Getting the SKINny
Current events and issues of relevance to WOC Nurse practice, updates on new website features and links to external sources of interest to WOC nurses.
Monday, March 03, 2014
In my current capacity, I do a lot of consulting in long term care facilities. So as a result, I have not only brought my wound/ostomy expertise to the table, but also a knowledge of the federal regualtions that these facilities function under. I have found myself meeting with state surveyors on a regular basis. And through these encounters, I have been increasingly troubled with the way facilities are 'graded'.
I am sure that you are aware of the CMS Nursing Home Compare website, that gives consumers information on the caliber of a given nursing home. These ratings are based on the annual state survey as well as data generated by the MDS. While nursing homes have a general idea when their state survey will happen, surveyors show up unannounced and spend several days observing the care in the given facility. Based on the observations of care and review of policies and documentation, certain scores or grades are given.
If you have ever been in a facility during a state survey, you will witness a very stressful enviornment. Surveyors can be quite intimidating. Staff are trying to be on their best behavior. Despite that, there does seem to be a 'gotcha' mentality, and this is unfortunate. We should all be trying to improve systems and processes of care. We should all have the same goal. The survey process should be one of education and support, not punishment and bullying.
I think about myself, imagining that I was looking to find a top-quality nursing home facility for an aging parent. What would I want to know? What factors would I use to judge the quality of a facility? And could I get the answers by looking at the website? Right now, the answer is questionable.
For example, I cetainly would want to know that my parent would be safe and protected from abuse. So is it useful to know that a facility could be sited for elder abuse simply because one of the staff is obserevd calling one of the residents by an endearing name such as "honey" or "dear?" Yes, staff needs to be respectful of resisdents, and the use of endearing terms should be discouraged. But does this really rise to the level of abuse?
And a recent survey cited a local facility for not providing a home-like environment simply because they had removed tablecloths from the dining room because of a safety concern. Really? When nursing homes are cited for what seems to be rather minor and insignificant issues, it makes the whole survey process a bit of a sham. If no body can be perfect, and everyone gets cited for something, then how does one distinguish the good homes from the really bad ones?
I think state surveyors are well aware of the 'bad' nursing homes and the 'good' nursing homes, well before they ever walk in the door. They know which facilities get regular complaints from residents and families. They know which facilities have a steady turnover of staff and administration, a big red flag to quality issues. They know which facilities smell of urine, stool and body odor. They know facilities where residents look unkempt. They know the facilities where the staff are in good spirits, working together as a team, and obviously enjoying the work they do. None of these factors are ever reflected on the website.
So in this economic climate, where we are all working to do more with less, maybe we should step back and look at this whole regulatory process. As a taxpayer as well as a future purchaser of nursing home care, I think there has to be a better way.
Wednesday, February 05, 2014
The American Heart Association has designated the month of February as Heart Month. This is certainly fitting, as Valentine's Day falls in February. Heart disease is the leading cause of death in both men and women, causing 1 out of every 4 deaths in the United States alone. The most alarming fact though is that this number one killer is both preventible and controllable. Heart diseae was once thought of as a problem for men. But the truth is that more women than men actually die of heart disease each year. This is thought to be because the symptoms are often different in women, can be vague, suble and often ignored until significant heart damage has already occurred.
As wound experts, we see patient's daily with leg wounds secondary to the lower extermity edema associated with chronic congetsive heart failure. And since nursing is largely a female profession, our radar should be tuned to this malady.
I have long believed that we need to serve as role models for our patients and our families. So I challenge all of us to use this month to get started on a heart-health game plan. February may be the shorest month of the year, but it is enough time to make some big improvements in our health and accept the Center for Disease Control plan of 28 Days to a Healthier Heart. Think about making one small change each week.
Week #1: Halt the Salt by reducing the amounts of processed foods in your diet. Eat more fruits and vegetables. Cook at home and eat out less.
Week #2: Get Moving by aiming for 30 minutes of exrecise a day. If necessary, break up the time into 10 minute intervals. Start slowly and gradually increase the resistance, the repetitions and intensity. Add a variety of activities that you enjoy.
Week #3: Kick Butt. More deaths are caused each year by tobacco use than by all other causes combined. Now is the time to quit for good.
Week #4: Know Your Blood Pressure: Check you blood pressure and track it regularly. Take any and all prescribed medications. Limit alcohol intake. Take time to relax, meditate and reduce stress.
Thursday, January 02, 2014
We all recognize that nursing research is necessary to produce the scientific evidence supporting the specialized care we deliver to wound, ostomy and continence patients. With limited federal funding, it is difficult for the nursing profession to compete with other interests for these precious resources.
