent free.
2. Manage your perceptions.
Remember that most relationship difficulties are due to a
dynamic between two people rather than one person being
“bad.” In other words it takes two to tango. This is one thing
that has been driven home to me time and time again as a
result of my coaching and consulting experiences. I listen
to one person and they tell me in excruciating detail how
badly someone else has behaved. In fact, because of their 5. Don’t beat yourself up. Avoid blaming yourself or the
vivid descriptions I’m often tempted to take their word for it. other person for negative interactions. It may just be a case
Until … wait for it … I talk to the other person, and then I find of two personalities being like “oil and water.” Remember
out that their reality is diametrically opposite of the other that you don’t have like everyone; just being polite goes a
party, and by the way, equally as convincing. In other words long way toward getting along and appropriately dealing
there is no reality, there are only perceptions, and we all cre- with difficult people.
ate our own.
6. Respond with a sense of humor. Much can be solved
The fastest way to begin to no longer perceive people as by just lightening up. Somehow a sense of humor often low-
“difficult” is to look for what they are doing right. And then ers the intensity of a difficult situation and allows both of you
let them know about that. In other words, look for the pos- to laugh instead of continuing to escalate the situation.
itive aspects in others, especially when dealing with the
important people in your life, and focus on those things. The 7. See it through the other persons’ eyes. As cliché as
neat part of this is that over the long run we all tend to find this may sound, we tend to forget that we become blind-
what we are looking for. (Read that again!) And before you sided when we are angry or stressed. Instead put yourself
know it, the other person will feel more appreciated, and in the other person’s position and consider how you may
you will begin to develop a more positive relationship. have hurt their feelings. This understanding will give you a
new perspective, may help you to become more rational,
3. Minimize the time you spend with difficult people. and help you develop compassion for the other person.
I know I’ve mentioned this before so this must be a biggie,
especially for people in leadership positions. Time and time
again I find that managers, supervisors and team leaders
tend to spend a disproportionate amount of time with trou-
ble makers. What they don’t get is that their time is a re-
ward. This means that they will get more trouble.
Remember: Whatever you reward is what you will get more
of. Instead, if you want peak performance, then you should
spend the greatest share of your time with the “water walk-
ers”—the people who make you look good.

What about the other difficult people in your life? Know

when it’s time to distance yourself, and do so. If no matter
what you do, the other person still antagonizes you, mini-
mizing your exposure may be the key. If they’re continually
abusive, it’s best to cut ties and let them know why. Explain
what needs to happen if there ever is to be a relationship,
and then let them go. If the difficult person is your boss it
may be time for you to find another job. We spend far too
great a portion of our life at work to be miserable. Life is
simply too short to work for a toxic boss or organization.

4. Avoid discussing divisive issues.

Issues such as religion and politics, or other topics that push
certain people’s “buttons” are best avoided. If the other per-
son tries to engage you in a discussion that has the poten-
tial to become an argument, change the subject or remove
yourself.

Improving Quality of Care Based on CMS Guidelines 77

 8. Hang out with positive people. Negative people drain
your battery. Positive people charge your battery. So mini-
mize the time you are together with “stinking thinking” peo-
ple and cultivate other more positive relationships in your
life to offset the negativity of dealing with difficult people.
(If you would like to know more about this, read my Beat
The Blues: How to Manage Stress and Balance Your Life
CPE program. It’s available at www.easyCPEcredits.com.)
9. Don’t fight fire with fire. When you interact with some-
one who is going into attack mode or becoming excessively
defensive, recognize that it is useless to argue with him.
Realize the other person may be behaving in this way
because he is feeling very insecure. Don’t continue to push
or attempt to convince him because he will only get more
difficult. Let it go, and come back at another time.
10. Make the other person right. I’ve left the best for last.
The most effective way you can deal with difficult people is
to make them right by expressing the most powerful conflict
resolution phrase of all time: “You are right about that.” (Try
it in any situation that appears to be spinning out of control.
78 Healthy Skin
What you will find will amaze you. It literally makes any type
of conflict evaporate. It’s so powerful that Superwoman and
I no longer even use the five words, we just hold up our
hand with all five fingers extended.) Or express agreement
in any other way you wish. For example you might say, “I
see why you feel that way;” or “I can understand why you
are upset,” or “That’s an interesting perspective.” (The
words are not important as long as you express agreement.)
If you find yourself arguing for the sake of being right, ask
“Does it matter if I am right?” If yes, then ask “Why do I need
to be right? What will I gain?” In virtually all situations you will
find that the only reason you feel a need to be right is to sat-
isfy your ego.
If that still does not let the “hot air out of the balloon” find
something, no matter how small, to agree on. And if noth-
ing else works you can at least agree to disagree, and get
on with your life.
© 2010 Wolf J. Rinke
Dr. Wolf J. Rinke, RD, CSP is a keynote
speaker, seminar leader, management con-
sultant, executive coach and editor of the
free electronic newsletters Make It a Winning
Life and The Winning Manager, available at
www.WolfRinke.com; and a new electronic
newsletter Read and Grow Rich, targeted
specifically to nutrition professionals, avail-
able at www.easyCPEcredits.com. In addi-
tion, he has authored numerous CDs, DVDs and books including
Make It a Winning Life: Success Strategies for Life, Love and Busi-
ness; Winning Management: 6 Fail-Safe Strategies for Building
High-Performance Organizations and Don’t Oil the Squeaky Wheel
and 19 Other Contrarian Ways to Improve Your Leadership Effec-
tiveness; all available at www.WolfRinke.com. His company also
produces a wide variety of quality pre-approved continuing pro-
fessional education (CPE) self-study courses, available at
www.easyCPEcredits.com, including his latest Delegation and
Coaching: High Impact Strategies for Doing More with Less,
approved for 15 CPEUs, from which this article was extracted.
Reach him at WolfRinke@aol.com.
 Special Feature

he Centers for Disease Control and

T Prevention (CDC) has just announced the
establishment of the Advisory Committee on
Breast Cancer in Young Women.

The committee has been established to assist

in creating a national evidence-based public
education and media campaign to provide
age-appropriate messages and materials to:
CDC Forms New
Advisory Committee 1. Increase awareness of good breast
health habits
on Breast Cancer in 2. Identify risk factors based on familial,
Young Women racial, ethnic and cultural backgrounds
3. Encourage young women and healthcare
professionals to increase early detection
of breast cancers
4. Increase the availability of health
information and other resources for
young women diagnosed with
breast cancer

For more information, contact Ena Wanliss,

MS, Lead Public Health Advisor, Centers for
Disease Control and Prevention, National Cen-
ter for Chronic Disease Prevention and Health
Promotion, Division of Cancer Prevention and
Control, 4770 Buford Highway, Mailstop K-57,
Chamblee, GA 30316. (770) 488-4225.

Source: Federal Register June 24, 2010. Available at

http://edocket.access.gpo.gov/2010/2010-15293.htm.
Accessed July 9, 2010.

Improving Quality of Care Based on CMS Guidelines 79

 Special Feature
Take the
Pink Glove Survey!

Precious. And Pink.

Soft and shimmery.

