Healthy Skin Magazine - Volume 9 Issue 1

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VOLUME 9, ISSUE 1
Improving Quality of Care Based on CMS Guidelines
Volume 9, Issue 1
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Join the team!
HEALTHY SKIN Pressure point answers

From page 101
1. Lateral malleolus
2. Lateral aspect of foot
3. Lateral aspect of knee
4. Greater trochanter
5. Ribs
6. Shoulder
7. Ear
8. Occiput
PERIOPERATIVE PRESSURE
9. Ear
ULCER EDUCATION.
10. Elbow
11. Dorsal thoracic area
MORE IMPORTANT
THAN EVER BEFORE
12. Sacrum/Coccyx
13. Heel
When it comes to hot

topics in long-term care,
you’re the experts!
14. Shoulder blade
15. Sacrum/Coccyx
16. Ischial tuberosity
17. Posterior knee
18. Foot
“ 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,
19. Medial malleolus CWS, BCLNC, FAAN
You, our readers, are on the front lines of everything that for writers and contributors. Whether you’d like to try your 20. Lateral malleolus
happens in the healthcare industry – and we want to hear hand at writing or offer suggestions for future articles, we Medline’s Pressure Ulcer Prevention Program now has a
from you! Have you ever wished you could write an want to hear what you have to say! You never know – the component designed specifically for the perioperative services.
article that would be published in a large-circulation next time you open an issue of Healthy Skin, it might be The easy-to-use interactive CD addresses the following:
magazine? Now’s your chance. Healthy Skin is looking to read your own article! • Hospital-acquired conditions
• CMS reimbursement changes
Contact us at healthyskin@medline.com to learn more! • Best practices for pressure ulcer prevention
• Perioperative assessment tools
• Critical patient and equipment risk factors
Content Key
We’ve coded the articles and information in this magazine to indicate which national quality initiatives To learn more about Medline’s Pressure
they pertain to. Throughout the publication, when you see these icons you’ll know immediately that Ulcer Prevention Programs for long-term
the subject matter on that page relates to one or more of the following national initiatives: care, acute care and perioperative
• QIO – Utilization and Quality Control Peer Review Organization services, call your Medline representative
• Advancing Excellence in America’s Nursing Homes or visit www.medline.com/pupp-webinar.
We’ve tried to include content that clarifies the initiatives or gives you ideas and tools for implementing
their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7. ©2011 Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
Improving Quality of Care Based on CMS Guidelines 103

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HEALTHY SKIN
Survey Readiness
Editor 44 What’s in Store for QIS and MDS 3.0
Sue MacInnes, RD, LD 45 Removing Stress from the QIS
Clinical Editor
Margaret Falconio-West, BSN, RN, Prevention
APN/CNS, CWOCN, DAPWCA 19 225-Bed Community Hospital Reduces Pressure Ulcers
from 9% to 0% in 90 Days
Managing Editor Page 12
Alecia Cooper, RN, BS, MBA, CNOR
30 Creative Techniques for Preventing Resident Falls in
Long-Term Care
Senior Writer 32 Improving Hand Hygiene Compliance: A Multi-disciplinary
Carla Esser Lake Team Approach
Creative Director
56 Protecting Vulnerable Heels: Tips for Nursing Assistants
Mike Gotti 69 Easy Does It: Safe and Effective Lifting Practices
74 5-Step Approach for Avoiding VAP
Clinical Team
Clay Collins, BSN, RN, CWOCN, CFCN, Treatment Page 26
CWS, DAPWCA
36 Osteoporosis in Men
Lorri Downs, BSN, RN, MS, CIC
66 The Use of Superabsorbent Containing Fluid Lock Dressing
Cynthia Fleck, BSN,MBA, RN, CWS, DNC,
CFCN, DAPWCA, FCCWS in Hospice Patients
Joyce Norman, BSN, RN, CWOCN,
DAPWCA Special Features
Kim Kehoe, BSN, RN, CWOCN, DAPWCA 11 NE1 Wound and Skin Assessment Tool Award
Elizabeth O’Connell-Gifford, BSN, MBA, RN, 12 Preparing for Reform in Your Post Acute Setting
CWOCN, DAPWCA 18 CE Article Special Insert! Positive or Negative? You Decide:
Jackie Todd, RN, CWCN, DAPWCA Healthcare Reform’s Impact on Nursing Homes and LTC Facilities Page 32
26 Wound Care and Rehab Training in Lesotho, Africa
Wound Care Advisory Board
49 Inspiring Change: The Cozy Project Makes Older Patients
Zemira M. Cerny, BS, RN, CWS
More Comfortable
Patricia Coutts, RN
58 Pediatric Pressure Ulcers in the “Darnedest” Places
Cindy Felty, MSN, RN, CNP, CWS
83 Pink Glove Dance: The Sequel
Evonne Fowler, MSN, RN, CNS, CWOCN
87 Pink Glove Survey Results
Lynne Grant, MS, RN, CWOCN
Diane Krasner, PhD, RN, CWCN, CWS,
BCLNC, FAAN
Caring for Yourself
64 Top Tips for Winter Skin Care Page 58
Dea J. Kent, MSN, RN, NP-C, CWOCN
Andrea McIntosh, BSN, RN, APN, CWOCN
78 8 Principles for Achieving Inner Peace
Linda Neiswender, BSN, RN, CPN, CWOCN
Laurie Sparks, BSN, RN,CWOCN
Forms & Tools
Lynne Whitney-Caglia, MSN, RN, CNS,
94 WHO Glove Pyramid
CWOCN 95 WHO Exam Glove Technique
Laurel Wiersema-Bryant, RN, ANP, BC 96 CDC Clean Hands Poster
Linda Woodward, BSN, RN, OCN, CWOCN 97 CDC Clean Hands Poster – Spanish
Deborah Zaricor, RN, CWOCN 99 Urinary Incontinence Assessment and Implementation
Page 83
101 How Well Do You Know Pressure Points?
About Medline Meeting the highest level of national and international quality standards, Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more is FDA QSR compliant and ISO 13485 certified. Medline serves on major
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.
©2011 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

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Healthy Skin
Letter from the Editor
W e realize that the more opportunities you have to educate yourself about our industry, the
latest trends, the constantly changing regulations, the financial challenges, the clinical
and quality issues in health care, the more valuable you are to your organization and to your
patients. It doesn’t matter what your specialty is, it is part of your responsibility to stay up-to-date
on our business.
So, as tax-paying citizens and concerned healthcare our money. And who would have thought that in the
professionals, many of you are delving deep into the category of infant mortality, the United States would rank
particulars of healthcare reform and what it means to dead last in this group. But we did.
you and your organization. (Be sure to check out the two
articles on healthcare reform in this issue!) As you dig So, there you have it, we are a country in trouble. But
deeper into where the United States stands as a country, what makes it even worse are the statistics for our aging
you will discover some head-turning data. population and what we can expect in the future. If we
look ahead to the year 2050, women age 85 and over
In 2009, 17.3 percent of the GDP (gross domestic product) will be the largest segment of the population. How can
in the United States was dedicated to health care. we sustain adequate health care for this important part
According to the Office of the Actuary in the Centers for of our population, how can we eliminate waste, how can
Medicare & Medicaid Services (CMS) National Healthcare we adopt better prevention strategies, and how can we
Expenditure projections, the dollars represented grew improve outcomes? All of these are questions depending
from $2.34 trillion in 2008 to $2.47 trillion in 2009—the on you in part for the answers.
largest one-year jump since 1960. CMS predicts total
U.S. healthcare spending in 2019 will be $4.5 trillion. And You are our future. Read more, learn more—and don’t
yet, as healthcare spending skyrockets, U.S. rankings be afraid to adopt new ideas.
against other countries are not what you would expect.
Best Regards,
In one study of seven different countries, including
Australia, Canada, Germany, Netherlands, New Zealand
and the United Kingdom, the United States consistently
ranked poorly (in most cases in last place), and yet the Sue MacInnes, RD, LD
cost of healthcare per capita was double that of any of Editor
the other countries. So, we spend more and get less for
According to Chip and Dan Heath, authors of the #1 New York Times bestseller Made
to Switch: How to Change Things When Change Is Hard, when it comes to change, the
rational mind and the emotional mind compete for control. This tension can sabotage
efforts to change. In Switch, the Heaths show how real people have brought both parts
of the brain together to achieve great results and successful change.
To order, visit www.barnesandnoble.com.
4 Healthy Skin
Camera not included.
NE1™ Wound Assessment Tool

Accurate identification, consistent documentation
Wound measurement made easy

The NE1 Wound Assessment Tool is a proven way to
accurately measure and record wound characteristics,
featuring a unique right angle design to see length and Winner of
width measurements at the same time. It also contains
National HCA
Innovators
areas to record the size and type of wound, plus the Award
date, time and clinician’s name who assessed and
photographed the wound.
Key benefits
• Increase accuracy of wound assessment Interactive training and online competencies available
on-demand at www.medlineuniversity.com
by more than 100 percent1
• Standardize wound documentation
To request a sample or additional details, contact your Medline
• Drive appropriate reimbursement due to
representative or call 1-800-MEDLINE (1-800-633-5463).
more accurate wound assessments
Reference
1. Young DL, Esocado N, Landers MR, Black J. A pilot study providing evidence
for the validity of a new tool to improve assignment of NPUAP stage to pressure
ulcers. Advances in Skin & Wound Care. In press.
©2011 Medline Industries, Inc. NE1 is a trademark of Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc. Patent pending.
Two Important National Initiatives

for Improving Quality of Care
Achieving better outcomes starts with an understanding of current quality
of care initiatives. Here’s what you need to know about national projects and
policies that are driving changes in nursing home and home health care.
QIO Utilization and Quality Control Peer Review Organization

1 9th Round Statement of Work
Origin: The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded
“Ninth Scope of Work” plan became effective August 1, 2008 and will remain in effect through July , 2011.
Purpose: To carry out statutorily mandated review activities, such as:
Stay tuned for
• Reviewing the quality of care provided to beneficiaries; details on 10th Round
• Reviewing beneficiary appeals of certain provider notices; Statement of Work
• Reviewing potential anti-dumping cases; and COMING SOON
• Implementing quality improvement activities as a result of case review activities.
Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The
content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities,
prevent illness, decrease harm to patients and reduce waste in health care.
Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare,
support the adoption and use of health information technology and reduce health disparities in their communities.
Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national
network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.
Quality Improvement Organization Program’s 9th Scope of Work Theme

The official Executive Summaries for the 9th SOW Theme are available at:
http://providers.ipro.org/index/9SOW_summaries
2 Advancing Excellence in America’s Nursing Homes
Origin: A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home
residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an
additional 2 years (until September 26, 2010).
Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers,
consumers and government that developed a grassroots campaign to build on and complement the work of existing
quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.
Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition
has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction
surveys into continuing quality improvements and increase staff retention to allow for better, more consistent
care for nursing home residents.
Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal and
one operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goals
for the next two-year campaign.
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 perform-
Theme #3: Patient Safety Activities will focus on six ance on Tasks within all Theme areas (Beneficiary Protection, Care
primary Topics: Transitions, Patient Safety and Prevention). The second evaluation will
1. Reducing rates of health care-associated methicillin-resistant take place at the end of the 28th month of the contract term and will be
Staphylococcus aureus (MRSA) infections based on the most recent data available to CMS. The performance
2. Reducing rates of pressure ulcers in nursing homes and hospitals results of the evaluation at both time periods will be used to determine
3. Reducing rates of physical restraints in nursing homes the performance on the overall contract.
4. Improving inpatient surgical safety and heart failure treatment
in hospitals Focus for the 9th Scope of Work
5. Improving drug safety – Move away from projects that are “siloed” in specific care settings
6. Providing quality improvement technical assistance to nursing – Focused activities for providers most in need
homes in need – New emphasis on senior leadership (CEOs, BODs) involvement
in facility quality improvement programs
Clinical and Operational/Process Goals
Clinical Goals: Goal Actual Operational/Process Goals: Goal Actual

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

Each nursing home participating in Advancing Excellence selects a minimum of three goals (outlined above).
The goals – and the percentage of participating nursing homes that have selected them – are listed below.
Participating nursing homes: 7,481

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

650 facilities have joined the program.

Are you one of them?
Get results with
Medline’s Pressure Ulcer Prevention Program
• Average reduction in facility-acquired If you are interested in:
pressure ulcers: 70.5% Implementing a program that allows you
• Average annual savings: $306,000 to achieve these results and sustain them
over time
How does it work? Reducing the incidence of pressure ulcers
With a compelling combination of products at your facility
and education: Learning more about Medline’s Pressure
1. Medline’s strategic product bundle, including Ulcer Prevention Program
skin care and incontinence products
2. Medline’s free educational program for Call Medline Pressure Ulcer Prevention Program
nurses and nursing assistants, including Manager Karen Frey at 1-847-643-4805 to get
4 CE credits for nurses plus online, started today!
interactive competencies
1. Medline Industries, Inc. Data on file.
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
BREAKING NEWS
New data released
Pennsylvania Pressure
Ulcer Partnership Reduces
Pressure Ulcers
In early January 2011, the Pennsylvania Pressure Ulcer Part- The rate of pressure
nership released the results of its pressure ulcer reduction ulcers decreased 23%
project showing collaborative efforts to reduce the rate
of pressure ulcers and prevent pressure ulcers from
getting worse.
The partnership also conducted a baseline and follow-up
Three of the state’s leading healthcare organizations—The
survey to assess the extent to which participating hospitals
Hospital & Healthsystem Association of Pennsylvania (HAP),
had adopted certain practices and strategies. The survey
The Healthcare Improvement Foundation (HCIF), and Hospital
collected information about specific processes identified
Council of Western Pennsylvania (HCWP)—collaborated in
as important to improvement, including leadership support
2008 to create the Pennsylvania Pressure Ulcer Partnership
for pressure ulcer prevention and treatment; organizational
for hospitals. The project involved 58 hospitals from across
policies; monitoring the accuracy of pressure ulcer risk
the state. They focused on risk assessments, turning and
assessments and skin inspections; use of triggers for risk
repositioning, pressure reduction devices and techniques,
reassessment; documentation; and education and training.
nutrition, skin cleansing and moisturizing, and diligent
wound care.
Of the 36 hospitals that completed both the baseline and
follow-up survey, improvements were achieved in 88% of the
The project was formed because Pennsylvania hospitals
41 questions asked.
recognized that pressure ulcers, are one of the five most com-
mon types of harm experienced by patients in healthcare
“As health reform rolls out, Medicare and Medicaid payments
facilities. The nationwide costs associated with pressure
to hospitals will be increasingly tied to quality and patient
ulcers and their complications are approximately $13 billion a
safety outcomes,” said Jane Montgomery, RN, vice president
year—under Medicare alone.
of clinical services and quality for HCWP. “It is critical that
hospitals across the state build on their patient care
Findings from the project: successes in the coming years.”
• the rate of pressure ulcers that developed decreased
by 23% (5.3% to 4.1%) The Pennsylvania Pressure Ulcer Partnership was made
• pressure ulcer risk assessments upon admission possible through funding from Medline Industries, Inc., Capital
improved from 93% to 97% Blue Cross, Highmark Blue Shield, and the Partnership for
• the rate of pressure ulcers that progressed (worsened) Patient Care, an initiative funded jointly by Independence Blue
decreased by 81% (2.1% to 0.4%) Cross and health systems in southeastern Pennsylvania.
• ongoing risk assessments improved from 87% to 97%
—both statistically significant Source: The Hospital & HealthSystem Association of Pennsylvania.
www.haponline.org

\ Cy∙an∙o∙a∙cry∙late \
A fast-acting adhesive that bonds with the skin
to create a barrier against moisture and friction.
Award Winners Honored

at Clinical Symposium on Advances
in Skin & Wound Care
October 2010, Orlando, FL
Elizabeth Ayello wins Sharon Baranoski

Founder’s Award
Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, Problem: Peristomal Irritation
MAPWCA, FAAN received the 2010 Sharon Bara- Solution: Marathon® Cyanoacrylate Liquid
noski Founder’s Award. The award honors the Skin Protectant
overall pursuit of excellence in the field of skin
Peristomal irritation can lead to decreased wear time, pain
and wound care. The award is named in honor and embarrassment about leakage. So it only makes
of Sharon Baranoski, MSN, RN, CWOCN, sense to do everything you can to protect the peristomal
DAPWCA, FAAN, the founder of the Clinical area. Marathon Liquid Skin Protectant helps protect
Symposium on Advances in Skin & Wound Care. against irritation and maceration by creating a barrier
against moisture and chemical assault.
Caroline Fife wins Outstanding Peer
Marathon, a cyanoacrylate, bonds to the skin surface,
Reviewer Award
integrating with the epidermis on a molecular level to
Caroline E. Fife, MD, received the Outstanding
seal in moisture. While other skin protectants may flake
Peer Reviewer Award, which honors the off, Marathon stays in place, offering robust protection
Advances in Skin & Wound Care peer reviewer and increased wafer wear time.
who has made the greatest contribution to
furthering the goal of peer review: to provide
constructive critiques that assist authors in revising
and improving their manuscripts so that they
make meaningful contributions to the literature
and the skin and wound care field.
Stoma site before Same stoma site after

treatment with Marathon.1 treatment with Marathon.1
To learn more, visit

www.medline.com/skincare.
1. Data on file
© 2011 Medline Industries, Inc. Medline and Marathon are registered

trademarks of Medline Industries, Inc.
10 Healthy
10 Healthy Skin
Skin
Treatment
NE1 Wound and Skin Assessment Tool Developer

Wins National HCA Innovators Award
Nancy Estocado, PT, CWS

Sunrise Hospital and Medical Center
Las Vegas, Nev.
Nancy Estocado, a physical therapist and certified used after five min-
wound specialist, won the National Hospital Corpora- utes of training, she
tion of America (HCA) Innovators Award for her idea said the results
“NE 1 Can Stage”— Skin and Wound Assessment Tool. showed nurses and
clinicians were 69
“I could fall out of my chair with how excited I am,” percent correct in
said Estocado. “Because of how many hospitals are wound assessments.
in the corporation and how many people entered the She said the nurses
contest, to think that mine made it to the top is mind- continue to improve
boggling,” she said. Sunrise President and CEO Sylvia their accuracy the
Young said employees are celebrating the recognition more they use the
alongside Estocado. tool.
“People are so thrilled that our hospital was selected Estocado’s findings
for this national award and they have such high regard have been approved
for Nancy,” said Young. “She’s a great caregiver, she’s for publication in
a real role model, and I think people are just proud Advances in Skin
to be associated with her and that it started here and Wound Care. Nancy Estocado won an HCA Innovators
at Sunrise.” She would like to Award for her NE 1 Can Stage — Skin
see the tool pilot- and Wound Assessment Tool.
Estocado’s innovative tool provides a simple, easy-to- tested at Sunrise
use, economical method for skin and wound assess- and expanded throughout HCA. Medline Industries,
ment and documentation by any care provider at the Inc. has also picked up the tool to make it avail-
bedside. The paper, single-use, L-shaped measuring able to the public.
device allows providers to frame the wound, take a
photograph and match the picture to the guide’s “I really hope it goes huge,” said Estocado. “I’ve been
nationally recognized wound conditions and meas- working on it for almost three years. I didn’t know
urements. This process allows the wound to be prop- where it was going to go, but I knew I could help
erly assessed and provides a standard in care for people. I knew I had something.”
wounds.
Estocado said she spent a lot of her own money to
“My goal is that this would become the standard of create the tool and apply for a patent, so she hopes
practice for everyone,” said Estocado. “Home health, to use the prize money to pay off some of her debt.
nursing homes, in the hospital — everyone can be on She said the entire HCA Innovators Award process
the same page, measuring and monitoring wounds in has inspired others around her to get creative.
the same way.”
“I can’t tell you how many other people have come up
In previous studies, the average clinician or nurse was to me with ideas. Through this contest and award, it’s
only about 30 percent correct when assessing motivating people to be innovative. They think, ‘Hey,
wounds, according to Estocado. When her tool was if she can do it, I can do it.’”
Used by permission from HCA and not intended as an endorsement for Medline Industries, Inc. or any other entity.

