Back Wednesday, May 14, 2008

Bits & Pieces
  • Guidelines for Restraint Use Form


    • CMS:
    Current CMS topics include:
    • the proposed rule for the skilled nursing facility prospective payment system for FY 2008 published in the May 4th, 2007 Federal Register
    • the final rule for DME bidding published in the April 10th, 2007 Federal Register allows SNF's to submit bids to be a contractor-can either choose to be a specialty provide, supply only your own residents, or compete to be an area supplier.
    • if a facility chooses not to submit a bid to be a supplier, it will have to use a contracted supplier to provide enterals and other DME products to residents beginning April 1st 2008
    According to House Oversight and Government Reform:
    • the price for 10 of the most prescribed brand-name medications jumped an average of 6.8% since December under Medicare private Part D insurance plans
    • wholesale prices for the same drugs for the same drugs rose just 3%
    • the biggest price increase was seen in Aricept-up by 11.3% and Lipitor rose 9.6%
    ADVANCING EXCELLENCE
    The campaign called Advancing Excellence in America's Nursing Homes is a national coalition designed to partner caregivers, long-term care providers, quality improvement professionals and other stakeholders for the purpose of improving the quality of care and quality of life for those living or recuperating in America's nursing homes. Advancing Excellence is a two year, coalition based campaign that promotes quality care and services that respect the individual's needs and choices. Supporting the residents' needs and choices help improve the likeliness of achievable clinical outcomes, and are consistent with evidence-based knowledge.

    1. By focusing on both clinical and organizational goals, campaign participants can contribute to quality improvement initiatives that are comprehensive, sustainable, and consumer-focused. Participating nursing homes volunteer to work on at least three of eight measurable goals:
    2. Reducing high risk pressure ulcers;
    3. Reducing the use of daily physical restraints;
    4. Improving pain management for longer term nursing home residents;
    5. Improving pain management for short stay, post acute nursing home residents;
    6. Establishing individual targets for improving quality;
    7. Assessing resident and family satisfaction with the quality of care;
    8. Increasing staff retention;
    9. Improving consistent assignment of nursing home staff, so that residents regularly receive care from the same caregivers.
    In Ohio, 275 nursing homes (28.7%) are participating in the campaign compared to 5,249 nursing homes (33%) that have enrolled nationally. Most of the nursing homes in Ohio have chosen to focus on improving pain management (both longer term and short stay) for residents; assessing resident and family satisfaction with the quality of care; and reducing high risk pressure ulcers. Participating providers will have their aggregate progress towards meeting the campaign goals monitored on a regular basis and will receive assistance from their Local Area Networks for Excellence (LANE) to help them towards their goals. Being part of this unprecedented campaign is also a great way participating consumers can use these quality improvement activities to help direct loved ones to providers striving for high quality care as well as help others raise their awareness and expectations when seeking long-term care.
    Go to www.nhqualitycampaign.org for more information and registration.

    CLARIFIED GUIDELINES FOR RESTRAINT USE
    The ODH 2007 Quality Forums Division of Quality Assurance has clarified the guidelines for restraint use, physical restraint definitions and the Federal and State guidelines for restraint use. The Survey and Certification Government Performance and Result Act (GPRA) goal is to reduce the number of physical restraints in nursing homes. The GPRA's goal for restraint use is to be equal to or less than the fiscal year of 2006 national goal of 6.4%. For the complete document, click here.

    NPUAP'S NEWLY REVISED PRESSURE ULCER STAGING SYSTEM
    Becky Dorner, RD, LD
    "The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research."
    As an officer of the NPUAP and a member of the Staging Task Force, I had the privilege of participating in the NPUAP Biennial Conference & Best Practice Conference held in San Antonio, Texas on February 9-10, 2007. The Consensus Conference is held every two years, and includes the input of pressure ulcer experts from all over the world. This year's conference had a record attendance of over 400 people, and attendees participated in the finalization of the newly revised pressure ulcer staging system for 2007. This is the culmination of more than five years of research and discussion-very exciting! The following information will provide some background on how decisions for the new staging revisions were determined.

    History of NPUAP's Staging Task Force
    The NPUAP first formed the Staging Task Force in 2001 to examine the problem of what some clinicians were calling "purple pressure ulcers." At that time the group adopted the term "deep tissue injury" (DTI) to describe a phenomenon of tissue injury that is commonly observed in the clinical setting, and which appeared to develop into a much more severe pressure ulcer in a short period of time. In 2002, the Task Force examined the literature related to DTI descriptions. From 2002-2004, the NPUAP presented material nationwide on DTI and received overwhelming support to continue to explore this phenomenon.