Layered with organic aloe.
Fashioned from nitrile.

1
The Pink Pearl.

To take the survey, go to Medline’s newest Generation Pink glove.

Supporting the National Breast Cancer Foundation.

www.medline.com/healthyskin/survey
or complete the business reply card. AD
©2010 Medline Industries, Inc. The cross-fingered pink glove hand image is a trademark
of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. 1

2 Answer these questions: AD 1

A. What does the Pink Glove Dance mean to you?
I only wear Pink Pearls.

B. Do you think pink gloves get people talking about

breast cancer?
Yes, They’re Genuine.

3
Only Medline’s Pink Pearl gloves combine

Take a look at the Pink Pearl ads on the next three

aloe, nitrile and breast cancer awareness.

Only Medline’s Pink Pearl gloves combine AD

aloe, nitrile and breast cancer awareness. 2
pages and pick your favorite. ©2010 Medline Industries, Inc. The Pink Pearl glove is a trademark of Medline
Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

AD 2

©2010 Medline Industries, Inc.

The Pink Pearl glove is a trademark
of Medline Industries, Inc. Medline is
a registered trademark of Medline
Industries, Inc.

AD
3

AD 3

Participate today!
The first 1,000 readers to respond
will receive the new Deb doll!

www.PinkGloveDance.com
80 Healthy Skin
 Precious. And Pink.

Soft and shimmery.

Layered with organic aloe.
Fashioned from nitrile.

The Pink Pearl.™

Medline’s newest Generation Pink glove.

Supporting the National Breast Cancer Foundation.

AD
©2010 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl
is a trademark of Medline Industries, Inc. 1
Improving Quality of Care Based on CMS Guidelines 81
I only wear Pink Pearls.

Only Medline’s Pink Pearl™ gloves combine AD

aloe, nitrile and breast cancer awareness. 2
©2010 Medline Industries, Inc. Medline is a registered trademark and Pink
Pearl is a trademark of Medline Industries, Inc.

82 Healthy Skin
Yes, They’re Genuine.
Only Medline’s Pink Pearl™ gloves combine
aloe, nitrile and breast cancer awareness.

©2010 Medline Industries, Inc.

Medline is a registered trademark
and Pink Pearl is a trademark of
Medline Industries, Inc.

AD
3
Improving Quality of Care Based on CMS Guidelines 83
 Caring for Yourself
Breast Self-Examination
1. In the Shower
Fingers flat – move gently over
every part of each breast.
Use your right hand to examine left
breast, left hand to examine right
breast. Check for any lump, hard
knot or thickening. Carefully observe
any changes in your breast.
2. Before a Mirror
Inspect your breasts with your arms
raised high overhead. Next, place
your arms at your sides. Look for
any changes in contour of each
breast; a swelling, a dimpling of
skin, or changes in the nipple.
Then rest palms on hips and press
firmly to flex your chest muscles.
Left and right breasts will not match
exactly. Few women’s breasts
do match.
3. Lying Down
Place pillow under right shoulder,
right arm behind your head. With
fingers of left hand flat, press right
breast gently in small circular
motions, moving vertically or in
a circular pattern covering the
entire breast.
Use light, medium and firm pressure.
Squeeze nipple, check for discharge
and lumps. Repeat these steps on
your left breast.
Recommended Reading
Dr. Susan Love’s Breast Book
Susan M. Love, MD
Da Capo Press, 2005
Everything you wanted to know about
breasts and breast cancer. Each treatment
option is reviewed with realistic outcome
statistics. Also check out Dr. Love’s
website www.dslrf.org/breastcancer.
84 Healthy Skin
Mammograms
Save Lives
The U.S. Preventive Services Task Force (USPSTF), a
group of health experts that reviews published research
to make healthcare recommendations, points out
that women who have screening mammograms die of
breast cancer less frequently than women who do not
get mammograms.
Although the USPSTF recently changed their breast
screening guildelines, recommending mammograms to
be performed every two years beginning at age 50.
The American Cancer Society (ACS), Mayo Clinic, and
others, however, have not changed their recommendations.
• The ACS and Mayo Clinic continue to recommend
yearly mammogram screening beginning at age 40
for women at average risk of breast cancer.
• ACS says breast self-exams are optional; however,
Mayo Clinic recommends breast self-exams to allow
women to identify breast abnormalities and become
familiar with their breasts so they can tell their doctor
about any changes.
If you are confused about any of these recommendations,
it is best to talk to your doctor to learn what’s right for you
based on your individual risk factors.
Source: Pruthi S. Mammogram guidelines: what’s changed? Mayo
Clinic website. Available at: http://www.mayocliic.com/health.mam-
mogram-guidelines/AN02052. Accessed July 30, 2010.
The Breast Cancer Survival Manual:
A Step-by-Step Guide for the Woman
with Newly Diagnosed Breast Cancer
John Link, MD
Henry Holt and Company, 2000
A complete guide on how to survive a
diagnosis of breast cancer: how to pick
a team of specialists, diagnostic tests,
adjuvant therapy choices, management
of side effects and diet.
 How 4 square inches of Puracol® Plus
changed chronic wound care.
Forever.

Look closely. It’s not a bandage. It’s Puracol Plus ™

MicroScaffold , made entirely of pure native collagen.

™

Chronic wounds tend not to heal when unbalanced levels

of elastase and MMPs (inflammatory enzymes) destroy the
body’s own collagen and growth factors.1
But apply Puracol Plus and help restore nature’s balance.
In vitro studies show that Puracol Plus has the ability
to reduce the levels of elastase and MMPs from
This is Puracol Plus Micro- surrounding fluid.2
Scaffold as seen through an
electron microscope. Its open,
cellular structure allows easy
fibroblast migration.2 The high
strength of the MicroScaffold2
also assists in establishing a
fresh wound bed. Each Puracol package is
a 2-Minute Course in ™

Advanced Wound Care.

1. Schultz GS, Mast BA. Molecular analysis of the environ- ©2010 Medline Industries, Inc.
ment of healing and chronic wounds: Cytokines, proteases, Puracol is a registered trademark of Medline Industries, Inc.
and growth factors. Wounds. 1998;10 (6 Suppl): 1F-9F. Medline is a registered trademark of Medline Industries, Inc.
2. Data on file.
Special Feature
The Dance Goes On:
Pink Glove Dance Sequel
Never in our wildest dreams did we think a video
of a few hundred people dancing in pink gloves at
Providence Medical Center in Portland, Ore., St. Vincent
would become an Internet sensation, generating more
than 11 million views on YouTube and launching a
wave of awareness.
Medline created the original Pink Glove Dance video
to help get people talking about breast cancer early
detection and to spotlight the healthcare workers who
are taking care of breast cancer patients.
The video went viral and Medline received a flood of
calls and e-mails from hospitals and breast cancer
survivors around the country expressing their gratitude
for the video and how much they want to participate
in the next video.
So this summer, the Pink Glove Dance crew traveled
the nation, stopping at 11 hospitals, three nursing
homes and five survivor sites, including New York City,
New Orleans, Chicago, Denver and San Francisco, to
film healthcare workers and breast cancer survivors
dancing in pink gloves and sharing their message of
joy, support and caring.
 Here is just a sampling of the comments we heard on the road:

“ Thanks for bringing so many people

together, I am so happy to have been able
to participate. It just goes to show there is
nothing we can't do to raise awareness.
- Veronique Nikki Thomas,
Chicago shoot
I encourage ANY and ALL Survivors to
participate. As a Breast Cancer Survivor
myself, this was an event that I will
never forget.
- Beth Parrish,
Portland survivor shoot

I absolutely loved partaking in the Pink Glove What an awesome time, experience and
Dance sequel video in Times Square. Thanks memory. This amazing experience will
again for the opportunity to be part of some- stay with me forever. Thank you for
thing so wonderful and the chance to speak including Chicago.