Special Feature
R
Preparing for EFORM
in your post acute setting
by Glen Roebuck
12 Healthy Skin
After years of debate and hand wringing, healthcare reform

is here. Though much lamented and often debated, the Patient
Protection and Affordable Care Act (PPACA) passed the
legislative branch and was signed into law by President Obama
in March of 2010. This may prove to be the single most
impactful piece of legislation for post acute care field since the
Johnson Administration introduced Medicare and Medicaid
under the Social Security Amendments of 1965. While the re-
cent mid-term elections have created sidebar conversations re-
garding potential repeal of certain components of the PPACA,
full repeal of the law is unlikely. It is time for responsible and for-
The bundling of services will
ward-thinking providers in the post acute field to become part- revolutionize the reimbursement
ners in making this evolution a success for the American people.
system for Medicare-certified
Common Reform Strategies Impacting Post Acute Care healthcare providers.
Four primary initiatives in the PPACA will directly impact how we
provide care and remain financially viable in the post acute care
sector. These initiatives will create the synergies and efficiencies Value-added services will be opportunities for ACOs to receive
to improve health care and reduce costs. increased reimbursement based upon performance levels for
clinical indicators such as lower infection rates and hospital
• Accountable care organizations (ACOs) readmission rates. The hospital readmission issue is currently
• Bundling of services the key touch point where PACs can partner with their current
• Value-added services hospital partners (and likely future ACOs). PAC providers
• Performance monitoring and penalties who evaluate and improve the management of unplanned
hospitalizations will find themselves to be active and value-added
Most ACOs likely will be formed by hospitals or large physician partners in the reform-driven healthcare system.
practice groups. ACOs must be able to provide services for a
minimum of 5,000 covered lives. They will become local or Funds for these value-added service incentives likely come from
regional gatekeepers of the healthcare system and look to the final component, performance monitoring and penalties. The
establish networks of providers to manage care most effectively converse of the value-added incentives, these measures will
and efficiently. They will work within their network of providers to reduce reimbursement based upon higher infection rates and
control and manage where patients enter into the healthcare re-hospitalization rates. It is clearly evident from these initiatives
system. As we begin to discuss the other primary initiatives that the ability for a post acute provider to partner and align with
impacting post acute care, the connectivity to one another will local and regional providers will be a prerequisite to continued
be evident. success in the market.
Currently reimbursement is on a fee-for-service basis, with no Becoming a Successful Partner in Healthcare Reform
connectivity or accountability between providers based upon a Below are specific steps that must occur for a post acute
patient’s care delivery through the system. In the paradigm of center to be successful in the reform-driven, ACO world:
bundled services, Medicare pays one entity: the ACO. It will then
fall to the ACO to effectively and efficiently manage the patient’s 1. Post acute centers must become masters of the
care and direct the patient to the most appropriate level of Medicare system. Becoming a master of the Medicare
services to impact effective and efficient care. The ACO then system will require that providers move from only providing
pays the PAC providers. Medicare services for residents who return to their facilities

to becoming market leaders in post acute short-stay

rehabilitation. Becoming a leader in this market may be a
massive undertaking for your center. If this is not a service
you are providing to the community currently, reach to
external consultation or management services to assist
you in correctly positioning your center in the market.
2. Understand your hospital CEO’s world. If you do not

have a relationship with the C-Suite staff at your local
hospital, you need to cultivate these relationships in
earnest. Without these relationships, you will not have
the operational agility necessary to be a part of your local
network of care.
3. Understand the impact on your physicians. Most

physicians with reputable practices have now realized that
it is simply financially detrimental to their practice to leave
their offices and see patients. We must develop alternative
opportunities in partnerships with physicians’ groups and
ACOs to provide timely quality physician attention to
patients, particularly those at risk for re-admission to the
acute care setting. Your role as a post acute provider is
to work with your physician community now to begin to
identify opportunities. This may include the addition of
nurse practitioners or physician assistants to support
physician presence within your center.
4. Align your medical director leadership for the future.

Does your medical director understand, embrace and
relish the thought of walking through the fires of reform as
your partner? Is he or she an active network member of
your local ACO? If you answered no to these questions, it
may be time for a change. Your medical director needs to
be actively engaged in clinical education, clinical pathway
development in alignment with local ACO models, an active
liaison to other physicians, and be an active participant in
the evolution of medical care in the post acute setting.
Patients who are admitted to a 5. Understand the impact of healthcare reform on your
discharge planners. Be aware that the role of the case
post acute setting on Thursday manager/discharge planner will evolve and change market
with a diagnosis of pneumonia to market. If discharge planners are held accountable for
re-hospitalization rates, it will be incumbent upon the PAC
simply cannot be readmitted to providers to keep them actively engaged and informed of
an acute setting on Saturday efforts to manage and control the issues that lead to
rehospitalization.
with… pneumonia.
14 Healthy Skin
Performance data
will become your
best friend or
your downfall.
6. Your “competitors” are now your “partners.” If you have experience to include the monitoring and analysis of
not developed close relationships with other post acute complex and integrated data. Performance data will
setting leaders, the time is now. As ACO networks mature, become your best friend or your downfall. Begin now to
you will likely receive admissions from sources other than develop ways to monitor and track performance data for
hospitals, including home health, skilled nursing, assisted your post acute center including things such as falls,
living, medical homes and hospice. Non-medical support wounds and re-hospitalizations. Having the tools and
services may report findings to physicians or ACO knowledge to track and improve these metrics will
admissions coordinators who may direct admissions position you as a valuable partner in health care reform.
to your setting.
10. Educate your direct customers. When these initiatives
7. Take care of sick people. You may think this sounds silly. begin to play out and directly impact the lives of your
But with up to two thirds of re-hospitalizations viewed as customers, it will be a time of confusion and angst for
preventable, it is not. Patients who are admitted to a post many. This presents a tremendous leadership opportunity
acute setting on Thursday with a diagnosis of pneumonia for you to become a public voice and positive influence.
simply cannot be readmitted to an acute setting on
Much will continue to evolve in the months and years to come
Saturday with… pneumonia. Post acute settings must
related to the passage of PPACA. The accompanying
be prepared to initiate more advanced care such as IV
regulations are yet to be released as of this writing. Will the
fluids and medications, closely monitoring vitals and
three-day required hospital stay be upheld with reform? Where
changes in condition, and assess potential declines to
will the rights of patients fall in choosing their post acute serv-
initiate interventions with the physician early in the process.
ice provider? How will your specific healthcare community
These measures help avoid unnecessary re-hospitalizations.
respond to reform? These issues, and others, will continue to be
8. Assess your clinical prowess and make changes now. a part of the changing reform landscape. Your active partnership
To achieve the cultural evolution noted above, the clinical in leading your post acute setting and your community is
talent and skills of your staff must be assessed and critical to your success.
necessary skills must be acquired quickly. This may
require additional certification and education, along
Glen Roebuck is senior vice president of operations for
with re-examination of the distribution of licensed staff,
Health Dimensions Group in Minneapolis. He can be reached
particularly LPNs/LVNs and RNs. These staff members at 612-770-6163, or via email at glenr@hdgi1.com. Health
must clearly understand that an unplanned re-hospitaliza- Dimensions Group is a leading provider of short term
tion will be reviewed as a measure of their performance. consultation and long term management solutions for health
care providers. For more information, please contact Glen and
9. Monitor your performance and share your results.
visit www.healthdimensionsgroup.com.
In the new world of healthcare reform, performance and
success will be expanded beyond a successful survey

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18 Healthy Skin
TRUE STORIES
225-BED COMMUNITY HOSPITAL

In CounCIl Bluffs, Iowa ReduCes PRessuRe ulCeRs
fRom 9% to 0% In 90 days
By Beth L. Edwards RN BA Clinical Quality Specialist
Our Hospital to take a closer look at this important

Jennie Edmundson Memorial Hospital is an opportunity to provide better outcomes for
acute care community hospital with 225 our patients.
licensed beds that provides health care
services to Council Bluffs, Iowa and the sur- Our Challenge
rounding community. It is an affiliate of the In January of 2009 we completed incidence
Nebraska Methodist Health System, and and prevalence of pressure ulcers on
has been serving southwest Iowa since patients hospitalized on our medical/surgery
Hospital: 1887. Today the hospital employs a staff of units, telemetry and ICU. On January 27,
Jennie Edmundson Hospital over 800 and is recognized for its state-of- 2009, fifty-three hospitalized patients had a
Location: the-art Advanced Wound Care Center as skin assessment completed. Nine patients
Council Bluffs, Iowa well as being the only hospital in Iowa or had a pressure ulcer present. On January
Nebraska to receive the prestigious Com- 31, 2009, twenty-three of the fifty-three
Size:
mission on Cancer Outstanding Achieve- patients remained hospitalized and skin
225 licensed beds
ment Award for 2010. assessments were completed. Two patients
Challenge: had new pressure ulcers. This 9% incidence
Initiate a systematic approach to Our Advanced Wound Care Center opened rate was much higher than previous
reducing hospital-acquired pressure
in February of 2009 and is the only one of incidence and prevalence assessments.
ulcers to zero, utilizing a program of
sound wound care principles including its kind in this part of the state. Many of the A performance improvement team consist-
staff education and improved skincare patients who visit our Center suffer from ing of myself, Jeri Smith, RN WOCN, Cathy
products. chronic non-healing wounds due to injury, Harvey, RN, Mary Grote, RN, Amy Wald-
burns, bedsores or diabetic ulcers. The stein, RN, Becky Krauel-Henkel, RN,
Results:
At the conclusion of a 90-day program Center offers wound assessment and care and Mary Krueger, RN, was formed. Work
trial, restricted to the telemetry unit of by specially trained staff. It has long been was started with a goal of addressing
the hospital, incidence of pressure our belief, that skin integrity and the preven- and decreasing the incidence of hospi-
ulcers was reduced from 2 to 0. This tion of pressure ulcers is an area of hospital tal acquired pressure ulcers at Jennie
pressure ulcer prevention program has health care where our nurses can really Edmundson.
now been activated throughout the
make a difference. We are continually trying
hospital. The current rate of incidence
remains at zero. Cost savings to the to improve on that care. So, in conjunction In order to achieve that goal, we realized we
hospital, year to date, are estimated with the new CMS guidelines, we decided were facing three separate challenges. The
to be $259,080 in nursing time,
“
pharmaceuticals and supplies (based
on a projected incidence rate of 6 We believe that skin integrity and the prevention of pressure ulcers is one area
“
pressure ulcer cases avoided through of hospital health care where our nurses can really make a difference. We are
this program and using calculations
continually trying to improve that care.
provided by the Centers for Medicare
and Medicaid Services).

TRUE STORIES
first challenge was to provide education to

our nursing staff. We wanted a program
that would enable us to educate all of the
nursing staff including RNs, LPNs, and
CNAs. The second challenge was to
analyze the kind of skin care products we
were using.
The third challenge was to continue

assessment of incidence & prevalence to
show improvement and prevention of
pressure ulcers in patients hospitalized at
our hospital. tional programs that would assist us in our We concluded that the Medline PUPP pro-
efforts to eliminate hospital-acquired pres- gram was based on sound wound care
In addition to the clinical challenges we sure ulcers. We were looking for learning principles backed by excellent teaching
faced, we also had some very real financial materials to educate and test our nursing materials and utilized skincare products
considerations. It is no secret that the treat- staff on pressure ulcer staging, skin as- with a proven record of success in treating
ment of hospital-acquired pressure ulcers sessment and nursing care. One of those and preventing pressure ulcers. We agreed
can be very expensive. The CMS (Centers vendors, Medline Industries, Inc., head- to a 90-day trial of the Medline PUPP pro-
for Medicare & Medicaid Services) esti- quartered in Mundelein, IL, introduced us to gram, starting with an evaluation of their line
mates the cost of treating a pressure ulcer their Pressure Ulcer Prevention Program of pressure ulcer prevention skin care prod-
case at $43,180. More than 50% of those (PUPP). Our local Medline reps, Brad ucts, including: Remedy skin repair lotion,
costs are in nursing time, approximately Bruner and Allison Ball, “walked” us through Remedy NutraShield barrier cream, and
39% of the costs are pharmaceuticals and the components of their program They had Remedy foaming cleanser. At the same
11% are in products. Based on those a clinical nurse specialist attend our Pres- time, and for the same 90-day trial period,
figures, we were looking at total costs of sure Ulcer Committee meeting to outline we agreed to evaluate their premier line of
$86,360 just to treat the two pressure ulcer their program. We soon realized this pro- UltraSorb underpads. The educational part
cases we had at the time. If we could gram had everything we were looking for. It of the program would be completed by all
eliminate pressure ulcers in our facility we included intensive staff education, a way to nursing staff including registered nurses,
could realize significant savings over the evaluate the effectiveness of that training, a licensed practical nurses and certified
long term. specifically designed line of pressure ulcer nursing assistants.
prevention skincare products and a plan for
The Solution hands-on implementation utilizing the The 90-day trial using three Medline skin
In early January of 2009 our committee met assistance of Medline personnel and aimed care products and the UltraSorb underpads
with three different vendor groups and at reducing pressure ulcer incidence levels would be conducted on one unit. We chose
asked each of them to present their educa- in our hospital to 0%. our 28 bed telemetry unit for the trial.
“ “
Medline introduced us to their Pressure Ulcer Prevention Program (PUPP) which included
intensive staff education and a specifically designed line of pressure ulcer prevention skincare
products aimed at reducing our incidence levels to 0%.
20 Healthy Skin
TRUE STORIES
“ The end goal of this training was to help modify behavior and motivate
our nurses and nurse assistants toward improved patient care.
“
But before any of that training could happen, we had to first establish
exactly where we were starting from.
Implementation According to a recent CMS roundtable, and tools and, of course, pre and post
We introduced these products into the sys- among the main roadblocks to creating an tests. The workbook Medline created for
tem and started using them in our targeted effective pressure ulcer prevention program the CNAs included basic information cov-
test area. Almost immediately we had a are: lack of resources, inconsistent staff ering skin care, patient turning, inconti-
number of patients say “I really like this education and nonexistent patient and fam- nence care and basic nutrition. The
product!” Even our staff commented on ily education. We were determined to start workbook created for the RNs and LPNs
how much they liked the smell and the feel with consistent staff education. covered pressure ulcer assessment, skin
of the Medline products. care, nutrition and documentation. The
Medline’s program addressed these issues overall acceptance of the training and of the
At the same time we were introducing by providing clinical and educational program was better than we anticipated.
these new products into the system, we resources and assessment tools to our One of our LPNs summed it up when she
kicked off the educational components of nurses from the beginning. The educational said “The workbooks make it very easy for
the Medline program. We started by ad- tools they provided were targeted to two us to do the right thing!” Everyone who par-
ministering a “pretest,” provided by Med- primary groups: first, our nursing assistants ticipated in the training received a certificate
line, to all of the nursing staff. This pretest (CNAs), because they are critical to early of completion and a lapel pin signifying they
was designed to give us an indication of detection and prevention of pressure ulcers. had gone through the training. Our staff’s
where our staff was starting from in terms of They turn the patients, deal with inconti- post test scores (taken after training) were:
pressure ulcer prevention knowledge. The nence when it occurs, and otherwise RNs and LPNs averaged 97% (up 18%
average scores for this pretest, by nursing administer creams and lotions for skincare. over the pretest) and CNAs averaged 93%
group were: RNs and LPNs 79%, and The second critical element was our RNs (up 29% over the pretest). These numbers
CNAs 64%. Upon completion of the and LPNs. The educational component for are significant because they indicate the
pretest, the nursing staff was provided with this group was designed to ensure that level of acquired knowledge and hands-on
either a nursing workbook or a nursing these nurses understood their role in experience our staff had achieved and they
assessing and documenting skin condition, give us confidence that going forward the
assistance workbook. We would administer nutrition, and overall health improvement of program will experience sustainability for
a “post test” at the conclusion of the 90- the patient. long-term success in our fight to eliminate
day trial period. We would be able to com- pressure ulcers in our hospital.
pare the pre and post test results as well as All nursing personnel included in the 90-day
the results from the 90-day trial on one unit trial satisfactorily completed all phases of Medline supplied the training materials and
utilizing the Medline skin care products, the pressure ulcer prevention training. The the management team at Jennie Edmund-
compared to the other units in the hospital. training materials provided included: a CMS son provided the encouragement to com-
We saw a dramatic improvement in nursing presentation, pressure ulcer prevention plete the training, but to a very large extent,
staff scores after the educational training. workbooks, an instructor’s guide, forms the staff took it upon themselves to learn