To help with this issue, the WOCN Society established the Center for Clinical Investigation (CCI), recognizing that considerable contributions to the specialty science can be made with small research projects. This arm of the Society exists to expand the existing research base for practice by enabling WOC specialty practice nurses to develop their roles as clinicical investigators. The foremost initiative is to administer the small research grant program. Research grants supported by our industry partners and the membership are available to any Society member. More information on the CCI and the small grant program is available following this link.
The CCI has also authored a variety of articles in the Journal to assist members in the steps of successful grantmanship. This Spotlight on Research
series is available following this link. And lastly, the Journal provides support to member authors looking to publish their study findings.
Since the majority of Society members are not Advanced-Practice, many may not feel qualified to be a principle investigator of a research study. Nontheless, the Magnet Recognition Program by the American Nurses Association Credentialing Center(ANCC) strongly supports and encourages nurses of all educational levels to participate in research activities and to incorporate research findings into clinical practice. The Society has a CEU activitiy titled Mining the Research Gold: "Treasure" in Your Own Backyard
which explains pragmatic approaches to mining clinical data. This activity produced by fellow WOC nurses Barb Dale, Janice Beitz, Laurie McNichol and Colleen Drolshagen, is a wonderful resource to clinicians looking to venture into the world of research and can be viewed following this link
Wednesday, December 04, 2013
Some people are born organized. Others are not. Reality television highlights exteme hoarding behaviors. But many of us have milder symptoms of packratitis and inarushitis, often genetically transmitted.
Are you a packrat? Do you have piles of paper cluttering your desk? Do you have lots of 'stuff' that others would call 'junk'? Do you save all of your print editions of JWOCN, just in case you might need them someday? Do you worry that as soon as you discard one, you will want it or need it for some reason? If I am describing you, you might have packratisits.
Inarushitis, on the other hand, happens when you get something out and use it, but don't put it away. Even though it usually only takes a few extra steps or minutes to put the item away, the person inflicted with this disorder doesn't have the strength to do it. This causes additional complications of anger and frustration when you need the item a few weeks or months later only to be unable to find it. Do you have a shelf full of past editions of JWOCN, knowing that you would have a hard time finding that one article you are looking for? Are you someone who has big plans to file away articles of interest, but never quite get the job done?
Now that the JWOCN is available in digital format, there are much fewer reasons to save past editions. Any ariticle can quickly be retrieved by the use of the search engine. And each subscriber can quickly organize favorite articles into collections for easy retrival in the future.
So if you are a reader of the print edition, I would encourage you to stop saving it after you are finished reading. Pass it on to others. Share the continuing education articles with fellow nurses interested in our specialty practice. Cure your packratitis by using the digital format.
Monday, November 04, 2013
While the research evidence supporting the role of nutrition in pressure ulcer prevention is inconclusive, at best, most wound clinicians believe that a relationship exists. Most wound experts see a profile of patients who develop pressure ulcers, and that profile includes the malnourished and those nutritionally deplete of protein, vitamins and minerals. Patients on both ends of the weight spectrum, the very thin and frail as well as the morbidly obese, are at pressure ulcer risk.
If we accept that nutrition is imporatnt, than we also have to weigh the risks of tube feedings, when patients are not able to take adequate oral intake. A recent research paper titled Feeding Tubes and the Prevention or Healing of Pressure Ulcers
published in the Archives of Internal Medicine studied the role of feeding tubes in nursing home residents. Their data showed that tube feedings were not associated with prevention or improved healing of pressure ulcers and that percutaneous gastrostomy tubes actually increased the risk of presure ulcer development in cognitively impaired patients two-fold.
Complications of feeding tubes can include aspiration pneumonia, diarrhea, aggitiation, wound infection and the need for physicial or chemical restraints, particularly in patient with dementia. To lower the aspiration risk, patient must be positioned with the head of the bed elevated higher than 30 degrees, thus increasing the friction/shear forces and limiting a turning/repositioning schedule. The moisture and caustic effects of involunary diarrhea can alter the tissue tolerance, increasing the risk of pressure ulcers. Chemical and physicial restrints often further immobilize a person already at high pressure ulcer risk.
The evidence in this article supports that when a patient has nutritional deficiencies and the only method of correction is a tube feeding, we must consider the negative consequences and complications, especially in a person with dementia. The authors also hypothesize that annoexia, poor intake and weight loss can be part of the chronic illness sequelae. "Illness can cause annorexia as part of sickness behavior. We generally eat less when we are sick and worse illness may lead to more severe annoxeia." Many patients reduce food and fluid intake, especially in the final weeks of life, causing weight loss. Family members may become upset with weight loss, perceiving that the annoexia is the cause of the infection, wound deterioration and even death, rather than a normal part of the dying process. Evidence further suggests that the administration of nutrients does not prolong life or improve the quality of that life for many persons with malnutrition, and weight loss persists in spite of medical intervention. The authors challenge us to consider their findings and to ask for evidence of benefit before we force feed beyond what the patient desires.