”
about something so important to me. - Tammy Moletz,
- Lisa Kisternberg-Solomon, Chicago shoot
New York City survivor shoot

Watch the Pink Glove Dance sequel at

pinkglovedance.com.

About 200 healthcare workers Follow Medline and Breast Cancer Awareness on
and breast cancer survivors Facebook at www.facebook.com/medlinebreast-
danced at the Chicago shoot. cancerawareness and on Twitter at
twitter.com/medlineindustr.
 Special Feature

Sharing Stories
More than 4,000 breast cancer survivors and healthcare workers participated in the making of the Pink
Glove Dance sequel. During that time, we heard many powerful and inspiring stories of survivorship and hope.
Thank you to the survivors and their families for allowing us to share a few of their stories.

The following is a letter from a woman who saw the original Pink Glove Dance featured on the news and was inspired
to share the story of her mother's final few days battling breast cancer.

To the Pink Glove Crew (aka Staff of

Providence St. Vincent Medical Center)
This evening, as I was watching ABC World News
Tonight with Charles Gibson, I heard him mention two of
the worst words I have ever heard: Breast Cancer. These
words leave a huge lump in my stomach and can almost
instantaneously bring a tear to my eye. It is because
these two horrific words took my mama, Eleanor Mar-
garet Strelecky away from me August 30, 2004 at 7:45
a.m. She was a mere 56 years of age. I was lucky
enough to say goodbye, but not willingly.
My mother was amazing. By amazing, I mean she was
both warm and loving. Don’t get me wrong, she was by
no means perfect, and, at times, she drove me up a wall!
She always encouraged me to try at everything though.
I loved to perform and she got me on every stage she
possibly could. I made up silly dances and songs and
she would sit in her recliner any time I needed an
audience. She laughed so hard and would applaud
every time.
My mother was so sarcastic. When I would cry and get
whiney, she would come at me as if to comfort me, and
then start applauding announcing I had won the award
for best dramatic performance!
She had a lust for life, and I know that she was so
cheated by breast cancer. She had battled it on and off
for four years. She knew way before I did that this little
terrorist was going to win, but she stood strong
in silence.
A week before her passing, I found out through my step-
father, that she did not have much time left. I scurried to
buy a plane ticket from Iowa down to Georgia where she
lived. In transit, I wrote down as many memories as I
could think of between her and me. Some of them were
the stupidest jokes, but I did not want to forget a thing.
The day before she passed, I walked into her bedroom
where she lay in a semi-conscious state. She was heav-
ily sedated and the cancer had metastasized to her liver,
lungs, and brain. I sat in a chair by her bed and read her
all of the memories I had written down, trying hard to
enunciate through the ever-growing tears in my eyes that
caused my voice to quiver. When I was done reading
them, I kissed my mother’s hand and told her over and
over again how much I loved her. This wasn’t enough
though; I had to hug her. I carefully sat down on her bed
and as I leaned in to embrace her frail body, I saw a tear
from her eye. I knew seeing her tear I was going to lose
it completely and become hysterical. At the brink of this
happening, my mother became completely coherent,
opened her eyes wide and said, “And the award for best
dramatic performance goes to: Bwinny (her nickname
for me)!” She then laughed, gave me a look of “Oh
please,” and said, “Now get off the bed. There isn’t
much room as it is!”
I took a step back and was stunned, but then began to
laugh uncontrollably at my mother’s comic relief in such
a sad moment as saying a final goodbye! There was my
mama, in all her glory, being a smart-ass just as if it was
any other day.

88 Healthy Skin
“ When I saw the brief [Pink Glove Dance] clip on ABC
World News, I smiled and shivers ran down my spine.

”
When I saw the brief [Pink Glove Dance] clip on ABC
World News, I smiled and shivers ran down my spine. It
was the same feeling that came over me that day in my
mother’s bedroom. I quickly jumped on YouTube and
watched the video in its entirety. I cried the entire way
through, but tears of joy. And I laughed. As I laughed,
I looked up at the sky and said to my mama: I know you
are thinking this is hilarious!

The point of this letter was not to ramble on and on, but
to thank you for making such a funny video and for
everyone’s commitment to participating in something
that is sure to increase breast cancer awareness. The
choreography was like nothing I’ve ever seen, and I think
you have some future Broadway dancers on your
hands! You made me laugh in a time when Christmas is
around the corner and I begin missing my mother more
than ever. Most importantly, you provided me with a
laugh that I shared with my mother up in heaven and for
that, I am forever grateful because I just received the
best Christmas present ever!

Happy holidays to each and every one of you at that

hospital and keep donning those pink gloves because
they suit you all very well. I send the biggest hug to every
star in that video!

All my love,
Melinda Sara Crane
Wellman, Iowa

Improving Quality of Care Based on CMS Guidelines 89

 Sharing Stories
Below is an e-mail from a Medline sales representative whose
36-year-old sister has stage 4 breast cancer. She and her
three-year-old daughter (see accompanying photo), danced
in New York’s Times Square for the sequel.

Thank you for everything you did last Saturday for my

sister, niece and family. To see my sister and niece
smiling meant everything to me and my family. I can not
express my gratitude enough through words. But again,
thank you. They truly had a blast and my niece loves her
Deb doll. What you guys and Medline are doing is so awe-
some and is touching the lives of so many. It makes me
proud to say I work for Medline.

Hank Israel
Medline Sales Representative
Ft. Lauderdale, Florida

Margaret Smith lost her battle with breast cancer on July 5,

2010. She participated in the original Pink Glove Dance while
being treated at Providence St. Vincent's Medical Center.
Following is a note from her family:

That video was such a special thing for Mom – something

so unique and different than anything she would have
ever done! After spreading her ashes at the coast, we
played the Pink Glove Dance song and danced to it in the
parking lot. I think she would have enjoyed it.

John Smith
Susan, Tim, Stephanie and Rachael Burke
Jay and Carmel Charland

90 Healthy Skin
Below is an e-mail from a Medline employee in the Information Services department. She and her five sisters tested positive for
the breast cancer gene and each underwent treatment. She danced in Chicago for the sequel.