TRUE STORIES
“
the material through reading, memorizing
Our results were so good we’ve now gone hospital wide with the “
and small study groups.
Medline PUPP program. We have adopted the Remedy products
The Results and UltraSorb underpads throughout the whole facility.
At the conclusion of the 90-day trial period,
in April of 2009, the PUPP program had
lived up to all our expectations. As of May
15, 2009 we had assessed 57 patients and Future Initiatives
had zero new pressure ulcers. Six months The success Jennie Edmundson has
later, on November 6, 2009 we assessed enjoyed as a result of engaging in a sys-
63 patients hospital wide and again we had tematic approach to the prevention and
no new pressure ulcers. As of the writing of treatment of pressure ulcers has encour-
this case study we are still experiencing a aged us to look at other programs that can
0% incidence rate of new hospital-acquired improve our patient outcomes through staff
pressure ulcers. However the real plus is and resident education as well as product
that even the skeptics among our nursing improvements. One area we are especially
staff have become converts. No change is interested in is the reduction of catheter-
easy when it comes to nursing care, and associated urinary tract infections (CAUTIs).
our new Pressure Ulcer Prevention Program Some of these catheter-associated infec-
was not only about change, but also about tions may be the result of catheters being
documenting the results of those changes. placed unnecessarily. Other potential
And that required some discipline. But as a causes for these infections include leaving
result of the positive direction this program the urinary catheters in place too long and
has taken, I am pleased to say everyone contamination that can occur during inser-
has gotten on board. tion. We are looking at another Medline
program, ERASE CAUTI, that we believe
At this point, our Administrator and our may offer the potential to help us reduce the
financial management people are in com- risk of CAUTI in our hospital. The Medline
plete support of the program. This, as a program includes three distinct parts:
result of showing them how by reducing the 1) a new innovative catheter tray design
number of potential pressure ulcers from six that promotes better processes 2) an edu-
(6) to (0) zero over a one year time span we cational component that provides strategies
had in fact saved the hospital $247,800 (the to prevent CAUTI in the first place and 3) an
number of pressure ulcers reduced multi- awareness campaign, “The Race to ERASE
plied by the average cost to treat one, CAUTI,” that we believe would get our
$41,300, as calculated by CMS). nurses on board.
About the Author – Beth L. Edwards, RN BS is the Clinical Quality Specialist at the Jennie Edmundson Hospital in
Council Bluffs, Iowa. In this position Beth has responsibility for performance improvement, Joint Commission readiness,
and variance event report monitoring. She brings over 25 years of nursing experience to the job, including 5 years in
Patient Safety & Quality Improvement and 10 years in clinical research. In addition to nursing, Beth enjoys spending
time with her daughter and family, and doing knitting and stitchery.
22 Healthy Skin
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.
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 Combined with the previous innovative tray redesign
technology for healthcare workers. So after we and comprehensive ERASE CAUTI education, these
revolutionized the outdated Foley catheter tray with three new features help to improve patient safety and
a unique, one-layer system design, we immediately quality, while reducing avoidable costs associated with
turned our attention to addressing how we could waste and urinary tract infections.
make it even easier to use. We studied how the
tray was being used in the field. The result was To learn about the ERASE CAUTI system, as well as
three more great improvements. 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.
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 place in the paper chart or
attach to the electronic medical record.
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.
WOUND CARE AND

REHAB TRAINING IN
LESOTHO, AFRICA
A travelogue
by Teresa Conner-Kerr, PhD, PT, CWS, CLT
My name is Teresa Conner-Kerr, and I am a physical

therapist, a professor, and chair of the department of
physical therapy at Winston-Salem State University.
I traveled to the mountainous, rural nation of Lesotho,
Africa in June 2010 to explore the possibility of
creating a rehabilitation training program at one of
Lesotho’s nursing schools or at the National Health
Training College in Maseru, Lesotho.
Rehab training greatly needed in Lesotho

Lesotho has the third highest prevalence of HIV in the
world,1 and a significant number of the children and
adults have physical disabilities related to HIV/AIDS.
Nevertheless, there are currently only six physical
therapists and one occupational therapist to serve
the entire country.
The goal is to find a funding source to assist Winston-

Salem State University with establishing a rehabilita-
tion assistant program in Lesotho. The intent is to
teach individuals to become rehab assistants so they
can provide care for the large numbers of children
and adults with disabilities.
Advanced wound care training

During the six days I spent in Lesotho, I also trained
approximately 20 nursing students, plus adult nurse
practitioners and three nursing education faculty at
the St. Joseph Nursing College in Roma using prod-
26 Healthy Skin
Special Feature
ucts and educational materials produced by

Medline®. The majority of them had never seen
modern wound care products. The only supplies they
had on hand were gauze and saline.
I mainly discussed pressure ulcers, explaining the

principles of wound bed preparation and moist
wound healing. I also provided an overview of
wound dressing selection and a hands-on demon-
stration of various Medline dressings. Dressings
were passed around for all to see and touch. Some
of the supplies included Optifoam®, Optifoam Ag,
Puracol®, Puracol Plus, Suresite, bordered gauze,
Medfix, Remedy Skin Repair Cream™, Arglaes®
powder, Arglaes film, and Marathon®.
In addition, I presented Medline wound care educa-

tion CDs to the nurse educator faculty members to
keep in their library at St. Joseph Nursing College.
The college is affiliated with St. Joseph’s Hospital,
which is run by a board under the Archbishop of
Maseru. The hospital, which opened in 1937, is
located in the city of Roma, and serves over
100,000 people across the entire nation of Lesotho.
About the author

Teresa Conner-Kerr, PhD, PT, CWS, CLT, is a pro-
fessor and chair of the department of physical therapy at
Winston-Salem State University, where she also serves
as program director for the doctor of physical therapy
program. She holds a PhD in Anatomy & Cell Biology
from the Brody School of Medicine, East Carolina Uni-
versity, and a BSPT from the same institution. She is a
certified wound care specialist and lymphedema
specialist. Her research inter-
ests include treatments
for antibiotic-resistant
bacteria and recalcitrant
wounds and the use
of simulation technology
in product testing and
teaching.

nt,
with an independe
so th o is a m ou ntainous country ac te ris tic
Le unique ch ar
m oc ra tic go ve rnment. It has the e Re pu bli c
de ighbor, th
be ing to ta lly su rrounded by its ne
of
of South Africa.
HIV AND AIDS IN LESOTHO

Just under 25 percent of the population in References
1. HIV and AIDS in Lesotho. AVERTing HIV and AIDs website.
Lesotho currently lives with HIV. In 2009 there
Available at: http://www.avert.org/aids-lesotho.htm. Accessed
were about 23,000 new HIV infections, and approxi- January 18, 2011.
mately 14,000 people died from AIDS. Over half of 2. UNICEF Executive Director launches “Facts for Life” in Lesotho.
UNAIDS website. April 12, 2010. Available at:
the 260,000 adults living with HIV in Lesotho are
http://www.unaids.org/en/resources/ presscentre/featurestor-
women.1 ies/2010/april/20100412unicef Accessed January 18, 2011.
In addition, one in ten children in Lesotho does not Marathon is a registered trademark of Medline Industries, Inc.
survive to see his or her fifth birthday, mostly as a Optifoam is a registered trademark of Medline Industries, Inc.
result of AIDS and preventable causes, such as pneu- Puracol is a registered trademark of Medline Industries, Inc.
monia and diarrhea, exacerbated by malnutrition.2 Arglaes is a registered trademark of Giltech Limited Corporation
Remedy Skin Repair Cream is a trademark of McCord Research Inc.
Lesotho’s AIDS effort is now guided by the National

AIDS Policy and Strategic Plan for 2006-2011. The
government intends to reverse the epidemic by
focusing on HIV prevention through condom promo-
tion, prevention of mother-to-child transmission, and
providing antiretroviral treatment for all those in need.1
Considering that more than half Lesotho’s population

lives in poverty, declining productivity as a result of
HIV/AIDS remains a stark threat to the overall survival
of the country. In 2007, Keketso Sefeane, chief
executive of the National AIDS Commission in
Lesotho, said HIV/AIDS has the potential to “wipe
out” the country.1
Teresa Conne
r-Kerr during
session with a a one-on-one
nurse practitio wound care ed
ner from the na ucation
tional health se
rvice.
28 Healthy Skin
St. Joseph’s
Nursing Co
one of the o llege in Rom
ldest and la a, Lesotho
rgest trainin is
nurses in Les g facilities for
otho.
ollege learn
at St . Jo se ph’s Nursing C
Studen ts re products
ed lin e’s ad va nced wound ca
about M
and dressings.
St. Joseph’s
Hospital in Rom
over 100,000 a, Lesotho se
people across rves
of Lesotho. th e entire nation

Prevention
Creative Techniques for

Preventing Resident Falls
in Long-Term Care
by Connie Yuska, MS, RN, CORLN
Ensuring the safety of individuals in all healthcare

settings has increasingly become a priority for the
entire healthcare system. In nursing homes, it is the
primary responsibility of both the licensed nurses
and unlicensed assistants to ensure the safety of
the residents.1
Falls are the most frequently reported adverse events among

nursing home residents.1 As many as three out of four nursing
home residents fall each year.2 Falls are most commonly caused
by an existing health condition, such as muscle weakness or
problems with walking, and environmental risk factors, such as
wet floors, poor lighting, incorrect bed height, and improperly
fitted or maintained wheelchairs.2
Studies have documented various fall prevention strategies,

such as providing staff education, reducing risk factors,
identifying the need for and providing exercise programming
and making modifications in the environment to ensure resident
safety.1 Unfortunately, the results of these intervention studies,
as measured by a reduction in falls and fall-related injuries have
been mixed and have not offered a clear solution to preventing
falls in the long-term care setting.1
So what can a facility do to be proactive in ensuring a safe

living environment for their residents? Nursing researchers in
Ontario, Canada explored the communication patterns among
staff working in long-term care settings and found one quite
obvious technique that just may help: Get EVERYONE
involved.1
30 Healthy Skin
“
“ One quite obvious technique that just
may help: Get EVERYONE involved.
Falls Prevention Strategies
Keeping the general rule of increased communication in mind,
some of the following strategies may be employed in your long-
term care facility:
1. Incorporate falls risk assessment and facility policies

and procedures regarding falls into new staff
orientation.
2. Examine how your staff currently communicates
falls prevention activities and make sure all members
of the healthcare team are included.
3. Include communication strategies about falls
in your quality improvement program and
include RNs/LPNs and nursing assistants in
the development of the plan.
4. Actively engage nursing assistants in the care
planning process.
5. Move away from a closed, vertical “chain of
command” method of communication to one
that is horizontal, open and positive.
6. Stress PREVENTION rather than REACTION
in the management of falls incidents.
7. Discuss all of these techniques with your staff
and listen to their input. They may have many
more ideas that can help prevent falls.
By actively engaging all members of the healthcare team in a

falls prevention program, you can improve the quality of care
provided to your residents, and most importantly — keep them
safe from falling.
References
1. Wagner LM, Damianakis T, Mafrici N, Robinson-Holt K. Falls communication
patterns among nursing staff working in long-term care settings. Clin Nurs Res.
2010;19(3):311-326. Available at: http:/cnr.sagepub.com/content/19/3/311.
Accessed December 21, 2010.
2. Falls in Nursing Homes. Centers for Disease Control and Prevention website.
Available at: http://www.cdc.gov/ncipc/factsheets/nursing.htm. Accessed
December 21, 2010.

Prevention
Improving
Hand Hygiene
Compliance
A Multi-disciplinary Team Approach
By Lorri A. Downs RN, BSN, MS, CIC
Although it’s been more than ten years since the Institute of hygiene, however, appears to encompass the ultimate know-
Medicine’s eye-opening report To Err Is Human issued its call ing/doing gap among healthcare professionals. That is to say,
to action to reduce healthcare errors, improving quality and they know when they are supposed to wash their hands, yet
reducing healthcare-acquired infections continue to be two of observed hand-hygiene compliance has been poor; with
the greatest challenges in health care today. We must get average baseline rates around 40 percent.2
healthcare professionals to understand that hands are com-
mon vessels for passing pathogens from patient to patient.1 Known barriers to proper hand hygiene are a lack of knowl-
edge and lack of accessibility to sinks and alcohol-based
Appropriate hand hygiene is one practice with the potential to foam and gels.1
prevent a great deal of healthcare-acquired infections. Hand
5 actions to help increase hand hygiene compliance1

1 Aggressive, continuous education programs 4 Empower patients, residents and families to ask
2 Ensure alcohol-based hand rubs and lotions caregivers if they have washed their hands
are easily accessible 5 To help maintain the integrity of skin, encourage healthcare
3 Ensure healthcare workers receive adequate professionals to use moisturizers and lotions to counteract
education on proper usage of these products the drying effects of alcohol-based products
32 Healthy Skin
Survey Readiness
RSV
Staphylococcus
Influenza
Candida
Klebsiella
Enterococcus
Pseudomonas

Steps to improved hand hygiene compliance1 violet light to see how well they cleaned their hands. Many
Improving hand hygiene is a daunting task, and using a employees had to repeat this activity two or three times
multidisciplinary approach can address numerous barriers. If before their hands were adequately washed.
your facility is having difficulty focusing on hand hygiene
compliance, try implementing the following steps to get Intervention # 3: Proper supplies.
your team motivated. All employees and physicians received pocket-sized bottles
of hand sanitizing gel to use throughout the day. Alcohol foam
1. Form a multidisciplinary team; include a wide range of staff dispensers were also placed both inside and outside patient
such as staff nursing, physicians, infection control and rooms, which addressed a barrier identified in the brain-
quality, and administration. Physician champions can help storming session that the dispensers inside the room were
reach every area quicker. not easily accessible. Signs were placed in patient rooms
2. Roll out an aggressive education program with clear reminding the staff to wash their hands, and patients were
expectations for compliance for employees. educated to remind the staff to sanitize their hands after they
3. Partner this campaign with education about hand hygiene entered the room.
Meet regularly to discuss the campaign progress and
make improvements. Intervention # 4: Hand sanitizing stations.
5. Remove unexpected barriers. The final part of the intervention was putting hand sanitizing
stations in the lobby and waiting rooms on the patient care
What does a successful multidisciplinary hand hygiene floors. The nursing staff educated visitors on the importance
campaign look like? of hand hygiene and educational handouts were also placed
The following is an example of one organization’s hand by the hand sanitizing stations.
hygiene campaign, as outlined in the American Journal of
Infection Control. The interventions were implemented as a way Using these interventions, the hand hygiene compliance rate
to break down the barriers to hand hygiene compliance.1 increased from 66 percent to 90 percent. As hand
hygiene compliance improved, it was noted that, during
Intervention # 1: “You Bugged Me” program. the same time, infection rates decreased.
This activity consisted of staff members presenting a “You
Bugged Me” card if they witnessed other employees not A prospective controlled trial conducted in a hospital
washing their hands or not following proper infection control nursery, and many other investigations conducted over the
practices. The card, which listed the misdoing, was turned past 40 years, have confirmed the important role
in to the employee’s supervisor by the end of the shift. The contaminated healthcare workers’ hands play in the
infection control coordinator was also notified by the individ- transmission of health care-associated pathogens.3
ual completing the card. Employees who received three cards
were required to present an educational in-service at a staff The time to act is now! We must partner and create multidis-
meeting. Those who received five cards were required to ciplinary clinical teams to get the message out that this rela-
write a research paper. Receiving seven cards meant the tively simple process of hand hygiene must be implemented
employees had to present their research paper to the facility’s in every healthcare setting and sustained at a compliance
policy and quality committee. Finally, employees who level of zero tolerance for poor practices. Our challenge in
received 10 cards were scheduled to meet with the CEO and leadership is to remove barriers, role model best practices
chief nursing officer (CNO) regarding their noncompliance. and hold our staff accountable.
References
Intervention # 2: Hand hygiene education. 1 Helms B, Dorval S, St. Laurent P, Winter M. Improving hand hygiene compliance:
The hospital’s infection control coordinator attended all the A multidisciplinary approach. The American Journal of Infection Control.
2010,38(7):572-574
staff meetings in all departments, providing education on 2 Boyce JM & Pittet D. Guideline for hand hygiene in health-care settings:
proper hand hygiene techniques. One of the tools involved recommendations of the Healthcare Infection Control Practices Advisory
Committee and the HICPAC/SHEA/APIC/IDSA/ Hand Hygiene Task Force.
was called Glitter Bug Potion, a fluorescent lotion that is used
MMWR. 2002;51(RR16):1-44.
with an ultraviolet lamp, making it possible to see how well 3 Historical perspective on hand hygiene in health care. In: WHO Guidelines on
hands are cleaned. After applying Glitter Bug, the employees Hand Hygiene in Health Care. 2009:9.
sanitized their hands, and then placed them under an ultra-
34 Healthy Skin
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36 Healthy Skin
Treatment
steoporosis
in men
Osteoporosis is a disease that causes the skeleton However, in the past few years the problem of osteoporosis in
to weaken and the bones to break. It poses men has been recognized as an important public health issue,
particularly in light of estimates that the number of men above
a significant threat to more than two million men
the age of 70 will continue to increase as life expectancy
in the United States. One in four men over age 50 continues to rise.
will have an osteoporosis-related fracture in their
remaining lifetime. Clearly, more information is needed about the causes and
treatment of osteoporosis in men, and researchers are turning
Despite these compelling figures, surveys suggest that a their attention to this long-neglected group.
]majority of American men view osteoporosis solely as a
“woman’s disease.” Moreover, among men whose lifestyle For example, researchers supported by the National Institutes
habits put them at increased risk, few recognize the disease as of Health are studying how much the risk of fracture in men
a significant threat to their mobility and independence. is related to bone mass and structure, biochemistry, lifestyle,
tendency to fall, and other factors.
Osteoporosis is called a “silent disease” because it progresses
without symptoms until a fracture occurs. It develops less often The results of such studies will help doctors to better understand
in men than in women because men have larger skeletons, their how to prevent, manage, and treat osteoporosis in men. This
bone loss starts later and progresses more slowly, and they fact sheet describes the highlights of what is already known.
have no period of rapid hormonal change and bone loss.
Osteoporosis – Projected Prevalence Age 50 and Older

(Figures in millions. Figures have been rounded.)
35
Key
30
2002 2010 2020
Number of people
25
20
15
10
Men with Women with Men with low Women with

osteoporosis osteoporosis bone mass low bone mass
Source: America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation.
Washington, DC: National Osteoporosis Foundation, 2002.