    The Task Force drafted a definition of DTI in 2004, and the 2005 Consensus Conference focused on DTI. With this new knowledge of DTI, the group determined the need to revise the pressure ulcer staging system. The revised staging system was drafted in 2005-2006. In 2006, NPUAP conducted a survey on clarity, succinctness, accuracy, discrimination and utility of the proposed stages. In 2007, the staging definitions were refined, and the definition of pressure ulcer was revised. All of this was then finalized at the 2007 NPUAP Biennial Conference.

    Deep Tissue Injury (DTI)
    Deep tissue injury is an NPUAP term used to describe a unique form of pressure ulcers that are likely to deteriorate rapidly. DTI may present as bruises over bony prominences. The reasons for the rapid deterioration seen with DTI may be a result of a long duration of ischemia which may cause "direct" damage resulting from hypoxia. Injury produced by reperfusion can be even more severe than the injury induced by ischemia. (Reperfusion: "Damage to tissue caused when blood supply returns to the tissue after a period of ischemia. Absence of oxygen & nutrients from blood creates a condition in which restoration of circulation results in inflammation & oxidative damage from oxygen rather than restoration of normal function.")

    The current stage I definition of pressure ulcers states clearly that these ulcers are of intact skin. The labeling of DTI as a stage I can reasonably be interpreted to mean that it is relatively minor and healing is likely with offloading of pressure. However, if enough damage has occurred prior to its identification, it is possible that no amount of pressure offloading will prevent further deterioration. DTI is often identified upon transfer of a patient from one facility to another. The receiving facility can inappropriately receive quality of care citations or medical malpractice claims for an injury that originated elsewhere. The hope is that proper labeling will afford clinicians a more accurate diagnosis and interventions.

    Pressure Ulcer Staging is NOT…
    Before sharing the new pressure ulcer staging definitions, it is helpful to understand that pressure ulcer staging is not designed to stage all wounds. Venous ulcers, diabetic ulcers, burns, skin tears, perineal dermatitis, maceration and arterial wounds are not pressure ulcers and therefore, the pressure ulcer staging system cannot be applied to these wounds.

    In addition, clinicians need to remember that staging a pressure ulcer does not tell the whole story. The history of the wound or healing in the wound is important knowledge in determining the type of wound and its stage of healing. Clinicians must communicate about maximum prior depth and not reverse stage. They must also attempt to see all wounds on admission, rather than relying solely on the reported history of the wound.

    The following information is copyrighted by NPUAP and is used with permission. This information can be found at: http://www.npuap.org/documents/NPUAP2007_PU_Def_and_Descriptions.pdf

      Pressure Ulcer
      A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

      A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure ulcers are staged using the following staging system.

      (Suspected) Deep Tissue Injury
      Definition: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
      Description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

      Stage I Pressure Ulcer
      Definition: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
      Description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk).

      Stage II
      Definition: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
      Description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
      *Bruising indicates suspected deep tissue injury.

      Stage III
      Definition: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
      < Description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

      Stage IV
      Definition: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
      Description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

      Unstageable
      Definition: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
      Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.

      ©2007 NPUAP
    Please visit www.NPUAP.org for more information.
    2007 Becky Dorner & Associates, Inc.


    MISCELLANEOUS: - Some viruses and bacterium cannot be killed using alcohol based hand sanitizers, for instance Clostridium Difficile (C-diff) and norovirus.

    - The institute for Safe Medication Practices has issued recommendations to reduce the risk of potentially harmful mix-ups between heparin and insulin. To access the full report and recommendations go to Safe Practices on the web.

    - According to researchers at the Massachusetts Institute of Technology's Picower Institute of Learning and Memory, certain cancer drugs or a stimulating environment appear to restore the memories of laboratory mice that have symptoms mimicking dementia.

    - Reporting resident to resident abuse and family to resident abuse:
    A provider update from CMS Region 5 references Interpretive guideline F223 under "Intent" where it reads, "residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals."

    - According to an annual report released by My Innerview, customers, residents and families are more satisfied with skilled nursing facilities than they were a year ago.

    - A new study indicates that a once-a-year injection could replace osteoporosis drugs. Treatment with injections of zoledronic acid reduced the risk of vertebral fracture by 70% and hip fracture by 41% according to researchers.


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