I am lucky thanks to early detection — without it, I would
still have breast cancer. Breast cancer runs in my family.
I have two sisters who were diagnosed and treated within
two years of each other. Their doctors suggested that they
be tested for the BRCA gene to see if that was going to be
an issue in the family. They were both tested and both were
positive for the BRCA-II gene. At that point, the doctors
suggested the family be tested. Let me tell you, I am one
of 12 children in my family. I tested positive for the BRCA-II
gene as well as five of five sisters tested. It was recom-
mended that I have a hysterectomy (full) to reduce my
chances of getting breast cancer from 80% to 40%. I got
the hysterectomy and two years later (almost to the day),
I was back on the table for a lumpectomy. It was biopsied
and was positive for cancer.
Participating in the Pink Glove Dance was AWESOME! It
was a great day and it felt wonderful to be with so many
others who had similar stories and the people who helped
us (the patients) through it all. When the healthcare work-
ers were dancing with us, we were high-fiving them and
thanking them for everything they do. I am so lucky to have
known about the breast cancer early and to be working
at Medline.
Helen Franklin
Medline Information Services
Mundelein, Illinois

Improving Quality of Care Based on CMS Guidelines 91

 Taste the
Fountain
ofYouth

92 Healthy Skin
 Caring for Yourself

Want to fight the effects of aging?

Add these powerful foods to your diet!

1. Fatty fish. Mackerel, bluefish, 6. Green tea. This traditional Asian

salmon and tuna are rich sources of drink has been shown to have anti-can-
omega-3 fatty acids, which improve cer properties. It also contains theanine,
circulation, reduce inflammation and an amino acid known for its relaxation
reduce the risk of heart disease. benefits.

2. Whole grains. Pass up the 7. Mangosteen. Never heard of it?

white bread, and fill your plate with Never mind. Just give it a try. This small,
whole grains, an excellent source purplish fruit from Southeast Asia contains
of B-complex vitamins, including anti-inflammatory compounds known as
riboflavin and niacin, which are xanthones, which have been shown to
essential for optimal energy improve gastrointestinal function, control
metabolism. pain and reduce markers of inflammation
in the blood, such as C-reactive protein.
3. Low-fat dairy products. The mangosteen is best in juice form.
Drink your skim milk, and eat
plenty of yogurt to receive the 8. Exotic spices. Jazz up your recipes
anti-aging benefits of calcium with turmeric, curry, cumin and ginger,
and vitamin D. Not only are they which have profound anti-cancer proper-
good for your bones, calcium ties. Used in Indian and Thai cuisine, each
also helps boost your metabolic of these spices has been linked with
rate, and vitamin D exhibits prevention and accelerated healing of
anti-cancer activity. cancers of the mouth, throat and
gastrointestinal tract.
4. Green leafy vegetables.
Never underestimate the power of 9. Citrus fruits. Whether it’s oranges,
spinach and salad greens. Green lemons, limes, grapefruit or tangerines,
leafy vegetables are terrific sources citrus fruits are a rich source of vitamin C.
of fiber, calcium and beta-carotene, Plus, the white underside of the peels is
an important antioxidant that pro- a source of specialized flavanoids known
tects the skin from the effects as poly-methoxylated-flavones (PMFs),
of ultraviolet radiation. which have been shown to reduce stress
hormones and cholesterol levels.
5. Berries. Try them all –
strawberries, blueberries, 10. Red wine. Sip a glass of your
raspberries. They are rich favorite Merlot, and reap the benefits of
in flavonoids, which have resveratrol, a flavanoid found in the skins
been shown to help reduce of red grapes. Animal studies have shown
the risk of heart disease, that diets high in resveratrol are associated
cancer and diabetes. with a unique set of anti-aging benefits.
Studies of resveratrol’s effects on humans
Source: Talbott S. Anti-aging power foods slideshow. HealthyAging. are underway.
Available at http://healthy-aging.advanceweb.com. Accessed May 16, 2010.

Improving Quality of Care Based on CMS Guidelines 93

 Healthy Eating

Nutrition
Information
Servings: 6
Calories: 271
Fat: 3.38 g
Sodium: 579 mg
Fiber: 4.9 g

Tuscan Tomato Soup (6 servings)

• 1 teaspoon olive oil • 3 pounds ripe tomatoes, cut into • 1 teaspoon sugar
• 1 clove garlic, minced quarters • ¼ teaspoon salt
• 2 cups (1-inch cubes) country style • ¼ cup loosely packed fresh basil
bread (only hearty dense bread will do) leaves, chopped

Directions: She subscribes to lots of different magazines, and always scans

In a small skillet, heat oil on medium heat until hot. Add garlic and
cook for one minute – stirring constantly. Remove from heat.
In a food processor with knife blade attached, pulse bread until
coarsely chopped. Add tomatoes and garlic. Pulse until mixture
is almost a puree. Pour soup into a bowl and stir in chopped
basil, sugar and salt. Serve warm or chilled.
Operations analyst Mary Lanciloti, who
works at Medline’s Vernon Hills, Ill. office,
won a bronze medal for this recipe in the
International Cookoff during Employee
Appreciation Week.
them for new recipes to try. This one caught her eye because
it’s quick, easy and nutritious. She also noted that it’s perfect for
anyone who is trying to drop a few pounds because it’s low in
calories and very filling.
“I’m a big gardener, so this recipe gives me a chance to use
fresh tomatoes and basil from my own garden,” Mary said. “Of
course, you can always find good summer tomatoes at the local
farm stand or supermarket, too.”
Mary shared that she likes to cook and loves to bake. She took
it up based on her grandmother’s advice that if you like to cook
and bake and sew, you’ll land yourself a good husband.

“I guess it wasn’t the greatest advice,” Mary said. “Because I’ve

always been single! Oh, well.”

94 Healthy Skin
 FORMS & TOOLS

The following pages contain practical tools for implementing

patient-focused care practices at your facility.

Online Skin & Risk Assessment Competency ................96

Pressure Ulcer Prevention

SKINSAVERS Initiative: A Pressure Ulcer

Prevention Tool ................................................................98

Impact of Healthcare Reform on Home Health ............103

Healthcare Reform

Patient Handout: Medicare and the New Health

Care Law – What it Means for You ..............................105

A National Framework and Preferred Practices for

Palliative Care

Palliative and Hospice Care Quality ............................109

Ten Tips for Cleaning and Disinfecting Shared

Infection Control

Medical Equipment ......................................................111

Some Things Should Not be Reused ..........................114
CDC Clinical Reminder: Use of
Fingerstick Devices ......................................................115

Improving Quality of Care Based on CMS Guidelines 95

 Announcing New Online Skin &
Risk Assessment Competency
The Latest Addition to Medline’s
Pressure Ulcer Prevention Program
Medline’s Pressure Ulcer Prevention Program –
an educational initiative aimed at reducing the inci-
dence of pressure ulcers – has added an interactive
online competency to allow nurses to demonstrate
what they’ve learned in a virtual clinical setting.
This approach provides consistency, as each
learner performs the same assessments.

The learner proceeds through the compe-

tency using the computer mouse to com-
plete each step – from dispensing hand
sanitizer at the wall unit to pulling back the
bed linens and patient gown, performing
assessments on three separate patients.
An illustrated hand replaces the usual
mouse arrow on the screen.

James is a 44-year-old male who

is recovering from a heart attack.

96 Healthy Skin
 Prevention

Sarah is in a coma with a naso-gastric

feeding tube. She has a visible wound
on her right arm.