By age 65 or 70 men and women are losing bone mass at the same rate.
What Causes Osteoporosis? men younger than 70 years old; in older men, age-related
Bone is constantly changing—that is, old bone is removed and bone loss is assumed to be the cause.
replaced by new bone. During childhood, more bone is
produced than removed, so the skeleton grows in both size and The majority of men with osteoporosis have at least one
strength. For most people, bone mass peaks during the third (sometimes more than one) secondary cause. In cases of
decade of life. By this age, men typically have accumulated secondary osteoporosis, the loss of bone mass is caused by
more bone mass than women. After this point, the amount certain lifestyle behaviors, diseases, or medications. The most
of bone in the skeleton typically begins to decline slowly as common causes of secondary osteoporosis in men include
removal of old bone exceeds formation of new bone. exposure to glucocorticoid medications, hypogonadism
(low levels of testosterone), alcohol abuse, smoking, gastroin-
Men in their fifties do not experience the rapid loss of bone mass testinal disease, hypercalciuria, and immobilization.
that women do in the years following menopause. By age 65 or
70, however, men and women are losing bone mass at the Causes of Secondary Osteoporosis in Men
same rate, and the absorption of calcium, an essential nutrient
• glucocorticoid medications
for bone health throughout life, decreases in both sexes.
• other immunosuppressive drugs
Excessive bone loss causes bone to become fragile and more
• hypogonadism (low testosterone levels)
likely to fracture.
• excessive alcohol consumption
• smoking
Fractures resulting from osteoporosis most commonly occur in
• chronic obstructive pulmonary disease and asthma
the hip, spine, and wrist, and can be permanently disabling.
• cystic fibrosis
Hip fractures are especially dangerous. Perhaps because such
• gastrointestinal disease
fractures tend to occur at older ages in men than in women,
• hypercalciuria
men who sustain hip fractures are more likely than women to die
• anticonvulsant medications
from complications.
• thyrotoxicosis
• hyperparathyroidism
Primary and Secondary Osteoporosis
• immobilization
There are two main types of osteoporosis: primary and
• osteogenesis imperfecta
secondary. In cases of primary osteoporosis, either the
• homocystinuria
condition is caused by age-related bone loss (sometimes called
• neoplastic disease
senile osteoporosis) or the cause is unknown (idiopathic
• ankylosing spondylitis and rheumatoid arthritis
osteoporosis). The term idiopathic osteoporosis is used only for
• systemic mastocytosis
Continued on page 40
38 Healthy Skin
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Glucocorticoid medications. Glucocorticoids are steroid

medications used to treat diseases such as asthma and
rheumatoid arthritis. Bone loss is a very common side effect
of these medications. The bone loss these medications cause
may be due to their direct effect on bone, muscle weakness
or immobility, reduced intestinal absorption of calcium, a
decrease in testosterone levels, or, most likely, a combination
of these factors.
When glucocorticoid medications are used on an ongoing

basis, bone mass often decreases quickly and continuously,
with most of the bone loss in the ribs and vertebrae. Therefore,
people taking these medications should talk to their doctor
about having a bone mineral density (BMD) test. Men should
also be tested to monitor testosterone levels, as glucocorticoids
often reduce testosterone in the blood.
A treatment plan to minimize loss of bone during long-term

glucocorticoid therapy may include using the minimal effective
dose, and discontinuing the drug or administering it through the
skin, if possible. Adequate calcium and vitamin D intake is
important, as these nutrients help reduce the impact of
glucocorticoids on the bones. Other possible treatments include
testosterone replacement and osteoporosis medication.
example, estrogen levels are low in men with hypogonadism and
Hypogonadism. Hypogonadism refers to abnormally low lev- may play a part in bone loss. Osteoporosis has been found in
els of sex hormones. It is well known that loss of estrogen some men who have rare disorders involving estrogen. There-
causes osteoporosis in women. In men, reduced levels of sex fore, the role of estrogen in men is under active investigation.
hormones may also cause osteoporosis.
Alcohol abuse. There is a wealth of evidence that alcohol
Although it is natural for testosterone levels to decrease with age, abuse may decrease bone density and lead to an increase in
there should not be a sudden drop in this hormone that is fractures. Low bone mass is common in men who seek med-
comparable to the drop in estrogen experienced by women at ical help for alcohol abuse.
menopause. However, medications such as glucocorticoids
(discussed above), cancer treatments (especially for prostate In cases where bone loss is linked to alcohol abuse, the first
cancer), and many other factors can affect testosterone levels. goal of treatment is to help the patient stop, or at least reduce
Testosterone replacement therapy may be helpful in preventing or his consumption of alcohol. More research is needed to
slowing bone loss. Its success depends on factors such as age determine whether bone lost to alcohol abuse will rebuild once
and how long testosterone levels have been reduced. drinking stops, or even whether further damage will be
Also, it is not yet clear how long any beneficial effect of prevented. It is clear, though, that alcohol abuse causes many
testosterone replacement will last. Therefore, doctors usually treat other health and social problems, so quitting is ideal. A
the osteoporosis directly, using medications approved treatment plan may also include a balanced diet with lots
for this purpose. Recent research suggests that estrogen of calcium- and vitamin D-rich foods, a program of physical
deficiency may also be a cause of osteoporosis in men. For exercise, and smoking cessation.
40 Healthy Skin
Smoking. Bone loss is more rapid, and rates of hip and

vertebral fracture are higher, among men who smoke, although
more research is needed to determine exactly how smoking
damages bone. Tobacco, nicotine, and other chemicals found in
cigarettes may be directly toxic to bone, or they may inhibit
absorption of calcium and other nutrients needed for bone
health. Quitting is the ideal approach, as smoking is harmful in so
many ways. As with alcohol, it is not known whether quitting
smoking leads to reduced rates of bone loss or to a gain in
bone mass.
Gastrointestinal disorders. Several nutrients, including amino

acids, calcium, magnesium, phosphorous, and vitamins D and
K, are important for bone health. Diseases of the stomach and
intestines can lead to bone disease when they impair absorp-
tion of these nutrients. In such cases, treatment for bone loss
may include taking supplements to replenish these nutrients.
Hypercalciuria. Hypercalciuria is a disorder that causes

too much calcium to be lost through the urine, which makes
the calcium unavailable for building bone. Patients with
hypercalciuria should talk to their doctor about having a BMD
test and, if bone density is low, discuss treatment options.
Immobilization. Weight-bearing exercise is essential for

maintaining healthy bones. Without it, bone density may decline
rapidly. Prolonged bed rest (following fractures, surgery, spinal
cord injuries, or illness) or immobilization of some part of the
body often results in significant bone loss. It is crucial to resume
weight-bearing exercise (such as walking, jogging, dancing, and
It is increasingly common for women to be diagnosed with
lifting weights) as soon as possible after a period of prolonged
osteoporosis or low bone mass using a BMD test, often at
bed rest. If this is not possible, you should work with your
midlife when doctors begin to watch for signs of bone loss. In
doctor to minimize other risk factors for osteoporosis.
men, however, the diagnosis is often not made until a fracture
occurs or a man complains of back pain and sees his doctor.
How Is Osteoporosis Diagnosed in Men?
This makes it especially important for men to inform their
Osteoporosis can be effectively treated if it is detected before
doctors about risk factors for developing osteoporosis, loss of
significant bone loss has occurred. A medical workup to
height or change in posture, a fracture, or sudden back pain.
diagnose osteoporosis will include a complete medical history,
X-rays, and urine and blood tests. The doctor may also order a
Some doctors may be unsure how to interpret the results of a
bone mineral density test. This test can identify osteoporosis,
BMD test in men, because it is not known whether the World
determine your risk for fractures (broken bones), and measure
Health Organization guidelines used to diagnose osteoporosis
your response to osteoporosis treatment. The most widely
or low bone mass in women are also appropriate for men.
recognized BMD test is called a dual-energy X-ray
Although controversial, the International Society for Clinical
absorptiometry, or DXA test. It is painless – a bit like having an
Densitometry recommends using separate guidelines when
X-ray, but with much less exposure to radiation. It can measure
interpreting BMD test results in men.
bone density at your hip and spine.

What Are the Risk Factors for Men? inadequate, dietary vitamin D intake should be between
Several risk factors have been linked to osteoporosis in men: 600 and 800 IU (International Units) per day. (See Table
• Chronic diseases that affect the kidneys, lungs, 1.) The amount of vitamin D found in 1 quart of fortified
stomach, and intestines or alter hormone levels milk and most multivitamins is 400 IU.
• Regular use of certain medications, such as • Engage in a regular regimen of weight-bearing
glucocorticoids exercises in which bones and muscles work against
• Undiagnosed low levels of the sex hormone testosterone gravity. This might include walking, jogging, racquet
sports, climbing stairs, team sports, weight training,
• Unhealthy lifestyle habits: smoking, excessive
and using resistance machines. A doctor should
alcohol use, low calcium intake, and inadequate
evaluate the exercise program of anyone already
physical exercise
diagnosed with osteoporosis to determine if twisting
• Age. The older you are, the greater your risk.
motions and impact activities, such as those used in
• Race. Caucasian men appear to be at particularly golf, tennis, or basketball, need to be curtailed.
high risk, but all men can develop this disease.
• Discuss with your doctor the use of medications that
are known to cause bone loss, such as glucocorticoids.
What Treatments Are Available?
• Recognize and seek treatment for any underlying
Once a man has been diagnosed with osteoporosis, his doctor
medical conditions that affect bone health.
may prescribe one of the medications approved by the FDA for
this disease. The treatment plan will also likely include the
nutrition, exercise, and lifestyle guidelines for preventing bone Table 1. Recommendations for Calcium
loss listed at the end of this fact sheet. and Vitamin D Intake
Age Calcium (mg) Vitamin D (IU)
If bone loss is due to glucocorticoid use, the doctor
19 to 30 1,000 600
may prescribe a medication approved to prevent or treat
glucocorticoid-induced osteoporosis, monitor bone density and 31 to 50 1,000 600
testosterone levels, and suggest using the minimum 51 to 70 1,200 600
effective dose of glucocorticoid. 70+ 1,200 800
Source: Institute of Medicine, 2010.
Other possible prevention or treatment approaches include cal-
cium and/or vitamin D supplements and regular physical activity.
If osteoporosis is the result of another condition (such

For more information on osteoporosis, visit the National
as testosterone deficiency) or exposure to certain other
Institutes of Health Osteoporosis and Related Bone Diseases ~
medications, the doctor may design a treatment plan to address
National Resource Center website at www.bones.nih.gov or call
the underlying cause.
800–624–2663.
How Can Osteoporosis Be Prevented?

There have been fewer research studies on osteoporosis in men Article provided by the NIH Osteoporosis and Related Bone
than in women. However, experts agree that all people should Diseases ~ National Resource Center which provides patients,
take the following steps to preserve their bone health: health professionals, and the public with an important link to
• Avoid smoking, reduce alcohol intake, and increase resources and information on metabolic bone diseases.
your level of physical activity.
• Ensure a daily calcium intake that is adequate for your age.
• Ensure an adequate intake of vitamin D. Normally, the
body makes enough vitamin D from exposure to as little
as 10 minutes of sunlight a day. If exposure to sunlight is
42 Healthy Skin
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What’s in Store for

QIS and MDS 3.0
By Dr. Andy Kramer
n case you were wondering, the new minimum data set Care Area has QCLIs mapped to it that originate from one or
I (MDS) 3.0 will not impact the performance of the Qual-

ity Improvement Survey (QIS). However, there are some as-
pects of the QIS treatment of MDS data that will remain the
more of the onsite assessments that are conducted during
Stage 1.
same going forward and some that will change temporarily. For example, the Pressure Ulcer Care Area currently has
seven QCLIs that are calculated from Staff Interviews, Census
New QIS software, implemented in November [2010], will still Sample Record Reviews, Admission Sample Record
generate random resident census samples and admission Reviews, and MDS. Only two of these are calculated from the
samples for the QIS process based on MDS data. Surveyors MDS items, so the remaining five pressure ulcer QCLIs will be
will continue to require from the nursing facility an alphabetical utilized during QIS surveys.
resident census list of all residents who are in the facility,
including those who may be in the hospital or out on a home The calculation and use of QCLIs based solely on MDS will
visit. They will also require the list of recent admissions. be on hold until sufficient numbers of MDS 3.0 assessments
have been submitted by nursing facilities. Thus, although MDS
Surveyors will also continue to reconcile the software-gener- QCLIs will temporarily not be used to determine triggered
ated random sample of residents with the alphabetical resi- Care Areas for a Stage 2 in-depth investigation, these care
dent census and new admission list to finalize their samples areas will be included in QIS because of the QCLIs from other
for survey. sources. Some of the MDS QCLIs that can be calculated from
MDS 3.0 data are expected to be used in QIS beginning in
What will change, temporarily, is that the QIS software will not early 2011.
calculate or utilize the 44 Quality of Care and Life Indicators
(QCLI) that are derived from MDS data. However, almost every Printed with permission from Provider magazine.
44 Healthy Skin
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46 Healthy Skin

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Special Feature
Inspiring change:
The Cozy Project makes older
patients more comfortable
By Tina Weitzel MA, RN-BC

While Rosemary Muller, 82, was hospitalized with pneumonia, she often
complained about feeling cold. One evening she told her nurse that she
couldn’t go to sleep because she was too cold. The temperature of her
room was 23[degrees] C (74[degrees] F), but Mrs. Muller was still uncom-
fortable, despite being covered with three blankets.
In an effort to help her relax and sleep, her nurse gave her a p.r.n. sedative.
During the night, Mrs. Muller woke up because she needed to urinate.
Feeling light-headed and confused, she fell when she got out of bed to go
to the bathroom.
The Professionals Improving Care for Health System Elders (PICHE) group
at our hospital recognized that being cold was a risk factor for older adults
such as Mrs. Muller. We questioned why hospitalized older adults are
dressed in short-sleeved, open-backed gowns that cover far less of the
body than clothing worn at home.
The amount and type of clothing selected by older adults may be related to
changes in thermoregulation, which cause them to feel cold in an environ-
ment that’s comfortable for younger people. The PICHE nurses decided to
investigate.
Reading up
The first step was to review the literature to better understand physiologic
changes that contribute to older adults feeling cold. We discovered that their
response to cold is affected by a decrease in their abilities to produce and
conserve heat.
Age-related changes in the temperature-regulating center in the hypothal-

amus as well as decreased vasoconstrictor response lead to less heat pro-
duction and decreased ability to maintain body heat in cooler environments.1
Researchers compared older adults with younger adults and measured
each group’s response to decreases in ambient room temperature.
Although core body temperature remained stable for the younger subjects,
older subjects experienced progressively lower core temperatures.2 Other
researchers found that increasing skin temperature as little as 0.4[degrees]
C led to decreased nocturnal wakefulness.3
Hospitalized older adults are likely to have chronic illnesses that may con-
tribute to thermoregulatory problems. Those who are malnourished will have
even less subcutaneous fat, which may contribute to less ability to maintain
warmth. Disorders such as hypothyroidism and hypoglycemia may affect
the shivering response, and immobility associated with conditions such as
stroke, arthritis, and parkinsonism may lead to decreased heat production.
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Medications for pain, depression, or anxiety can diminish the nurse and said they were much more comfortable. One of the
shivering response or act as vasodilators, further increasing patients with dementia seemed very pleased and said, “I have
discomfort in a cool environment.4 When the thermostat can’t one just like this at home.” Patient ages ranged from 75 to 89,
be adjusted, older adults need extra clothing and bedcovers beds had 2 to 4 blankets, and room temperature ranged from
to trap warm air next to their body. 74[degrees] F to 77[degrees] F.
Introducing the Cozy Project After the intervention, the nurses documented nonverbal
The PICHE group decided to investigate whether warmer behavior. Notes included the words smiling, quiet, and sleeping.
clothes could make a difference in the comfort of our older We discovered that when the older women were offered a
patients, starting with donated “gently worn” long-sleeved long-sleeved shirt, they often refused, but when we called it
turtleneck shirts. We decided to evaluate the effectiveness of a long-sleeved blouse, they usually accepted the garment.
the Cozy Project in a trial of patients with these characteristics:
women age 75 and older in a medical unit who said they’re The story of one patient demonstrates the effectiveness of our
cold and uncomfortable and were observed to be restless project. This patient, 88, said she was cold and tired but couldn’t
or fidgeting. go to sleep. She was covered with two blankets, and her room
temperature was 77[degrees] F. During the first observation
The women who met these criteria were offered a warm period, the nurse noted that the patient constantly fidgeted.
garment. For patients with I.V. devices, the garment was cut Ten minutes after the nurse helped her put on a long-sleeved
up the back to make it easier to get on and off and to facilitate turtleneck, the patient was sleeping.
changing the devices and dressings.
We decided to systematically collect data for the PICHE group
to analyze. The RNs who participated and documented their
observations attended a 2-hour educational session that
included the opportunity to practice taking notes while watch-
ing a videotaped patient-interaction scenario. Before and after
the intervention, the nurses were asked to:
• describe the patient and the setting

• note all actions, gestures, and nonverbal behaviors
• include the room temperature and the number of
blankets on the bed.
When they documented the situation, the nurses were

encouraged to include (in parentheses) their feelings, ideas,
and impressions about what they observed. The data were
reviewed by the PICHE group.
Comforting results
We evaluated the results based on notes about the first five
women who were identified as patients who might be more
comfortable wearing a long-sleeved turtleneck. Immediately
after their shirts were put on, three of the patients thanked their
52 Healthy Skin
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This project indicates that this simple intervention can improve In a previous study in our hospital, blankets from a blanket
comfort in older adults. The PICHE group decided to solicit warmer were also found to improve the comfort level of older
additional donations of gently worn long-sleeved turtlenecks adults.5 The long-sleeved garments may be an additional sim-
and expanded our project to additional units. These donated ple intervention to enhance warmth.
turtlenecks were laundered and then stored in a designated bin
on the nursing units. Nurses could take a turtleneck and cut it Florence Nightingale wrote that nurses should provide comfort
as needed; for example, to accommodate any venous access through proper use of “fresh air, light, warmth, cleanliness,
devices. The garment would then be discarded when it was quiet, and the proper selection and administration of diet.”6
soiled or when the patient was discharged. Making a patient comfortable has always been an integral com-
ponent of nursing.
We placed a collection box near the cafeteria and requested
donations in the hospital newsletter. Very quickly, the collection
box was filled. When supplies get low, we place another References
1. Talley HC, Talley CH. AANA Journal course. Update for nurse anesthetists.
request in the hospital newsletter. We’ve had no difficulty
Evaluation of older adults. AANA J. 2009;77(6):451-460.
obtaining long-sleeved turtlenecks. 2. Degroot DW, Kenney WL. Impaired defense of core temperature in aged humans
during mild cold stress. Am J Physiol Regul Integr Comp Physiol.
2007;292(1):R103-R108.
Understanding the implications
3. Raymann RJ, Swaab DF, Van Someren EJ. Skin deep: enhanced sleep depth by
Feeling cold may aggravate pain for those who suffer from cutaneous temperature manipulation. Brain. 2008;131(Pt 2):500-513.
arthritis or any other musculoskeletal illness. Patients who are 4. Halter J, Ouslander J, Tinetti M, et al., eds. Hazzard'sGeriatric Medicine and
recovering from surgery and report acute pain may also bene- Gerontology. 6th ed. Chicago, IL: McGraw-Hill; 2009.
5. Robinson S, Benton G. Warmed blankets: an intervention to promote comfort for
fit from wearing long-sleeved garments because the warmth elderly hospitalized patients. Geriatr Nurs. 2002;23(6):320-323.
may decrease muscle tension. 6. Nightingale F. Notes on Nursing: What It Is and What It Is Not. London, England:
Harrison and Sons; 1860.
Older patients may sleep better if they’re comfortably warm.

Printed with permission from Nursing2011. 41(1):18-19.
Because the rooms, hallways, and diagnostic areas in the hos-
pital are generally cool, nurses need to be sure that older adults
are covered sufficiently.
54 Healthy Skin
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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 over-
all.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
2 Strapping Methods
heel protection devices that relieve pressure by elevating the heel.
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
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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.
Prevention
Protecting
Vulnerable
Heels
Tips for Nursing
Assistants
By Evonne Fowler, MSN, RN, CNS, CWOCN
Patients who spend long periods of time in bed can be

especially susceptible to pressure ulcers and other
injuries to their heels. Heel pressure ulcers are a serious
health concern for patients. Besides being painful, they
can possibly lead to infection, cellulitis, osteomyelitis,
septicemia, limb amputation and even death.
Pressure ulcers often form on the heel because:

• It has a bony prominence
• There are no oil glands, so the skin gets dry1
Heel pressure ulcers can also be very expensive for

facilities. They’re the most common facility-acquired
pressure ulcer in long-term care facilities and the second
most common among all healthcare settings. And
complex heel pressure ulcers are among the most
costly complications for the elderly.2
56 Healthy Skin
You can help prevent heel pressure ulcers by turning Moisturizers and padding devices
patients regularly and by making sure they’re well- Padding devices (sheep skin or bunny boots) and mois-
nourished and well-hydrated. There are also many helpful turizers help minimize friction and shear, but they don’t
products available for heels. provide protection from excessive pressure.5
Pillows Tip: Look for moisturizers with nourishing topical

The National Pressure Ulcer Advisory Panel (NPUAP) nutrients and ingredients that add a layer of
recommends the use of pillows. Pillows are an easy and protection on top of the skin, such as dimethicone.
cost-effective way to elevate the heels of cooperative
individuals. 3 But pillows are not recommended for Despite the best efforts of caregivers, some patients still
patients who might move the leg off the pillow or if the experience heel pressure ulcers. When you find a heel
leg must be elevated longer than 24 hours. For these pressure ulcer, contact your facility’s wound care or
patients, it’s best to use a product that stays on the foot treatment nurse, as these wounds often require special-
during movement, such as a heel offloading device, or ized care.
heel boot.4
Heel pressure ulcers can pose a significant threat to your
Tip: For best results, place pillows lengthwise patients’ health and your facility’s bottom line. However,
under the calf with the heel suspended in the air.3 there are steps you can take to reduce heel pressure
ulcers.
Heel offloading devices
References
Often shaped like a large boot, heel offloading devices 1. Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure
surround the foot and ankle on all sides and leave space 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
for needed air flow.
can improve outcomes. Advance for Nurses. 2010; 8(24):25.
3. Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for
Benefits of heel offloading devices: preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10).
Available at www.o-wm.com/content/practice-recommendations-prevent-
• Stays in place ingheel- pressure-ulcers. Accessed August 25, 2010.
• Pressure redistribution 4. Cuddigan JE, Ayello EA, Black J. Saving heels in critically ill patients. WCET
Journal; 28(2):2-8.
• Friction and shear reduction 5. FAQs: Preventing heel pressure ulcers in immobilized patients. Advances in
• Ankle separation and protection Skin & Wound Care; 18(1):22.
• Foot drop prevention
Tip: Remove heel offloading devices every shift

and inspect the patient’s skin for redness.

Special Feature
t r i c P r e s s u r e
Pedia
U l c e r s i n t h e
s t” P l a c e s
“Dar nede
by Margie Rodriguez, RN, MSN, WCC
Pediatric pressure ulcers have been somewhat overlooked

by the medical community as an area of concern for patient
safety. Although there is little data regarding the extent of the
problem, there is anecdotal evidence that critically ill children
are at greater risk for pressure ulcers than the general
pediatric population. I am finding more and more that
children do get pressure ulcers, and I must add — in the
“darnedest” places.
Skin breakdown in children

Key factors that contribute to skin breakdown in children
differ from those for premature infants or adults.1 Many
children in the special needs pediatric population
acquire pressure ulcers that are related to the use
of equipment, and it takes very little time to
produce a pressure-related injury. The application
of pressure on the skin of a special needs child
with risk factors such as supplemental nutrition,
chronic illness, limited mobility or increased mobil-
ity or incontinence is just as detrimental as it is in the geriatric
population.
Children with special needs often lack the ability to clearly

communicate their needs, especially when it comes to iden-
tifying discomfort. If a child demonstrates any verbal or
non-verbal signs or symptoms of discomfort, a head-to-toe
skin assessment should be performed immediately to check
for discoloration and signs of skin breakdown – likely precursors
to pressure ulcers.
58 Healthy Skin
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A pressure ulcer is a localized injury to the skin and/or under-

lying tissue usually over a bony prominence, as a result
of pressure, or pressure in combination with shear and/or
friction. A number of additional contributing or confounding
factors are also associated with pressure ulcers; the signifi-
cance of which is yet to be elucidated.2
Confounding factors
A majority of the special needs population are subject to skin
issues related to the use of medical devices, alternate feed-
ing modalities, cognitive impairment (congenital or patholog-
ical), metabolic compromise, neurological deficits and chronic Stage III just below the occipitus/present upon admission
illness, making this population vulnerable to pressure ulcers
during their childhood years and into adulthood—basically for
their entire lifetime. Technological advancements in the care of
critically ill infants and children has undoubtedly saved lives
and greatly extended the life span among many children.
However, these successes have posed unforeseen chal-
lenges as these individuals enter adulthood.3
Pressure ulcers in the pediatric special needs population

and/or chronically ill child can be acquired at home, during
hospitalization, or during an extended stay at a rehabilitation
or long-term care facility. In my experience, children are no Unstageable (eschar) on the first digit of the
different from adults regarding the most common areas of the foot/unknown etiology
body where pressure ulcers form, such as the coccyx,
sacrum, ischial tuberosities, heels, and over bony promi-
nences, to name a few. In addition, because of children’s frag-
ile, vulnerable, compromised and not yet matured skin,
pressure ulcers also appear in the “darnedest” places and for
many different reasons.
Stage IV on the lateral side of the malleolus/status post

hospitalization
Unstageable
60 Healthy Skin
The greater the neurological deficit the child presents, the

more likely that signs of discomfort will be difficult for care-
givers to interpret. Caregivers of children with significant neu-
rological deficits must be sure to assess skin meticulously and
use extra caution when placing equipment. The caregiver
must always check, check and recheck these children’s
equipment for safe placement.
Abdominal pressure ulcers

I have also seen in my practice that the abdomen is a com-
mon site for the development of pressure ulcers among chil-
Healing Stage II on the heel over calloused skin/cast
dren with special needs. For example, the gastrostomy tube
when first placed, often comes with a retainer disk. The
Mucosal pressure ulcers retainer disk keeps the internal balloon that forms a stoma
The pediatric population is not exempt when it comes to sealed at the level of the abdomen. It is placed as close as
newly recognized mucosal pressure ulcers. According to the possible to the abdomen to keep the tube in place as it forms
National Pressure Ulcer Advisory Panel (NPUAP) position a track and allows for healing to occur. This close placement,
statement,4 mucosal pressure ulcers are found on mucous however, can also contribute to Stage II pressure ulcers.
membranes where a medical device has been in use.
These include ulceration of the nare/septum or any mucous
membrane site due to the insertion of catheters.
NPUAP states pressure ulcers found on mucous mem-

branes are not to be staged according to the usual pres-
sure ulcer staging system. Although it is understood that
these ulcers may indeed be due to pressure, anatomically
analogous tissue comparisons cannot be made. Further, it is
NPUAP’s position that mucosal pressure ulcers not be clas-
sified as partial or full thickness, because clinical assessment
of the tissue does not allow for the distinction. Therefore,
NPUAP’s position is to label pressure ulcers on mucous
membranes as mucosal pressure ulcers without a stage
identified.4
In my experience, the pediatric population is at higher risk for

these types of mucosal ulcerations in part because children
cannot always follow the clinician’s instructions not to touch
a device. Many children instead arrange and rearrange
devices for comfort or play, unaware that they could be harm-
ing themselves.

Even though children can suffer from pressure ulcers, very About the author
little research is available regarding the prevalence, incidence Margie Rodriguez, RN, MSN, WCC, is a
and risk factors associated with pressure ulcers among the wound care nurse at the Elizabeth Seton
Pediatric Center, a pediatric long-term care
pediatric population.1 Despite the lack of available research,
facility for palliative, rehabilitation and long-
suffice it to say there is a possibility we are not reaching far term care services in New York City. Her
enough in pursuit of this data, which encompasses not just accomplishments include creating a skin
the acute care setting but all spectrums of care. Evidence- care program, publishing articles, and in
based clinical practice guidelines for prevention and treatment 2010, working with NPUAP to help revise
of pressure ulcers specifically addressing the unique needs definitions for pressure ulcer staging. She is also on faculty for
the Beth Israel School of Nursing. You can reach her at
of the neonatal and pediatric population are needed.
margie.rodriguez@setonpediatric.org.
This population is especially deserving of the time it would

require to gather such data and develop clinical practice
guidelines. I know from my own clinical experience that
chronically ill children and those with special needs are at risk
for pressure ulcers and in fact acquire them not only in all the
same areas as adults, but also in the “darnedest” places.
References
1 Suddaby EC, Barnett S, Facteau L. Skin breakdowns in acute
care pediatrics. Pediatric Nursing. 2005; 31(2):132-138.
2 National Pressure Ulcer Advisory Panel (2009). Prevention
of Pressure Ulcers: Quick Reference Guide.
3 Gray M. Context for WOC practice – urban myths and the
randomized control trial. 2010. JWOCN; 37(6):583–585.
4 National Pressure Advisory Panel. (Dec. 2010). Mucosal
Pressure Ulcers: A NPUAP Position Statement.
62 Healthy Skin
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In a recent poll of 762 Medline customers
and subscribers of The OR Connection
and/or Healthy Skin magazine:
• 41 percent were RNs
• 10 percent own an iPhone
Of those who own an iPhone:

• 89 percent said they would download
available content from Medline
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from the iTunes store
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Caring for Yourself
Top Tips
for Winter Skin Care
You may not realize the health threats associated with the
glaring sun and bitter cold air of the winter season. By itself,
dry skin isn’t a medical worry, but serious cases can result
8 more ways to keep your skin healthy:
1 Use a humidifier to put moisture back

in cracking, inflammation, serious burns and skin condi-
tions such as eczema.1 in the air.
2 Turn down the thermostat. Hot air is
If you do nothing else for your skin during the winter, be often very dry.
sure to protect it from the cold, dry air and moisturize as 3 Bundle up with a scarf, hat and gloves
often as possible. to protect your face, scalp and hands
from harsh winds.
Granted, choosing a moisturizer can be confusing. The 4 Remember to wear sunscreen and
number of choices seems endless. One reason for the lip balm with SPF, especially when
development of so many moisturizers is the continuing participating in outdoor winter sports.
search for a mix of ingredients that holds in water like Ultraviolet rays are still present even
petroleum jelly, yet allows for air circulation and feels nicer during the winter.
on the skin. 2 One such ingredient is dimethicone, a 5 Avoid hot showers and baths. Hot
silicone-based substance that forms a protective layer on water can strip the skin of the fatty
top of the skin while also allowing oxygen to reach the skin substances (lipids) that help it
cells underneath. retain water.
6 Skip the soap. Soaps, especially
Regardless of which moisturizer you choose, almost all will deodorant bars, can be drying
help with dry skin. In most cases, the choice simply comes and harsh. Use mild cleansers or
down to whether you like the feel and the fragrance. It’s moisturizing body washes instead.
best to apply moisturizer right after a bath or shower while 7 Drink plenty of water. Hydrating from
your skin is still damp to help seal in your own natural moisture. the inside as well as the outside
helps keep your skin healthier.
References 8 Eat right. A balanced diet rich in
1 Dos and don’ts for winter skin: winterize your skin. American Society for
vitamins and nutrients also helps
Dermatologic Surgery. Available at: www.asds.net/dosanddontsforwinterskin.aspx.
Accessed January 14, 2011. promote healthy skin.
2 Tips for soothing dry winter skin. News from Harvard Health. Available at:
www.health.harvard.edu/press_releases/tips-for-dry-skin. Accessed
64 Healthy Skin
®
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.
©2011 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.
CASE STUDY
The Use of Superabsorbent Containing Fluid

Lock Dressing* in Hospice Patients
INTRODUCTION METHODOLOGY
The management of exudating wounds presents chal- In this safety and effectiveness study, a convenience
lenges in the hospice environment, where the focus is on sample of three patients with multiple wounds were cho-
the comfort of the resident and the elevation of quality of sen. In all cases, the dressings were changed as needed
life factors. In our practice, we have sought the use of based on visual observation of the dressing saturation
absorbent dressings that are versatile on wound exudate, and potential exudate overloads. More frequent change
emerge at variable rates depending on the type of wound, was not needed during use.
and act as a single product across the spectrum of exu-
dation levels. Such optimization is desirable because it CASE DETAILS AND OBSERVATIONS
allows us to focus more energy on the patient rather Case 1: DG is a 74-year-old female, admitted to our
than on managing the choice and inventory of many program with multiple Stage lll and lV pressure ulcers.
different dressings for various types of wounds. Her terminal diagnosis is AFTT. Her albumin level was
2.4. During her hospital stay just prior to her hospice
We chose patients who suffered from exudating wounds, admission, lab cultures revealed MRSA in her ulcers and
with some wounds being more exudative than others, at one point she was treated for septicemia. Initially,
even within the same patient. The purpose of this limited while in hospice care she required dressing changes
trial was to check if a new variety of superabsorbent par- as frequently as 2 times a day for several of the pres-
ticle containing dressings were versatile enough on this sure ulcers with foam dressings. When the new super-
vulnerable population, and whether the dressings had any absorbent dressing was introduced, dressing change
undesirable properties such as tendency to leak, or to frequently decreased considerably. The trial with the new
cause discomfort during removal. This new superab- product was started with two of her pressure ulcers. The
sorbent dressing consists of a contact layer that has spe- high capacity of the dressing contributed to our patient’s
cial microchannels that allow directional fluid flow, from comfort by reducing occasions of dressing change, and
the wound into superabsorbent particles dispersed inside proportionally reduced the caregiver’s time which then
an internal core layer. Laboratory data shows that these impacted the cost of care.
dressings, when subjected to pressure, still allow fluid
absorption. Compression on the dressings leads to min- Case 2: JH is a 68-year-old female who was admitted
imum fluid loss. These properties are thought to be sig- to our program with a terminal diagnosis of pancreatic
nificant in managing periwound maceration. Because cancer. She presented on admission with four ulcers,
maceration of periwound skin is a major problem in hos- which were identified as being Pyoderma Gangrenosum
pice patients with exudating wounds, and all too frequent in etiology. We used the superabsorbent dressing on a
dressing changes impact cost and quality of care. This highly exudating wound on her right hip. The new dress-
trial also examined whether the new superabsorbent ing managed exudate without any maceration to peri-
dressing can alleviate care and cost concerns in a hos- wound skin.
pice environment.
Case 3: MKL, an 84-year-old female, was admitted to
our program with a terminal diagnosis of vascular
dementia. She presented with two venous leg ulcers.
The foam dressings in use initially were replaced with the
new superabsorbent dressing. Compared to the
frequency of the foam dressing change, the number of
dressing changes was greatly reduced, increasing our
patient’s comfort and freeing up the caregiver to focus
on patient comfort.
66 Healthy Skin
P. Sue Hashley, RN, CWS, FACCWS Treatment

St Francis Hospice
Honolulu, HI
RESULTS AND CONCLUSION

The use of a superabsorbent based dressing on our
patients was a new and valuable experience for us. We
found that the use of these products on wounds whose
exudate level ranged from low (Case 2) to high (Cases 1
and 3) produced excellent results. Minimal or no peri-
wound maceration, with no accidental strike through,
and no adhesion of the dressing to the wound site was
observed, even on the low exuding wound (Case 2).
There was no leakage of the superabsorbent particles
from the dressing into the wound during use, even when
the dressing was used on the coccyx of a patient (Case
1) and the dressing was sporadically subject to the
weight of the patient. Patients reported no discomfort
during dressing use. Since the dressing has no observ-
able adhesion there was also no pain reported during
dressing removal. This was especially notable in the
patient with Pyoderma Gangrenosum.
In our view, the availability of this affordable product to

potentially replace more expensive products represents
a step in the right direction both in product performance,
as well as in terms of reducing cost and time for care in
this hospice environment.
References
1. Sibbald Gary et al. The role of moisture balance in wound healing.
Advances in Skin and Wound Care: 2007: 20:39-53.
2. Steinlecher E, Rohrer C, Abel M. Absorbent dressings with superabsorbent
polymers – a new generation of wound dressings. Poster 374.
18th Conference of the European Wound Management Association.
*OptiLock™, Medline Industries, Inc. Mundelein, IL

OptiLock is a trademark of Medline Industries, Inc.