When the learner clicks on Sarah’s

arm, a close-up photograph of her
wound and a related multiple choice
question appear on the screen.

At the end of each skin assessment, the

learner completes the Braden Scale to
determine the patient’s level of risk for
pressure ulcers.

The only way to access the Skin and Risk

Assessment Competency is by joining the
Pressure Ulcer Prevention Program. Visit
www.medline.com/PUPP-webinar to sign up
for an informational webinar to learn more.
(See back cover for webinar dates.)

Improving Quality of Care Based on CMS Guidelines 97

 Forms & Tools SKINSAVERS Initiative

SKINSAVERS Initiative
A pressure ulcer prevention tool
By Feddy S. Emmanuel, RN, MSN, FNP-BC, CWOCN

Pressure ulcers are a great health concern with considerable financial implications and ability
to cause considerable pain and suffering. Accordingly, the SKINSAVERS initiative was put into
place at Lutheran Medical Center in Brooklyn, NY, and includes the following:
• WOCN consultation of all patients with pressure ulcers stage II and greater
• Standardization of skin and advanced wound products
• Staff education on skin and wound product utilization
• Braden Scale risk assessment performed on admission and daily
• Recruitment, training, empowerment of SKINSAVERS RN unit champions
• Implementation of SKINSAVERS bundle for pressure ulcer prevention

SKINSAVERS Bundle
S – Side lying positioning at 30-degrees
K – Keep HOB at 30 degrees
I – Inspect skin daily & at every turn
N – Nutrition & hydration improvement/nutrition consult
S – Suspend heels
A – Apply moisture barrier after incontinence episodes
V – Vigilant skin care & moisturizer
E – Encourage mobility
R – Reposition at least every 2 hours
S – Support surfaces: bed & chair

Since its implementation the initiative has shown considerable reduction in the incidence of
pressure ulcers. Ongoing staff education is an essential part of the program. With increased
knowledge comes increased compliance and subsequently improved patient outcomes.

© 2010 Feddy S. Emmanuel. Printed with permission.

About the author

Feddy S. Emmanuel, RN, MSN, FNP-BC, CWOCN is a practicing WOC
Nurse Practitioner at Lutheran Medical Center in Brooklyn, NY. She earned
her Master of Science degree and Family Nurse Practitioner certificate in 2008
from SUNY Downstate Medical Center in Brooklyn, NY, and is board certi-
fied by the ANCC. She obtained her WOCN certificate from Albany Medical
Center WOCNEP in 1998, has been board certified by the WOCNB for 11
years and holds a certificate in HBOT. She has been a registered nurse for
over 30 years with experience in acute care, critical care, long-term care, home
health and outpatient services.

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

Avoiding unnecessary catheter use is a primary strategy

for preventing CAUTI, and clinical guidelines recommend
the consideration of alternatives to catheterization.2
Bladder scanners accurately assess bladder volumes,
and many urinary catheterizations can be avoided.3

To learn more about

CAUTI prevention, visit
www.medline.com/erase
or contact your Medline
sales representative.

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K,

Anderson DJ, et al. SHEA/IDSA practice recommendation:
strategies to prevent catheter-associated urinary tract infections
in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.
2. Stokowski, LA. Preventing catheter-associated urinary tract infections.
Medscape Nursing Perspectives. February 3, 2009.
3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations.
Med/Surg Nursing. 2005; 14(4):249-253.

©2010 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.
 What did we do after
designing a revolutionary
new catheter tray system?

We found THREE more ways

to make it even better.
We’re obsessed with engineering new and better
technology for healthcare workers. So after we
revolutionized the outdated Foley catheter tray with
a unique, one-layer system design, we immediately
turned our attention to addressing how we could
make it even easier to use. We studied how the
tray was being used in the field. The result was
three more great improvements.
Combined with the previous innovative tray redesign
and comprehensive ERASE CAUTI education, these
three new features help to improve patient safety and
quality, while reducing avoidable costs associated with
waste and urinary tract infections.
To learn about the ERASE CAUTI system, as well as
other strategies for minimizing the risk of CAUTI, sign
up for a free Innovation in the Prevention of CAUTI
webinar at www.medline.com/erase/webinar.

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
1 Real photography on the outside –
so you know exactly what’s inside
A photo on the package helps identify the
contents of the kit, serves as an educational
tool for the clinician and can be used to
discuss the procedure with the patient.
Also, the label opens up to a booklet with
step-by-step instructions and helpful tips
for the clinician.

2 A checklist that fits better

in the medical record
The reformatted checklist is smaller, making
it easier to fit in the patient chart or medical
record. It is also available as an attachment
for electronic documentation.

3 Education you’ll want to present

to your patient
There’s nothing like the new Patient
Education Care Card. Designed to look
and feel like a “Get Well Soon” card, it
tells patients about catheterization so
they know you are providing them the
best care possible.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Impact of Health Care Reform on Home Health Forms & Tools

Tip Sheet

Impact of Health Care Reform

(The Patient Protection & Affordable Care Act) on
Home Health Care Agencies and Nurses

Joan M. Marren, RN, MA, MEd,

Chief Operating Officer, Visiting Nurse Service of New York /
President, VNSNY Home Care

Payment Changes
Reduces reimbursement to home care by $39.7 billion over 10 years beginning in
2011. Home health agencies will be under great pressure to manage costs,
including nursing costs, case mix and utilization closely. This raises concerns
about the potential impact on access to and quality of home care.
Mandates two studies - first (due 1/2015) to assess the impact of home care
reductions on access, quality and number of agencies and types; second (due
3/2014) to evaluate costs to serve low income, complex care patients and their
patterns of admission to home health care. The Act authorizes up to $500million,
based on study findings, for demonstrations to see if changes to PPS
reimbursement will improve access for high need patients.
Take Away Message: Home health agencies, and their nurses in particular, serving
high cost, complex care patients have a unique opportunity to articulate the
characteristics and needs of these patients and to participate in demonstrations to
assure their access to care.

Quality Reporting & Incentives/Value Based Purchasing

Requires development of a national strategy and action plan to improve health
service delivery, outcomes and population health with emphasis on managing
high cost chronic illness, reducing preventable hospital admissions and decreasing
health disparities
Implements value based purchasing/pay for performance
Take Away Message: A national health care improvement strategy can raise
awareness of the role and contributions of home health nurses to management of
chronic illness and avoidance of hospitalization. Success in a value based purchasing
model will highlight the impact of home care nurses on quality of care but nurses
must be sure that measures are properly risk adjusted and within the home care
agencies’ and nurses’ control.
Chronic Care Coordination & Service Innovation

Improving Quality of Care Based on CMS Guidelines 103

 Forms & Tools Impact of Health Care Reform on Home Health

Establishes Federal Coordinated Health Care Office and creates a Center for
Medicare and Medicaid Innovation to better integrate Medicare/Medicaid strategy
at the federal and state level and to test new payment and service delivery models
for elderly and chronically ill.
Proposes demonstration programs to reduce cost and improve coordination and
quality for the chronically ill by expanding medical and health care homes
(Independence at Home/Medicaid “health homes”), developing new models and
incentives for improved cross continuum collaboration (Community Care
Transitions Program and “bundled payment”), and sharing savings with
accountable, collaborative, multi-provider organizations (Accountable Care
Organizations).
Take Away Message: Proposed initiatives present many opportunities for home
health care nurses and nurse practitioners, as lead providers and in partnership
with others, to play a greater role in the care management of chronic illness patients
in the community.