OPTILOCK™
Super Absorbent Wound Dressing
Gentle on wounds,
tough on exudate
OPTILOCK’s superabsorbent polymer
core absorbs moderate to heavy exudate,
locks in fluid—even under compression—
and protects periwound skin from maceration.
Non-adherent contact layer prevents the dressing
from sticking to the wound. Gentle removal and fewer
dressing changes mean greater patient comfort.
To learn more or request a sample, contact your

Medline representative or call 1-800-MEDLINE
(1-800-633-5463).
Prevention
EASY DOES IT
Safe and Effective Lifting Practices
A major issue in nursing homes is the frequent lifting and repo-

sitioning of residents who exceed the lifting capacity of most
caregivers. Numerous studies have shown that training
caregivers how to use proper body mechanics to lift residents
is not an effective prevention measure because lifting the weight
of adult patients is intrinsically unsafe.
Factors that contribute to the difficulty of lifting and moving a

resident include the size and weight of the resident, combat-
iveness and propensity to fall or lose balance. In addition,
performing resident transfers in small bathrooms and rooms
cluttered with medical equipment and furniture works against
the caregiver being able to use good body mechanics.
When lifting or repositioning a resident in bed, the bed gener-

ally prevents caregivers from bending their knees to assume
the proper posture for lifting. The forward bending required for
many patient lifting and moving activities places the caregiver’s
spine in its most vulnerable position. Even under ideal lifting
conditions, the weight of any adult far exceeds the lifting
capacity of most caregivers, 90 percent of whom are female.
These conditions contributed to the 211,000 occupational

injuries suffered by caregivers in 2003.1 Because of the rapidly
expanding elderly population in the United States, employment
for nursing aides, orderlies and attendants is projected to
increase by 25 percent between 2002 and 2012, adding an
estimated 343,000 jobs.2 Due to the ongoing demand for
skilled care services, musculoskeletal injuries to the back,
shoulders and upper extremities of caregivers are expected
to increase.

Research has shown that safe

resident lifting programs reduce
resident-handling workers’
compensation injury
rates by
61%
How effective is mechanical lifting equipment indicated that residents’ acceptance of a safe lifting program
in preventing injuries to caregivers? was moderate when the program was first implemented but
Safe resident lifting programs can be highly effective in high at the end of the research study. 5,6
reducing a healthcare worker’s exposure to heavy loads and
awkward working postures that contribute to back and other Injuries to residents are also reduced because the mechanical
musculoskeletal injuries. Research has shown that safe res- lifts protect residents from being dropped. Anecdotal infor-
ident lifting programs reduce resident-handling workers’ mation indicates that a reduction in skin tears and bruises
compensation injury rates by 61 percent, lost work day injury may result when residents are handled mechanically rather
rates by 66 percent, restricted work days by 38 percent, and than manually.8
the number of workers suffering from repeat injuries.3 Similar
findings have been reported by other investigators.4,5,6 Fur- Does it take more time to use a mechanical lift to move
thermore, this research has shown an increase in caregiver a resident than to manually transfer the resident?
job satisfaction and a decrease in “unsafe” patient handling It is quicker to manually transfer a resident. However, using a
practices performed. Nurses ranked lifting equipment as the mechanical lift is much safer for the caregiver and provides a
most important element in a safe lifting program.5,6 The more comfortable and secure transfer for the resident. The
increase in bariatric residents has also led lifting equipment long-term health and wellness of the caregiver will be much
manufacturers to develop equipment with higher lifting greater over the long term by taking a few extra minutes to
capacities to accommodate the special needs of some lighten the daily burden of work. Much of the extra time to
bariatric residents. use a mechanical lift is spent in locating and bringing the lift
to the bedside. Convenient storage and adequate numbers
How does lifting equipment benefit nursing home residents? of mechanical lifts greatly reduce the time required to move
Although some residents may be reluctant to try new lifting a resident and increase staff adherence to the program.
devices, the use of mechanical lifting equipment increases Ceiling-mounted lifts address the concern of bringing the lift
a resident’s comfort and feelings of security when to the bedside because they are conveniently stored in the
compared to manual methods.7 The findings from one study resident’s room.
70 Healthy Skin 70 Healthy Skin

How can nursing home management motivate staff to

use lifting equipment initially and maintain long-term
commitment?
• Provide sufficient training on lift usage so that
caregivers learn how to properly operate the
equipment. Training should be provided to all newly
hired caregivers, and a plan should be in place to
assess competency in use of the equipment at
least annually.
• Post a graph to show caregivers the decrease in
injuries after the lifts are being used routinely.
• Do not permit manual lifting except in
life-threatening circumstances.
• Include caregivers and residents in the selection of
lifting equipment.
• Allow caregivers the opportunity to work with
different mechanical lifts. Some vendors will allow
equipment to be evaluated on a short-term
trial basis.
• Ask maintenance and housekeeping staff to
provide their opinion and input on the equipment
being considered.
• Ensure that all shifts are covered by an adequate
number of caregivers who have been trained to use
the lifts to help decrease injuries.
• Follow up to check if lifting equipment is being
used properly.
• Keep equipment readily available and accessible.
The number of lifts required will depend on the level
of physical dependency among the residents. As a
general rule, one full-body lift should be provided for
every eight to 10 non-weight bearing residents and
one stand-up lift should be provided for every eight
to 10 partially weight bearing residents.
• Provide back-up battery packs as needed so that
lifts can be used 24 hours per day while batteries
are being recharged.
• Ensure that sufficient slings of the proper size
are available.
• Consider a single-patient-use disposable sling for One full-body lift should be
each resident; reimbursement may also be available.
• Store equipment in a convenient location.
• Implement a routine maintenance program to
ensure equipment is kept in good working order.
provided for every to 8 10
non-weight bearing residents
The maintenance program should include tag-out
and repair procedures for broken equipment.
• Provide training to a knowledgeable person with
enthusiasm and leadership capabilities on each shift
to serve as a peer safety leader. A peer safety
leader can provide education, bedside assessments
and training/re-training on lifting equipment.

What kind of training is necessary to ensure all caregivers What approaches promote the effective implementation of a
are prepared to use lifting equipment? safe resident lifting program?
Training should focus on how to use the lifting equipment for It is important to include caregivers and staff from all depart-
residents with a range of physical limitations and should ments in the program development. Keeping the staff trained
include hands-on practice. Caregivers should be required to and competent in the use of the mechanical lifting equipment
demonstrate that they are proficient in the use of the lifting is a key component of a successful program. Lack of com-
equipment for residents with a range of disabilities. Training is pliance may result if newly hired employees do not know how
generally provided by the lifting equipment manufacturer to use the equipment.
when equipment is purchased; however, a member of the
care giving staff and/or peer safety leaders should be trained Adapted from “Safe Lifting and Movement of Nursing Home
in all aspects of lifting equipment usage and should be pre- Residents,” Department of Health and Human Services.
pared to provide periodic refresher training to newly hired and
existing staff.
Is it helpful to have a written resident lifting policy?

Yes. A written policy establishes:
• Manual lifting is unsafe for residents and staff and is
not permitted
• Minimum standards for the lifting program
• The transferring needs of each resident are assessed
and reassessed as a resident’s transferring needs change
• The amount of lifting equipment required
• Requirements to select appropriate lifting methods
• Training requirements for caregivers
• Responsibilities for all caregivers
What if a resident refuses to be lifted by a mechanical lift?

References
Upon admission, explain to incoming residents that your
1. U.S. Department of Labor Bureau of Labor Statistics. Total Recordable Occupa-
facility has a policy requiring the use of a mechanical lift for tional Injury Cases in Nursing and Residential Care Facilities. 2003. Available at
non-weight bearing residents. It should be explained that the http://www.bls.gov/data/home.htm. Accessed January 14, 2011.
2. U.S. Department of Labor, Bureau of Labor Statistics. February 2004. Monthly
lift is for the safety of the resident and the caregiver. If care- Labor Review, Table 4 – Occupations with the largest job growth, 2002-2012.
givers are injured, it will compromise the nursing home’s abil- Available at: http://www.bls.gov/data/home.htm, http://www.bls.gov/emp.
Accessed January 14, 2011.
ity to provide quality care. If a resident refuses to be lifted with
3. Collins JW, Wolf L, Bell J, Evanoff B. An evaluation of a “best practices”
a mechanical lift, the caregiver, therapy staff and the social musculoskeletal injury prevention program in nursing homes. Injury Prevention.
worker should spend extra time with the resident to secure 2004; 10(4):206-211.
4. Tiesman H, Nelson A, Charney W, Siddharthan K, Fragala G. effectiveness of a
their trust and to help them understand that the lifts increase ceiling-mounted patient lift system in reducing occupational injuries in long term
resident and staff safety. care. Journal of Healthcare Safety. 2003; 1(1):34-40.
5. Nelson A, Fragala G, Menzel N. Myths and facts about back injuries in nursing.
American Journal of Nursing. 2003; 103(2):32-40.
The social worker, administrator, nurse manager or therapy 6. Nelson A, Matz M, Chen F, Siddharthan K, Lloyd J, and Fragala G. Research
staff can intervene with the resident’s family by explaining the report: a multifaceted ergonomics program to prevent injuries associated with
patient handling tasks in the VHA. Occupational Safety and Health Administration
benefits of lifts for the resident and the caregivers. Offer to website.
demonstrate the lift using a family member and explain that 7. Zhuang Z, Stobbe TJ, Collins JW, Hsiao H, Hobbs G. Psychophysical assessment
of assistive devices for transferring patients/residents. Applied Ergonomics. 2000;
the use of the lift will not compromise the resident’s dignity.
31(1):35-44.
Furthermore, the resident’s comfort and security may be 8. Garg A. Long-term effectiveness of “zero-lift program” in seven nursing homes
improved, while reducing the risk of injury. and one hospital, Contract No. U60/CCU512089-02. 1999.
72 Healthy Skin
“ Oh
Yeah!
Learning opportunities for
“
CNAs at Medline University
Online CNA courses available at

www.medlineuniversity.com.
Visit today to learn more about:

• Hand hygiene
• Incontinence
• Skin care
• Long-term care
• Pressure ulcers
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Ventilator-associated pneumonia (VAP)

is a hospital-acquired infection that occurs in up
to 27 percent of all mechanically ventilated
patients. 1 It is specifically defined as an airway
infection that develops more than 48 hours after a
patient is intubated.2
Among ICU patients, nearly 90 percent of episodes

of hospital-acquired pneumonia occur during
mechanical ventilation.1 Because half of all episodes
of VAP occur within the first four days of mechani-
cal ventilation, it is especially critical to prevent the
condition all together.1 Reducing mortality due to
ventilator-associated pneumonia requires an
organized process that guarantees early recognition
Five Step of pneumonia and consistent application of

evidence-based practices.2
The Institute for Healthcare Improvement (IHI)

advocates use of a bundle approach to help fight
Approach VAP. The ventilator bundle is a series of interventions

related to ventilator care that, when implemented
together, achieves significantly better outcomes.2
The five components of the (IHI) Ventilator
for Avoiding Bundle are:2

1. Elevating the head of the bed 30 degrees
2. Daily “sedation vacations” and assessment
of readiness to extubate
VAP
3. Peptic ulcer disease prophylaxis
4. Deep vein thrombosis prophylaxis
5. Daily oral care with chlorhexidine
References
1. Kollef MH. What is ventilator-associated pneumonia and why is it
important? Respiratory Care. 2005;50(6):714-724. Available at:
www.rcjournal.com/contents/06.05/06.05.0714.pdf. Accessed
November 4, 2010.
2. Implement the Ventilator Bundle. Institute for Healthcare
Improvement (IHI) website. Available at: www.ihi.org/IHI/Topics/Criti-
calCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm.
Accessed November 4, 2010.
74 Healthy Skin
Prevention
Tips for Complying with the

VAP Prevention Bundle
1. Elevating the Head of the Bed 30 Degrees 3. Peptic Ulcer Disease Prophylaxis
• Implement a mechanism to ensure head-of-the-bed • Include peptic ulcer disease prophylaxis as part of
elevation, such as including this intervention on your ICU order admission set and ventilator order
nursing flow sheets and as a topic at set. Make application of prophylaxis the default
multidisciplinary rounds. value on the form.
• Create an environment where respiratory therapists • Include peptic ulcer disease prophylaxis as an item
work collaboratively with nursing to maintain for discussion on daily multidisciplinary rounds.
head-of-the-bed elevation. • Empower pharmacy to review orders for ICU
• Involve families in the process by educating them patients to ensure that some form of peptic ulcer
about the importance of head-of-the-bed elevation disease prophylaxis is in place at all times.
and encourage them to notify clinical personnel
when the bed does not appear to be in the 4. Deep Venous Thrombosis Prophylaxis
proper position. • Include deep venous prophylaxis as part of your
• Use visual cues to easily identify when the bed is ICU order admission set and ventilator order set.
in the proper position. Make application of prophylaxis the default value
• Include this intervention on order sets for initiation on the form.
and weaning of mechanical ventilation, delivery of • Include deep venous prophylaxis as an item for
tube feedings, and provision of oral care. discussion on daily multidisciplinary rounds.
• Empower pharmacy to review orders for ICU
2. Daily “Sedation Vacations” and Assessment patients to ensure that some form of deep venous
of Readiness to Extubate prophylaxis is in place at all times.
• Implement a protocol to lighten sedation daily at
an appropriate time to assess for neurological 5. Daily Oral Care with Chlorhexidine
readiness to extubate. Include precautions to • Educate registered nurses (RNs) about the rationale
prevent self-extubation such as increased supporting good oral hygiene and its potential
monitoring and vigilance during the trial. benefit in reducing ventilator-associated pneumonia.
• Include a “sedation vacation” strategy in your overall • Develop a comprehensive oral care process that
plan to wean the patient from the ventilator; if you includes the use of 0.12% chlorhexidine oral rinse.
have a weaning protocol, add “sedation vacation” • Schedule chlorhexidine as a medication, which then
to that strategy. provides a reminder for the RN and triggers oral
• Assess that compliance daily during care process delivery.
multidisciplinary rounds.
Source: www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/Implement-
• Consider implementation of a sedation scale
theVentilatorBundle.htm
(e.g., the Riker Scale) to avoid oversedation.

Ventilator-Associated Pneumonia
can be deadly.
VAPrevent can be easy.
Convenient,
space-saving
packaging
VAPrevent
follows IHI
Ventilator Bundle
guidelines. With
this checklist,
you can too.
Sequential dispensing
system and thumb grip for
easy, one-at-a-time access
— in the right order
Evidence-based innovation in oral care for ventilator patients
VAPrevent is a comprehensive system to give your staff the tools to deliver excellent oral
care. And for ventilator patients, excellent oral care may be part of the difference between
ventilator-associated pneumonia and staying healthy.
The three parts of the VAPrevent program you’ll want to know:
Product
Only Medline gives you these three options for oral care: IHI-recommended
chlorhexidine gluconate (CHG), the alcohol-free moisturizing of Biotene®,
or the proven antisepsis of hydrogen peroxide. Procedure kits feature
innovative components, like graduated suction catheters and toothbrushes
with integrated gum and tongue scrubbers. Breakthrough package design
communicates and educates, all while leaving less waste behind. And the
intuitive stack-pack design with its one-at-a-time dispenser makes it easy
for caregivers to stay on track with care protocols.
Clear visuals let

you identify the
right kit quickly
for your patient’s
needs
Program
When your staff knows how to use a product appropriately, its effectiveness
increases greatly. That’s why Medline developed the Medline VAP program,
which helps build knowledge and clinical skills with educational modules
for both novice and experienced clinicians, as well as an online interactive
competency for oral care. A program manager helps you implement your
program and stays active as you progress, providing 90-day reports to
help you track your incidence of VAP.
Price
If you expected a VAP program this innovative would come at a price
premium, you’re in for a pleasant surprise. VAPrevent from Medline
comes to you for five to ten percent lower than competitors. In a tough,
pay-for-performance environment, VAPrevent represents a major value.
To schedule your evaluation of the VAPrevent System,

contact your Medline representative or call
1-800-MEDLINE (633-5463).
References
1 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probability
of ventilator-associated pneumonia. Nursing Research. 2010; 59(1): S40-S47.
2 Trouillet J, Chastre J, Vuagnat A, Joly-Guillou M, Combaux D, Dombret M, et al. Ventilator-associated
pneumonia cased by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998. 157(2):531-539.
78 Healthy Skin
Caring for Yourself
8 Principles
For Achieving Inner Peace
by Wolf J. Rinke, PhD, RD, CSP
Travel alerts, seemingly never ending natural and manmade 2. Think empowering thoughts
disasters, cranky patients bugging you…stress accelerat- As a man thinkest, so he becomes, says
ing at logarithmic speed! We certainly live in a very unsettling the Bible. And yet most of the time we
and stressful time. A time where achieving inner piece are totally inattentive to our thoughts.
seems totally out of reach. And yet I have found that you It’s almost like they run amok—totally
can attain it by relentlessly practicing the eight principles out of control—doing their own thing. To
that follow. achieve inner peace requires us to first
become aware of our thoughts—instead
1. Be honest of just letting them ruminate at the sub-
BP, politicians, clergy … do I need to conscious level. Second we must ask ourselves: is this a
say more? But before you get too smug, thought that empowers me and makes me stronger, or does
better look at the face in the mirror. it make me feel mad, bad or sad? And third we must be-
Study after study has shown that most come aware that at any one nanosecond our minds can
people lie. We inflate our resumes, hold only one thought. It can be a positive thought that gives
fudge our accomplishments and exag- us inner peace and improves our quality of life, or it can be
gerate even inconsequential events. a negative thought that does just the opposite. It’s so sim-
And when we lie there is no trust, and ple, yet difficult, to develop this powerful new awareness
without trust you can’t have solid relationships, without and transform it into a habit.
relationships there is no love, and without love you won’t
have inner peace. Call me old-fashioned; I believe there is 3. Take advantage of the
no excuse for lying … none. There is not even a good rea- abundance all around you
son for exaggerating. Because if you do, you will have to When we are struggling and having trou-
talk from the head, always checking your memory to make ble making ends meet, it is really difficult
sure you are consistent. And who can keep track of that, to see the abundance. What we see
when most of us have trouble remembering where we put instead—almost oppressively—is scarcity.
our car keys. Only by getting in the habit of always telling I know firsthand. Having been born right
the truth—especially if it is at your own expense—will you be after World War II in Germany, with my
able to talk form the heart and that will set you free. This in parents losing all their earthly posses-
turn will enhance your leadership skills because people sions—yes, everything—we had less than scarcity, we had
follow people they can trust. And it will put you on the fast desperation. Finding enough food and shelter to keep us
track in any endeavor. It will also enrich your personal rela- alive is what consumed my parents. Then some 17 years
tionships and, most importantly, will get you to like and later—when I immigrated to the United States—scarcity,
respect yourself—the foundation for achieving inner peace. although not as extreme, reared its ugly head again. Basi-

8 Principles For Achieving Inner Peace
cally I only spoke a few words of English, had $20 in my pocket So begin right now to become your own best friend, because if
and the proverbial shirt on my back. And I certainly had trouble it is not you, who is it going to be? In addition to taking really
finding all “the milk and honey” that supposedly was just wait- great care of your thoughts, also take extraordinary care of your
ing for me. However, it was all around me, and over time body. And if you want to avoid psychosomatic illnesses—which,
I learned to find it by internalizing a powerful concept that I as you probably know, account for the majority of illnesses in
learned from several different mentors: If you want more of this country—then you must eat right—which means you learn
something, you have to give it first. I know it sounds counterin- to stop when it tastes the best. Get adequate rest—seven to
tuitive. (By the way, lots of things are…otherwise men would eight hours of sleep is a great start—and do 25-30 minutes of
ride sidesaddle. If that didn’t at least make you smile, you’re aerobic exercise three times per week, alternating with strength
taking this much too seriously.) Here is how it works: If you want training for the other three days. (Go ahead and take Sunday
more love in your life, give more love. If you want to be happier, off.) It also means that you don’t put stuff into your body that
make others happy. If you want people to trust you, give does not belong there—read drugs and nicotine. (Please don’t
unconditional trust. Of course the only way you can take yawn. This is important. You only will be given one body—a the
advantage of this principle is to internalize the next one. one you’ve got is it. So treat it accordingly.)
4. Take really great care of #1 first 5. Become your own creator

Gotcha! Especially if you are a cynic. Those Movie directors, such as James
who are cynics immediately translate this Cameron of Avatar, are geniuses at cre-
into selfishness, conceit and greed. Nothing; ating exciting “realities.” You can be your
however, could be further from the truth. own “creator” once you realize that there is
(Why do you suppose that in an emergency, no reality. There is only perception. (No, I
you are told to put your oxygen mask on haven’t lost it.) Let me explain with a won-
first, before you help anyone else, even your derful story: A young man was interviewing
own child?) for his dream job. He had done his home-
work. He spent hours on the Internet learning all he could about
It’s also important to remember that you can’t give away what the hospital of his choice and the people he was going to be
you don’t own. Going back to the previous paragraph. If you interviewing with. He had read the last three annual reports and
want to love someone you must first love yourself, if you want knew the hospital’s mission, vision and core values by heart.
to be happier you must choose to be happy. It you want to trust In short he was ready to ace this interview. On the big day, he
someone…I’m sure by now you’re catching on. entered the impressive lobby of the hospital and had to check
in with the security guard to get his visitor badge. Wanting to
Achieving inner peace requires you to begin to love who you leave no stone unturned he said to the elderly gentleman behind
are, not who you ought to be…by someone else’s standard, the desk, “Sir, I’m interviewing for my dream job today. Tell me
whether that’s your parents, spouse or friend. The unvarnished about the people at this hospital. What are they like?”
fact is that at this very nanosecond you are who you are. And The elderly man replied with a question. “Tell me young man,
no wishing, hoping or praying is going to change that one iota. what were the people like at the last hospital you worked for?”
Now, who you will become in the future will be determined by “Oh, they were deceitful, unsupportive and mean. There simply
your thoughts (see Principle #2), which in turn will drive the was no vestige of teamwork or joy. In fact that’s why I left.”
actions you take. “Well,” the security guard answered, “I believe you will find the
same kind of people here.”
80 Healthy Skin
Just about an hour later the scene repeated itself all over again. us. And then, we wonder why our life stinks. Part of what we
Except this time it was a young lady who was also interviewing carry around in our bag is resentment, hate and blame. All of
for the same job. She, too, had done her homework and these emotions will attack our souls and diminish the quality of
wanted to make a great impression. She also asked the secu- our spirit and our physiology.
rity guard, “What are the people like around here?”
In turn, he asked, “What were they like where you came from?” Instead, go ahead pay tribute to your past. Visit it. And then
The vivacious young lady answered, “Oh, I just loved the people toss it in the trash. You can make that happen by taking own-
at my former hospital. They were kind, supportive and hard- ership of all that is going on in your life. Your life is not a func-
working. Everyone worked together as a team. We cared so tion of what other people have done to you; it is today what it
much for each other that I developed some of the best friend- is because of the choices you have made in the past. And if
ships. It’s really a shame that my husband is relocating to this your feelings of resentment, hate and blame are attributed to
area. I just hate to leave all those wonderful people behind.” the actions of others, then you have to wait for those people to
“Well,” the wise elderly man answered, “I believe you will find change—which may never happen. And don’t even try to
the same kind of people here.” change them! Think about how many of us have difficulty
changing ourselves, let alone others. Instead live by the axiom:
6. Let go of the past If it is to be it is up to me. Once you’ve done that, you are ready
It’s amazing how much we mental energy to take it to the next level by substituting the emotions of love,
we spend in a place over which we have empathy and kindness for resentment, hate and blame, which
absolutely no control—the past. It was Dr. will put you on the fast track to inner peace.
Wayne Dyer who likened our past to a bag
of manure that we carry around with us. We And while you are at it, force yourself to get off your case, quit
keep putting more and more manure into living in the past, and become future-oriented by learning from
the bag. Once in a while we put the bag every action. If an action gives you the results you desired, keep
down, reach in and smear manure all over doing it. If the action did not accomplish the intended result,

8 Principles For Achieving Inner Peace
review what happened; make a commitment to do it differently 8. Never give up on your dreams
in the future, then quit doing it and let it go. No wait, I mean The purpose of life is not to make it safely to
really let it go. Get on with your life by refocusing your thoughts the grave. Pursue your dreams no matter
on the only moment you and I have any control over, the now. how late or how “weird.” Let me share an
example. Doris Haddock had a passion. She
7. Kill your ego felt that Congress needed to get off their
Ego, right along with greed and envy, is one duff and change the campaign finance
of the most powerful destroyers of inner laws! Unlike most of us; however, Doris did
peace. A look at history confirms that these not sit around and complain and whine.
emotions are responsible for more evil. Instead, Doris started to walk from
Think Napoleon, Stalin and Hitler—and more Pasadena, Calif.; walking 10 miles a day, every day. Fourteen
corporate catastrophes. Think Toyota’s and months and 3,200 miles later she arrived in Washington, DC.
even venerable Johnson & Johnson’s recent Now, here comes the startling part of the story. Doris, better
recalls—as well as relationship killers. And known as Granny D, had a severe case of arthritis, wore a brace
yet we can get rid of our ego with just five and turned 90 years “young” while on the trail. And for an added
powerful phrases expressed liberally and from the heart: measure, she was arrested twice demonstrating for her beliefs.
• You are right about that. Any time you get into a conflict, Why? Because she had a dream and a passion. So whatever
use this phrase and you will have no more conflict— you do, don’t ever give up on your dreams, it’ll make you
guaranteed! cranky. Instead, get off your butt and act on your dreams today,
• I’ve made a mistake. This phrase helps you get off your and you, too, will be on the road to achieving the most coveted
high horse gracefully. All human beings make mistakes— of all possessions—inner peace.
and since you are a…I think you get it. There is only one
omnipotent force in the universe—and it is not you. So © 2011 Wolf J. Rinke
quit defining unrealistic expectations for yourself.
• I changed my mind. You are an evolving human being,
one who is like red wine and gets better all the time. That Dr. Wolf J. Rinke, RD, CSP is a keynote
means you have to let go of your past beliefs. (Remember speaker, seminar leader, management con-
that the only person who can change his/her mind is the sultant, executive coach and editor of the free
electronic newsletter Read and Grow Rich,
one who has one.)
available at www.easyCPEcredits.com. In
• I don’t know. Admit it. You don’t know everything. It lets
addition he has authored numerous CDs,
other people know that you have high levels of self-esteem.
DVDs and books including Make It a Winning
(Only people who are OK inside of their own skin can admit Life: Success Strategies for Life, Love and
they don’t know everything.) Business, Winning Management: 6 Fail-Safe
• Let’s agree to disagree. The phrase to use if all else fails. Strategies for Building High-Performance Organizations and Don’t
By the way, do try all five of these at home; the positive Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve
results will astound you. Your Leadership Effectiveness; available at www.WolfRinke.com.
His company also produces a wide variety of quality pre-approved
continuing professional education (CPE) self-study courses, avail-
able at www.easyCPEcredits.com, including his Beat the Blues:
How to Manage Stress and Balance Your Life, approved for 28
CPEUs, from which this article was extracted. Reach him at
WolfRinke@aol.com.
82 Healthy Skin
Special Feature
PGD2
Pink Glove Dance: The Sequel
From Halifax, Novia Scotia to San Francisco, Califor- Pink Gloves for a Cause
nia, Medline traveled across North America in 2010 Our goal is to create a Pink Glove Nation – that is, get
showcasing the spirit of breast cancer survivors and as many people as possible talking about breast can-
caregivers who performed in the Pink Glove Dance: cer and to raise awareness for early detection. To that
The Sequel. To see videos of Pink Glove Dancers in end, medline donates partial proceeds from our pink
action visit www.pinkglovedance.com. gloves and other pink ribbon products to the National
Breast Cancer Foundation (NBCF) to help fund mam-
Thank you, Pink Glove Dancers, for welcoming us to mograms for women who cannot afford them.
your city!
• New York, NY • La Jolla, CA
• Chicago, IL • Portland, OR
• San Francisco, CA • New Orleans, LA
• Indianapolis, IN • Denver, CO
• Minneapolis, MN • Halifax, Novia Scotia
• Richmond, VA • Plano, TX
• Tallahassee, FL • Baltimore, MD
• Newark, NJ

Pink Glove Dance: The Sequel
San Francisco Survivors at the Golden Gate Bridge. San Francisco, CA
Providence St. Vincent Medical Center. Portland, OR
University of Minnesota Medical Center, Fairview. Minneapolis, MN
84 Healthy Skin
Thibodaux Regional Medical Center. Thibodaux, LA
Burgess Square Healthcare and Rehab Centre. Westmont, IL
Isabella Geriatric Centre. New York, NY

New York City Survivors at Times Square. New York, NY
Capital Health. Halifax, Nova Scotia
DID YOU
KNOW?
Medline has donated over half
a million dollars to the National
Breast Cancer Foundation (NCBF)
since 2005.
Providence St. Vincent

Medical Center. Portland, OR
86 Healthy Skin
And the winning pink glove ad is…

Yes, They’re Genuine.
Only Medline’s Pink Pearl™ gloves combine
aloe, nitrile and breast cancer awareness.
Precious. And Pink. only wear Pink Pearls.
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.

Medline is a registered trademark
and Pink Pearl is a trademark of
Only Medline’s Pink Pearl™ gloves combine Medline Industries, Inc.
©2010 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl ©2010 Medline Industries, Inc. Medline is a registered trademark and Pink
is a trademark of Medline Industries, Inc. Pearl is a trademark of Medline Industries, Inc.
The results are in!

We’ve tallied your votes and compiled your thoughts about Medline’s pink gloves
and the Pink Glove Dance. Thank you for your heartfelt comments and participation
in last issue’s survey.
Turn the page to find the winner!

59% Voted for Pearls!

Yes, They’re Genuine.
Only Medline’s Pink Pearl™ gloves combine

Medline is a registered trademark
and Pink Pearl is a trademark of
Medline Industries, Inc.
88 Healthy Skin
Pink glove survey
A
What our readers said:
It means unity, joy, excitement, a cause
“on the go” for all involved.
Shannon Sessoms, RN, BSN, CNOR
Southeast Missouri Hospital
Cape Girardeau, MO
The Pink Glove Dance shows how

teamwork is effective whether it’s a family
team or a team that helps patients with
their journey.
Q
Christina Zoltowski, RN
Greenville Memorial Hospital
Greenville, NC
I thought it was excellent – tears to

my eyes.
Steve Hoffarth
Lake Regional Healthcare Corp.
What does the Fergus Falls, MN
Pink Glove Dance It is a fun but touching video that shows

the true concern healthcare workers have
mean to you? for people with breast cancer.
Holly Creel, RN
The Kirklin Clinic
Warrior, AL

What does the Pink Glove Dance mean to you?
Bay Radiology Associates, Panama City, FL.

Pictured, left to right. Front row: Virginia Dunn,
Kristie Willoughby, Janice Skipper, Linda Pitts.
Back row: Marian Hamilton, Janice Mulligan,
Dr. James Strohmenger, Rhonda Miller,
Jennifer Valle.
Those with cancer are not alone.

We together will beat breast cancer.
We are out there standing beside
We are not alone.
them and showing our support.
Cory Pritchett, RNC, ADON
Mallard Bay Care Kathleen Ingraham
Cambridge, MD FirstHealth Moore Regional Hospital
Pinehurst, NC
It is inspirational! People from all different walks of life

R. Peter Rossi, RN, BS
coming together for a common cause
Halifax Regional Medical Center
Roanoke Rapids, NC – fighting breast cancer.
Sue Montgomery, RN
Foothill Presbyterian Hospital
It shows how caring healthcare workers
Glendora, CA
of ALL types are towards supporting
the cause!
Helen Aylward, RN, BSN, L.Ac.
Maine Medical Center
Portland, ME
It made me cry to see the teamwork that

went into making it. I’m a breast cancer
survivor.
Carolyn Meyer, RN, BSN, CNOR
St. John Medical Center
Bartlesville, OK
The Breast Health Center at Excela Health Westmoreland,

I believe that it shows we are all in Greensburg, PA.
Pictured, left to right. Front row: Joleen Brewer, Linda White.
this together. Middle row: Candy Suarez, Nancy Pavlik, Shirley Coulson.
Benna Coleman Back row: Michelle Kelley, Cindy Clair, Margaret Clark, MD,
Covenant Hospital Levelland Sue Cholock, Karen Smith.
Levelland, TX
90 Healthy Skin
The dance demonstrates the joy of

living while increasing awareness Lorien Health Systems
about breast cancer. Maryland
Paula Bishop, RN, MSN, CNOR
Aultman Hospital Nursing care staff members boogie
Canal Fulton, OH to the beat during the filming of the
Pink Glove Dance: The Sequel.
A hospital works as a unified unit to
complete its mission.
Colleen Witt, RN BSN
Roswell Park Cancer Institute
Buffalo, NY
People getting involved to bring

awareness to breast cancer.
Darlene McCraney, RN
South Central Regional Medical Center
Laurel, MS
It energizes you and makes you want to

move, especially when you see everyone
working toward the same goals.
Jerlene McClain, RN, BSN, MHR, CNOR
Reynolds Army Community Hospital - Fort Sill
Lawton, OK
Wonderful healthcare providers, not

professional dancers, working hard
to spread the word about breast
cancer awareness.
Mary Valley, RN, CNOR
Frisbie Memorial Hospital
Rochester, NH
Joy for cancer survivors and hope

for more.
Carol Athey, RN, MSN, CNOR
Woodland Heights Medical Center
Lufkin, TX
It makes me smile.
Debra Ann Caise, RN, BSN
Provena St. Mary’s Hospital
St. Anne, IL