The CLASS Act

Creates a new federally administered, voluntary insurance program that supports
community living for beneficiaries with long term cognitive or functional
impairments
Provides a modest benefit to cover non medical ADL services and support.
Take Away Message: Program could expand the market for community based
assessment, care management and direct care services provided or supervised by
home health care nurses.

Expansion of Medicaid & Long Term Care Home and Community Based Services
Proposes various models and incentives that expand Medicaid coverage and
promote community based care in lieu of nursing home placement.
Take Away Message: More insured individuals and emphasis on access to
community care options will probably create greater demand for home care
services. This will drive demand for skilled home care nurses to deliver services and
to train and oversee paraprofessional home care workers.

Workforce Development
Authorizes grants and training programs for “community health workers”,
“community based long term care entities” and health professionals who provide
direct care
Focuses particular emphasis on targeting training programs to serve underserved,
high risk communities and populations.
Take Away Message: Access to increased numbers of well prepared home care
nurses and paraprofessional staff will be essential to meet anticipated demand from
demographic changes in the population and from health care reform’s emphasis on
building community care options and capacity.

104 Healthy Skin

Medicare and Health Care Reform – Patient Handout Forms & Tools

CENTERS FOR MEDICARE & MEDICAID SERVICES

MAY 2010

Medicare and the New Health Care Law —

What it Means for You
A Message from Kathleen Sebelius,
Secretary of Health & Human Services
The Affordable Care Act passed by Congress and signed by President
Obama this year will provide you and your family greater savings and
increased quality health care. It will also ensure accountability
throughout the health care system so that you, your family, and
your doctor—not insurance companies—have greater control
over your care.
These are needed improvements that will keep Medicare
strong and solvent. Your guaranteed Medicare benefits won’t
change—whether you get them through Original Medicare or
a Medicare Advantage plan. Instead, you will see new benefits
and cost savings, and an increased focus on quality to ensure
that you get the care you need.
This brochure provides you with accurate information about
the new services and benefits to help you and your family now
and in the future.
The Centers for Medicare & Medicaid Services (the federal
agency that runs the Medicare, Medicaid, and Children’s Health
Insurance Program) will continue to provide you with up-to-date
information about these new benefits and will ensure that your personal
information is safe.
Remember—rely on your trusted sources of information when it comes
to accurate information about Medicare, and don’t hesitate to call
1-800-MEDICARE or go on-line at Medicare.gov if you have questions
or concerns. Don’t give your personal Medicare information to anyone
who isn’t a trusted source.

Improving Quality of Care Based on CMS Guidelines 105

 Forms & Tools Medicare and Health Care Reform – Patient Handout

HEALTH CARE LAW

What Stays the Same

The guaranteed Medicare benefits you currently receive will remain the same. During open enrollment
this fall, you will continue to have a choice between Original Medicare and a Medicare Advantage plan.
Medicare will continue to cover your health costs the way it always has, and there are no changes in
eligibility. But, there are some important benefits that you and your family can take advantage of starting
this year. Look for more details in your Medicare and You Handbook coming this fall.

Improvements in Medicare You Will See Right Away

More Affordable Prescription Drugs
• If you enter the Part D “donut hole” this year, you will receive a one-time, $250 rebate check if you
are not already receiving Medicare Extra Help. These checks will begin mailing in mid-June, and will
continue monthly throughout the year as beneficiaries enter the
coverage gap.
• Next year, if you reach the coverage gap, you will receive a 50%
discount when buying Part D-covered brand-name prescription drugs.
• Over the next ten years, you will receive additional savings until the
coverage gap is closed in 2020.

Important New Benefits to Help you Stay Healthy

• Next year you can get free preventive care services like colorectal
cancer screening and mammograms. You can also get a free annual
physical to develop and update your personal prevention plan based
on current health needs.

Improvements to Medicare Advantage

• Today, Medicare pays Medicare Advantage insurance companies over
$1,000 more per person on average than Original Medicare. These
additional payments are paid for in part by increased premiums by all
Medicare beneficiaries—including the 77% of seniors not enrolled in a
Medicare Advantage plan.
• The new law levels the playing field by gradually eliminating Medicare
Advantage overpayments to insurance companies.
• If you are in a Medicare Advantage plan, you will still receive guaranteed Medicare benefits.
• Beginning in 2014, the new law protects Medicare Advantage members by taking strong steps to ensure
that at least 85% of every dollar these plans receive is spent on health care, rather than administrative costs
and insurance company profits.
106 Healthy Skin
 HEALTH CARE LAW

Improvements in Medicare You Will See Soon

Better Access to Care
• Your choice of doctor will be preserved.
• The law increases the number of primary care doctors, nurses, and physician assistants to provide better
access to care through expanded training opportunities, student loan forgiveness, and bonus payments.
• Support for community health centers will increase, allowing them to serve some 20 million new patients.

Better Chronic Care

• Community health teams will provide patient-centered care so you won’t have to see multiple
doctors who don’t work together.
• If you’re hospitalized, the new law also helps you return home successfully—and avoid going back—by
helping to coordinate your care and connecting you to services and supports in your community.

Improvements Beyond Medicare That You and Your Family Can Count On
Improves Long-Term Care Choices
• New tools and resources in the Elder Justice Act, which was included in
the new law, will help prevent and combat elder abuse and neglect, and
improve nursing home quality.
• The new law creates a new voluntary insurance program called CLASS
to help pay for long-term care and support at home.
• Individuals on Medicaid will receive improved home- and community-
based care options, and spouses of people receiving home- and community-
based services through Medicaid will no longer be forced into poverty.

Helps Early Retirees

• To help offset the cost of employer-based retiree health plans, the new law creates a program to preserve
those plans and help people who retire before age 65 get the affordable care they need.

Helps People with Pre-existing Conditions

• The new law provides affordable health insurance through a transitional high-risk pool program for
people without insurance due to a pre-existing condition.
• Insurance companies will be prohibited from denying coverage due to a pre-existing condition for
children starting in September, and for adults in 2014.
• Insurance companies will be banned from establishing lifetime limits on your coverage, and use of
annual limits will be limited starting in September.

Expands Health Coverage for Young People

• Young people up to age 26 can remain on their parents’ health insurance policy starting in September.