Healthy Eating
Nutrition
Information
Servings: 6
Calories: 749
Fat: 19.5 g
Sodium: 1427 mg
Crock Pot Chili Fiber: 21.8 g
1 lb. lean ground beef 1 green pepper, chopped 1 15-ounce can kidney beans
1 lb. lean ground turkey 4 teaspoons minced garlic 1 15-ounce can spicy chili beans
4 teaspoons chili powder 1 16-ounce can tomato sauce 1 bottle beer
1 teaspoon ground cumin 1 16-ounce can diced tomatoes 1 teaspoon black pepper (or to taste)
1 large onion, chopped 1 15-ounce can chili with beans Hot sauce to taste
2 jalapeno peppers, chopped 1 6-ounce can tomato paste
Directions: recipe in Medline’s 2010 Chili Cookoff. She offers product

Place ground beef and ground turkey in a large skillet, along with expertise for Medline customers, sales representatives and cus-
1 teaspoon chili powder and 1 tsp. ground cumin. Cook until tomer service reps in the areas of diabetic testing, diagnostics,
crumbled and brown. Drain and place in crock pot. sharps containers, over-the-counter medications, enterals, oral
care, ReadyBath and wet wipes.
Spray empty skillet with cooking spray. Saute onion, garlic,
jalapenos and green pepper until tender. Place in crock pot. Add Jennifer originally found her chili recipe in one of her husband’s
tomato sauce, diced tomatoes, beer, chili with beans and fitness magazines, and they have tweaked it a little over the
tomato paste. Simmer 20 minutes on high setting. years to get it just right.
Add kidney beans, chili beans, 3 teaspoons chili powder, pepper “It’s a healthier chili recipe, made with lean meat,” she said. You’ll
and hot sauce and simmer at least 30 minutes. also notice that the onions and peppers are sautéed with cooking
spray rather than oil.
“I find the longer it simmers, the better the
taste, so after the last round of ingredients Jennifer has always enjoyed cooking, having learned by watching
are added, I let it simmer on low for 6 to 8 her mother from the age of six. Her favorite meals include
hours,” Jennifer said. seafood with lots of butter and garlic.
Senior Product Specialist Jennifer In addition to cooking, Jennifer, who lives on Illinois’ Chain
Sutschek, who has worked Medline’s O’Lakes with her husband and two children, enjoys water
corporate headquarters in Mundelein, Ill. sports, such as boating, and in the winter months, she
since 1998, won second place for this enjoys snowmobiling and skiing.
92 Healthy Skin
FORMS & TOOLS
The following pages contain

practical tools for implementing
patient-focused care practices
at your facility.
Hand Hygiene
WHO Glove Pyramid……………………………………….94
WHO Exam Glove Technique……………………………..95
CDC Clean Hands Poster………………………………… 96
CDC Clean Hands Poster – Spanish……………………. 97
Incontinence
Urinary Incontinence Assessment
and Implementation………………………………………. .99
Pressure Ulcers
How Well Do You Know Pressure Points?..................... 101

Forms & Tools WHO Glove Pyramid
The Glove Pyramid – to aid decision making

on when to wear (and not wear) gloves
Gloves must be worn according to STANDARD and CONTACT
PRECAUTIONS. The pyramid details some clinical examples in
which gloves are not indicated, and others in which examination or
sterile gloves are indicated. Hand hygiene should be performed when
appropriate regardless of indications for glove use.
STERILE
GLOVES
INDICATED
Any surgical procedure;
vaginal delivery; invasive
radiological procedures;
performing vascular access
and procedures (central lines);
preparing total parental nutrition
and chemotherapeutic agents.
EXAMINATION GLOVES
INDICATED IN CLINICAL SITUATIONS
Potential for touching blood, body fluids, secretions,
excretions and items visibly soiled by body fluids.
DIRECT PATIENT EXPOSURE: Contact with blood; contact with
mucous membrane and with non-intact skin; potential presence of
highly infectious and dangerous organism; epidemic or emergency
situations; IV insertion and removal; drawing blood; discontinuation
of venous line; pelvic and vaginal examination; suctioning non-closed
systems of endotrcheal tubes.
INDIRECT PATIENT EXPOSURE: Emptying emesis basins; handling/cleaning
instruments; handling waste; cleaning up spills of body fluids.
GLOVES NOT INDICATED (except for CONTACT precautions)

No potential for exposure to blood or body fluids, or contaminated environment
DIRECT PATIENT EXPOSURE: Taking blood pressure, temperature and pulse; performing SC
and IM injections; bathing and dressing the patient; transporting patient; caring for eyes and ears
(without secretions); any vascular line manipulation in absence of blood leakage.
INDIRECT PATIENT EXPOSURE: Using the telephone; writing in the patient chart; giving oral medications;
distributing or collecting patinet dietary trays; removing and replacing linen for patient bed; placing non-invasive
ventilation equipment and oxygen cannula; moving patient furniture.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published
material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with
the reader. In no event shall the World Health Organization be liable for damages arising from its use.
94 Healthy Skin
WHO Exam Glove Technique Forms & Tools

Technique for donning and removing
non-sterile examination gloves

96 Healthy Skin
CLEAN HANDS SAVE LIVES
Forms & Tools
DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION
Protect patients, protect yourself
Candida
Staphylococcus
Influenza
RSV
Hand Hygiene Poster
Klebsiella Pseudomonas
Enterococcus
Alcohol-rub or wash
before and after EVERY contact.
www.cdc.gov/handhygiene
LAS MANOS LIMPIAS SALVAN VIDAS
Departamento de Salud y Servicios Humanos
CENTERS FOR DISEASE CONTROL AND PREVENTION
Proteja a los pacientes, protéjase usted
Gripe
Estafilococo
Candida
VSR
Klebsiella Pseudomonas
Hand Hygiene Poster - Spanish
Enterococo
Lávese o frótese con alcohol
antes y después de CADA contacto.
Forms & Tools

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.

Urinary Continence Assessment and Implementation Forms & Tools
Resident ______________________________________________ Room #___________
Assessed by _______________________________________________________________ Date: ___________________

Current Product Information: Size: ______ Type: ________ Frequency of Leakage: ________ times/week None
1. Determine Type of Incontinence See Tab 2 (Survey Readiness Resource Book)
Resident is continent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y proceed to section 2

Do you leak when you cough, sneeze, exercise, laugh? . . . . . . . . . . . . . N Y stress
QUESTIONS
Do you need to rush suddenly to toilet? . . . . . . . . . . . . . . . . . . . . . . . . . N Y urge

Do you sometimes not make it to the toilet? . . . . . . . . . . . . . . . . . . . . . . N Y urge
Do you urinate more than 7 times/day or 2 times/night? . . . . . . . . . . . . N Y urge
Do you have a weak stream of urine? . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y overflow
Do you have frequent dribbling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y overflow
Do you have burning or blood in urine? . . . . . . . . . . . . . . . . . . . . . . . . . N Y transient
Is the incontinence related to something other than urinary tract,
functional
CHART
such as inability to undo a zipper? . . . . . . . . . . . . . . . . . . . . . . . . . . N Y

Does the resident have a postvoid residual greater than 200 cc? . . . . . . N Y overflow
Does the resident take stool softeners, antipsychotic, anticholergenic,
narcotic analgesics, or other drugs that may affect continence? . . . . N Y further evaluation may be necessary
Female
Is there presence of pelvic prolapse or other abnormal finding? . . . . . . . N Y stress
Is the vaginal wall reddened and/or thin? . . . . . . . . . . . . . . . . . . . . . . . . N Y transient
PHYSICAL
Is there abnormal discharge? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y transient

Male
Is the foreskin abnormal (difficult to draw back, reddened)? . . . . . . . . . . . N Y transient
Is there drainage from the penis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y transient
Is the urethral meatus obstructed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y overflow
Select (circle) the type of incontinence that most fits the resident based on answers above:
Urge Stress Mixed Overflow Functional Transient
Sudden urge, large Leakage when Combination of Weak stream, Unable to get to Temporary or
amounts, can’t get coughing, standing urge and stress dribbling, toilet without recent onset,
to toilet in time up, sneezing symptoms incomplete voiding assistance (mobility) variety of causes
2. Determine Resident’s Voiding Pattern See Tab 3 (Survey Readiness Resource Book)
Every resident should have a completed voiding diary upon admission and with significant changes in condition.
Voiding diary scheduled (date) ________________________ Date completed _______________________ Initials__________
Did the resident have a pattern? _______ For pattern, see voiding diary.
3. Evaluate for Behavioral Program See Tab 4 (Survey Readiness Resource Book)
What is the MDS coding for item B0800 (Ability to understand others)?
If 0, 1 If 2, 3
Consider MDS coding on G0110, 1-I Scheduled Voiding
(self performance/toileting)
Residents with the following conditions could still benefit from
participating in a prompted or scheduled voiding program:
If 0, 1, 2 If 3, 4 • Those who cannot feel “urge” to urinate
• Agitated or disoriented residents
Bladder Rehabilitation or Prompted Voiding
• Bedridden residents or those with mobility limitations
Pelvic Floor Rehab
Based on above, the resident may be a candidate for _______________________________________________________________________________

Resident is not a candidate for a bladder program due to: Use of appliances No bowel or bladder pattern Other ______________________

Forms & Tools Urinary Continence Assessment and Implementation
4. Determine Appropriate Absorbent Product See Tab 5 (Survey Readiness Resource Book)
Minimum Data Set (MDS) Version 3.0 — Section H 0300 & 0400, Bladder and Bowel
0 1 2 3
Always Continent Occasionally Incontinent Frequently Incontinent Always Incontinent
H0300 & H0400 Bladder—less than 7 episodes Bladder—7+ episodes, at least Bladder—No episodes of
of incontinence 1 episode of continence continent voiding
Bowel—1 episode of Bowel—2+ episodes, at least Bowel—No episodes of
incontinence 1 continent bowel movement continent voiding
Ambulatory
Liner Heavy Liner
Weight-bearing Bladder Control Pad:
(females without bowel
incontinence episodes)
Liner
Nonambulatory Adult Brief
Protective Underwear
Contracted Heavy/Overnight Brief
Chronic diarrhea Adult Brief Ultrasorbs Dry Pad
Combative Ultrasorbs Dry Pad (on a low air loss mattress) (on a low air loss mattress)
Low air loss mattress
Daytime selection: _____________________________________ Overnight protection: __________________________________
5. Determine Sizing of Absorbent Product See Tab 6 (Survey Readiness Resource Book)
Determine and document the size by selecting the larger of the hip or waist measurement,
or use sizing matrix reference based on gender/weight.
Gender: M F Weight ___________________
MOLICARE BRIEF WITH STRETCH BACKING
Hip measurement ________ Waist measurement ________
Small: Blue backing 20" – 34"
ADULT BRIEF Medium/Large: White backing 27" – 47"
Small: Green backing 20" – 31" Large/X-Large: Blue backing 39" – 59"
Medium: White backing 32" – 42"
Regular: Purple backing 40" – 50" KNIT PANTS FOR TWO-PIECE SYSTEMS
Large: Blue backing 48" – 58" Med/Large: Blue/Brown thread at waist 20" – 60"
X-Large: Beige backing 59" – 66" X-Large: Green thread at waist 45" – 70"
XX-Large: Green backing 60" – 69" XX-Large: Purple thread at waist 50" – 75"
Bariatric: Beige or Green backing 65" – 94" XXX-Large: Red thread at waist 65" – 85"
5. Catheterization See Tab 7 (Survey Readiness Resource Book)
Catheter — Type ____________________________________ Size: ____________________________

Medical Justifications
• Urinary retention that cannot be treated medically or surgically, related to:
- Post void residual volume over 200 ml - Persistent overflow incontinence
- Inability to manage retention/incontinence - Symptomatic infections
with intermittent catheterization - Renal dysfunction
• Contamination of stage III or IV pressure ulcers with urine which impeded healing.
• Terminal illness/severe impairments – which makes positing/changing uncomfortable or associated with intractable pain.
100 Healthy Skin

Pressure Point Quiz Forms & Tools
How well do you know

Pressure Points?
Feel free to use this quiz for skill 6
fairs, training and in-services. 7
1
Choose from (some may be used twice)
Dorsal thoracic area
Ear
Elbow
5
Foot 2 4
Greater trochanter 3
Heel
Ischial tuberosity 10
Lateral aspect of foot
Lateral aspect of knee
Lateral malleolus
Medial malleolus
Occiput
Posterior knee 8 12
Ribs 9 11 13
Sacrum/Coccyx
Shoulder
Shoulder blade
1. _____________________ 19
2. _____________________
3. _____________________
14 20
4. _____________________
5. _____________________
6. _____________________
7. _____________________
8. _____________________
9. _____________________
10. _____________________ 15
11. _____________________
12. _____________________
13. _____________________
14. _____________________
15. _____________________ Answer key to
16 quiz on page 103
16. _____________________
17. _____________________
18. _____________________
19. _____________________
20. _____________________
17 18

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- ©2011 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.
JBK_CVR1_Layout 1 2/14/11 9:11 AM Page 2
Join the team!
HEALTHY SKIN Pressure point answers

From page 101
1. Lateral malleolus
2. Lateral aspect of foot
3. Lateral aspect of knee
4. Greater trochanter
5. Ribs
6. Shoulder
7. Ear
8. Occiput
PERIOPERATIVE PRESSURE
9. Ear
ULCER EDUCATION.
10. Elbow
11. Dorsal thoracic area
MORE IMPORTANT
THAN EVER BEFORE
12. Sacrum/Coccyx
13. Heel
When it comes to hot

topics in long-term care,
you’re the experts!
14. Shoulder blade
15. Sacrum/Coccyx
16. Ischial tuberosity
17. Posterior knee
18. Foot
“ 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,
19. Medial malleolus CWS, BCLNC, FAAN
You, our readers, are on the front lines of everything that for writers and contributors. Whether you’d like to try your 20. Lateral malleolus
happens in the healthcare industry – and we want to hear hand at writing or offer suggestions for future articles, we Medline’s Pressure Ulcer Prevention Program now has a
from you! Have you ever wished you could write an want to hear what you have to say! You never know – the component designed specifically for the perioperative services.
article that would be published in a large-circulation next time you open an issue of Healthy Skin, it might be The easy-to-use interactive CD addresses the following:
magazine? Now’s your chance. Healthy Skin is looking to read your own article! • Hospital-acquired conditions
• CMS reimbursement changes
Contact us at healthyskin@medline.com to learn more! • Best practices for pressure ulcer prevention
• Perioperative assessment tools
• Critical patient and equipment risk factors
Content Key
We’ve coded the articles and information in this magazine to indicate which national quality initiatives To learn more about Medline’s Pressure
they pertain to. Throughout the publication, when you see these icons you’ll know immediately that Ulcer Prevention Programs for long-term
the subject matter on that page relates to one or more of the following national initiatives: care, acute care and perioperative
• QIO – Utilization and Quality Control Peer Review Organization services, call your Medline representative
• Advancing Excellence in America’s Nursing Homes or visit www.medline.com/pupp-webinar.
We’ve tried to include content that clarifies the initiatives or gives you ideas and tools for implementing
their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7. ©2011 Medline Industries, Inc.

JBK_CVR_Layout 1 2/14/11 9:00 AM Page 1
VOLUME 9, ISSUE 1
Volume 9, Issue 1
Free CE Inside!
Introducing ...
HEALTHY SKIN
Achieve
THE NEW REMEDY WEBSITE
www.RemedyAdvancedSkincare.com ZERO
Pressure LTC: HOW
Now you and your family can enjoy professional
quality Remedy skin care products at home. Ulcers HEALTHCARE
REFORM
Order online at
www.remedyadvancedskincare.com
8
Principles
for Achieving
AFFECTS
YOU
Save 15% off your first order by using
Promo Code “ISaved15” Inner Peace Making a
Offer expires 5/31/11.
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Removing Stress
©2011 Medline Industries, Inc. Medline and
Remedy are registered trademark of Medline
Industries, Inc.
from the QIS
MKT211020/LIT822/30M/JBK5

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Join the team!

HEALTHY SKIN Pressure point answers

When it comes to hot

Improving Quality of Care Based on CMS Guidelines 103

Improving Quality of Care Based on CMS Guidelines 3

Camera not included.

NE1™ Wound Assessment Tool

Wound measurement made easy

©2011 Medline Industries, Inc. NE1 is a trademark of Medline Industries, Inc.

Two Important National Initiatives

QIO Utilization and Quality Control Peer Review Organization

Quality Improvement Organization Program’s 9th Scope of Work Theme

2 Advancing Excellence in America’s Nursing Homes

The 9th Scope of Work Content Themes

Clinical and Operational/Process Goals

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

Trends in Goal Selection

Participating nursing homes: 7,481

Improving Quality of Care Based on CMS Guidelines 7

650 facilities have joined the program.

1. Medline Industries, Inc. Data on file.

Improving Quality of Care Based on CMS Guidelines 9

Award Winners Honored

Elizabeth Ayello wins Sharon Baranoski

Stoma site before Same stoma site after

To learn more, visit

© 2011 Medline Industries, Inc. Medline and Marathon are registered

NE1 Wound and Skin Assessment Tool Developer

Nancy Estocado, PT, CWS

Improving Quality of Care Based on CMS Guidelines 11

After years of debate and hand wringing, healthcare reform

Improving Quality of Care Based on CMS Guidelines 13

to becoming market leaders in post acute short-stay

2. Understand your hospital CEO’s world. If you do not

3. Understand the impact on your physicians. Most

4. Align your medical director leadership for the future.

Improving Quality of Care Based on CMS Guidelines 15

TenderWet ACTIVE GENTLY REMOVES

TenderWet Active dressings have a “rinsing” effect as

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

By debriding necrotic tissue, absorbing and retaining

225-BED COMMUNITY HOSPITAL

Our Hospital to take a closer look at this important

Improving Quality of Care Based on CMS Guidelines 19

first challenge was to provide education to

The third challenge was to continue

Improving Quality of Care Based on CMS Guidelines 21

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

Each package is a 2-Minute Course

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

What did we do after

We found THREE more ways

1 Real photography on the outside –

2 A checklist that fits better

3 Education you’ll want to present

WOUND CARE AND

My name is Teresa Conner-Kerr, and I am a physical

Rehab training greatly needed in Lesotho

The goal is to find a funding source to assist Winston-

Advanced wound care training

ucts and educational materials produced by

I mainly discussed pressure ulcers, explaining the

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