Improving Quality of Care Based on CMS Guidelines 107

 Forms & Tools Medicare and Health Care Reform – Patient Handout

HEALTH CARE LAW

The New Law Preserves and Strengthens Medicare

New Tools to Fight Fraud and Protect Your
Medicare Benefits
• The new law contains important new tools to help
crack down on criminals seeking to scam seniors
and steal taxpayer dollars.
• It reduces payment errors, waste, fraud, and
abuse to make Medicare more efficient and return
savings to the Trust Fund to strengthen Medicare
for years to come.
• You are an important resource in the fight against
fraud. Be vigilant and rely only on your trusted
sources of information about your Medicare
benefits.
• Call 1-800-MEDICARE if you have any questions
or want to report something that seems like fraud.
Keeps Medicare Strong and Solvent
• Over the next 20 years, Medicare spending will
continue to grow, but at a slightly slower rate as
a result of reductions in waste, fraud, and abuse.
This will extend the life of the Medicare Trust
Fund by 12 years and provide cost savings to
those on Medicare.
• In 2018, seniors can expect to save on average
almost $200 per year in premiums and over $200
per year in co-insurance compared to what they
would have paid without the new law.
• Upper-income beneficiaries ($85,000 of annual
income for individuals or $170,000 for married
couples filing jointly) will pay higher premiums.
This will impact about 2% of Medicare
beneficiaries.

For More Information

For more information about the new health care law now, visit
www.medicare.gov. If you have any questions, call 1-800-MEDICARE
(1-800-633-4227) or your State Health Insurance Assistance Program (SHIP).
Visit www.medicare.gov or call 1-800-MEDICARE to get their telephone
number. TTY users should call 1-877-486-2048. If you need help in a language other than English or
Spanish, say “Agent” at any time to talk to a customer service representative.
Visit the Eldercare Locator at www.eldercare.gov to find out how to access home- and community-
based services and benefits counseling, transportation, meals, home care, and caregiver support services.
You can also call 1-800-677-1116. The Eldercare Locator, a public service of the U.S. Administration on
Aging, is your first step for finding local agencies in every U.S. community.

CMS Product No. 11467

108 Healthy Skin

Preferred Practices – Palliative & Hospice Care Quality Forms & Tools

A National Framework and

Preferred Practices for Palliative Center to Advance
Palliative Care

and Hospice Care Quality 1255 Fifth Avenue, Suite C-2

New York, NY 10029
Phone 212.201.2670
Fax 212.426.1369
A National Quality Forum (NQF) Consensus Report www.capc.org

The National Quality Forum has recently identified palliative care and hospice care as national
priority areas for healthcare quality improvement. The highly influential NQF report provides
TM
a framework and set of NQF-endorsed preferred practices that focus on improving palliative
care and hospice care across the Institute of Medicine’s six dimensions of quality – safe,
effective, timely, patient-centered, efficient, and equitable. The preferred practices mark a
crucial step in the standardization of palliative care and hospice.

Preferred Practices…
1. Provide palliative and hospice care by an interdisciplinary team of skilled palliative care professionals, including,
for example, physicians, nurses, social workers, pharmacists, spiritual care counselors, and others who collaborate
with primary healthcare professional(s).
2. Provide access to palliative and hospice care that is responsive to the patient and family 24 hours a day,
7 days a week.
3. Provide continuing education to all healthcare professionals on the domains of palliative care and hospice care.
4. Provide adequate training and clinical support to assure that professional staff is confident in their ability to
provide palliative care for patients.
5. Hospice care and specialized palliative care professionals should be appropriately trained, credentialed, and/or
certified in their area of expertise.
6. Formulate, utilize, and regularly review a timely care plan based on a comprehensive interdisciplinary assessment
of the values, preferences, goals, and needs of the patient and family and, to the extent that existing privacy laws
permit, ensure that the plan is broadly disseminated, both internally and externally, to all professionals involved in
the patient's care.
7. Ensure that upon transfer between healthcare settings, there is timely and thorough communication of the patient's
goals, preferences, values, and clinical information so that continuity of care and seamless follow-up are
assured.
8. Healthcare professionals should present hospice as an option to all patients and families when death within a
year would not be surprising and should reintroduce the hospice option as the patient declines.

9. Patients and caregivers should be asked by palliative and hospice care programs to assess physicians'/healthcare
professionals' ability to discuss hospice as an option.
10. Enable patients to make informed decisions about their care by educating them on the process of their
disease, prognosis, and the benefits and burdens of potential interventions.

Improving Quality of Care Based on CMS Guidelines 109

 Forms & Tools Preferred Practices – Palliative & Hospice Care Quality

A National Framework and Preferred Practices

for Palliative and Hospice Care Quality (continued)

11. Provide education and support to families and unlicensed caregivers based on the patient's individualized
care plan to assure safe and appropriate care for the patient.
12. Measure and document pain, dyspnea, constipation, and other symptoms using available standardized
scales.
13. Assess and manage symptoms and side effects in a timely, safe, and effective manner to a level that is
acceptable to the patient and family.
14. Measure and document anxiety, depression, delirium, behavioral disturbances, and other common
psychological symptoms using available standardized scales.
15. Manage anxiety, depression, delirium, behavioral disturbances, and other common psychological
symptoms in a timely, safe, and effective manner to a level that is acceptable to the patient and family.

16. Assess and manage the psychological reactions of patients and families (including stress, anticipatory grief,
and coping) in a regular, ongoing fashion in order to address emotional and functional impairment and loss.
17. Develop and offer a grief and bereavement care plan to provide services to patients and families prior to
and for at least 13 months after the death of the patient.
18. Conduct regular patient and family care conferences with physicians and other appropriate members of the
interdisciplinary team to provide information, to discuss goals of care, disease prognosis, and advance care
planning, and to offer support.

19. Develop and implement a comprehensive social care plan that addresses the social, practical, and legal needs of
the patient and caregivers, including but not limited to relationships, communication, existing social and cultural
networks, decision making, work and school settings, finances, sexuality/intimacy, caregiver availability/stress, and
access to medicines and equipment.
20. Develop and document a plan based on an assessment of religious, spiritual, and existential concerns using
a structured instrument, and integrate the information obtained from the assessment into the palliative care plan.
21. Provide information about the availability of spiritual care services, and make spiritual care available either
through organizational spiritual care counseling or through the patient's own clergy relationships.

22. Specialized palliative and hospice care teams should include spiritual care professionals appropriately trained
and certified in palliative care.
23. Specialized palliative and hospice spiritual care professionals should build partnerships with community
clergy and provide education and counseling related to end-of-life care.
24. Incorporate cultural assessment as a component of comprehensive palliative and hospice care assessment,
including but not limited to locus of decision making, preferences regarding disclosure of information, truth telling
and decision making, dietary preferences, language, family communication, desire for support measures such as
palliative therapies and complementary and alternative medicine, perspectives on death, suffering, and grieving,
and funeral/burial rituals.
25. Provide professional interpreter services and culturally sensitive materials in the patient's and family's
preferred language.

Healthy Skin
continued on next page

110
 Cleaning and Disinfecting Forms & Tools

10
Ten Tips for
Cleaning and
Disinfecting
Shared Medical
Equipment

1 Make a list of every piece of shared medical equipment.
(Assign appropriate staff to help identify and generate the
equipment list.)
2 Assign the cleaning and disinfection responsibility to the
type of healthcare worker who will be performing the task
within your policy.
3 Communicate this administrative decision to all members
of your staff, both written and verbally, and document.
6 Clean medical device surfaces when visible blood or bloody
fluids are present by wiping with a cloth dampened with
soap and water to remove any visible organic material,
and then disinfect.
7 If no visible organic material is present, disinfect the exterior
surfaces after each use using a cloth or wipe with either an
EPA-registered detergent/germicide with a turberculocidal
or HBV/HIV label claim, or a dilute bleach solution of 1:10
to 1:100 concentration.

4 Educate and train staff on proper care, maintenance, cleaning 8 Note that alcohol also is not an EPA-registered
and storage of each piece of equipment. At a minimum, detergent/disinfectant.
provide this education upon initial employment, when the
equipment is replaced with a newer model and annually. 9 Disposable professional grade wipes with a short “kill time”
Document that this training has occurred. (60 seconds after application) can make the time spent
cleaning equipment quick and easy.
5 Select easy-to-use, EPA-registered hospital grade
disinfectants and cleaning products. Make sure the products 10 All cleaning should be done in well-ventilated areas with
list which microorganisms and viruses it kills. Common gloves to protect healthcare workers’ hands.
cleaners are sodium hypochlorite (bleach solution) or
quaternary ammonium products. However, to help avoid
warranty issues or equipment damage, be sure to follow
manufacturers’ recommendations regarding which cleaning
products to use.

Improving Quality of Care Based on CMS Guidelines 111

 EDUCATIONAL OPPORTUNITIES
FOR LONG-TERM CARE PROFESSIONALS
Making Sense of the New Quality Indicator Survey
Two free online courses available at www.medlineuniversity.com
The Role of the CNA in
Resident-Centered Care and the
New Quality Indicator Survey
Designed for: Nurses and CNAs
You’ll earn: One Continuing Education Credit*
This course covers:
• How the state survey process has evolved
into the new Quality Indicator Survey (QIS)
• The importance of the CNA in QIS and
resident-centered care
• The different aspects of QIS, including the
resident interview, resident observations
and family interviews
• How the CNA can help improve the overall
quality of care in long-term care facilities
* Courses approved for continuing education by the Florida Board
of Nursing and the California Board of Reigistered Nursing.
112 Healthy Skin
Understanding the
Quality Indicator Survey
Designed for: Long-Term Care Administrators
You’ll earn: One Administrator Credit
Approved by the National Association of
Long-Term Care Administrator Boards (NAB),
this course covers:
• How the Quality Indicator Survey (QIS)
process evolved to standardize state surveys
in accordance with federal guidelines
• The top six objectives of the QIS
• How surveyors in all states are being trained
in a structured and consistent manner
• How the QIS differs from traditional
state surveys
 LEARN MORE ABOUT THE ONLY INTEGRATED SOLUTION
FOR SURVEY READINESS IN NURSING HOMES

Quality Assurance
System Webinar

This webinar gives a QIS overview and demonstration on how the abaqis® system can
help prepare for both the traditional and QIS survey processes. This demonstration also
highlights how abaqis® provides:
• Rich reporting capabilities to identify which care areas to target for
quality improvement
• Root cause analysis on a facility-wide or individual-resident basis, enabling
prioritization and focusing of interventions for maximum impact
• Emphasis on information reported by residents and families to help identify
the needs of residents, aiding your efforts to improve consumer satisfaction

Now with the new Stage 2 module featuring:

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

Free Webinar at www.medline.com/abaqisdemo

Improving Quality of Care Based on CMS Guidelines 113

Some things should not be reused
About the One & Only Campaign
The goal of the One & Only Campaign is to improve
safe injection practices across healthcare settings.
The practices within an organization are highly
influenced by its culture or are an expression of its
culture. Thus, through education, outreach, and
grassroots initiatives, the One & Only Campaign
will seek to influence the culture of patient safety.
The One & Only Campaign is an education and
awareness campaign aimed at both healthcare
providers and the public to increase proper
adherence to safe injection practices to prevent
www.ONEandONLYcampaign.org
disease transmission from the misuse of needles,
syringes, and medication vials in outpatient
Inc (APIC), BD (Becton, Dickinson and Company),
Centers for Disease Control and Prevention (CDC),
settings. While the campaign will be initially CDC Foundation, HONOReform Foundation,
rolled out in targeted locations, the vision is Nebraska Medical Association (NMA), Nevada
to develop a concept that can be replicated State Medical Association (NSMA), and Premier
nationwide. For more information, please visit: Safety Institute.
www.ONEandONLYcampaign.org.
Safe Injection Practices Coalition partners include
the following organizations: Accreditation
Association for Ambulatory Health Care (AAAHC),
American Association of Nurse Anesthetists (AANA),
Ambulatory Surgery Foundation, Association for
Professionals in Infection Control and Epidemiology,
 HEALTHY SKIN
Join the team! CDC CLINICAL REMINDER

Use of Fingerstick Devices on More than One Person Poses

Risk for Transmitting Bloodborne Pathogens
Summary: The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the
risks for transmitting hepatitis B virus (HBV) and other bloodborne pathogens to persons undergoing fingerstick
procedures for blood sampling -- for instance, persons with diabetes who require assistance monitoring their blood
1,2,3
glucose levels. Reports of HBV infection outbreaks linked to diabetes care have been increasing . This notice
serves as a reminder that fingerstick devices should never be used for more than one person.

Background

Fingerstick devices are devices that are used to prick the skin and obtain drops of blood for testing. There are two
main types of fingerstick devices: those that are designed for reuse on a single person and those that are
disposable and for single-use.

When it comes to hot
topics in long-term care,
you’re the experts!
You, our readers, are on the front lines of everything that
happens in the healthcare industry – and we want to hear
from you! Have you ever wished you could write an
article that would be published in a large-circulation
magazine? Nowʼs your chance. Healthy Skin is looking
Reusable Devices: These devices often resemble a pen and have the
means to remove and replace the lancet after each use, allowing the device
to be used more than once (see Figure 1). Due to difficulties with cleaning
and disinfection after use and their link to numerous outbreaks, CDC
recommends that these devices never be used for more than one person. If
these devices are used, it should only be by individual persons using these
devices for self-monitoring of blood glucose.
Single-use, auto-disabling fingerstick
devices: These are devices that are
for writers and contributors. Whether youʼd like to try your disposable and prevent reuse through an
hand at writing or offer suggestions for future articles, we auto-disabling feature (see Figure 2). In
want to hear what you have to say! You never know – the settings where assisted monitoring of blood
next time you open an issue of Healthy Skin, it might be
glucose is performed, single-use, auto-
to read your own article!
disabling fingerstick devices should be used.

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

Figure 1: Reusable
fingerstick devices* Figure 2: Single-use, disposable
fingerstick devices*

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
The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such
as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk
for transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons
are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier this
year, dozens of attendees were potentially exposed to bloodborne pathogens when fingerstick devices were
reused to conduct diabetes screening.

Weʼve tried to include content that clarifies the initiatives or gives you ideas and tools for implement-
ing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion (DHQP)
 VOLUME 8, ISSUE 2
Improving Quality of Care Based on CMS Guidelines

Volume 8, Issue 2
Free CE Inside!

Influenza:
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Guidelines

HEALTHY SKIN
Survivors
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