1. Strategies for Managing Incontinence Challenges and Related Wound Care Management Presented by Steve Salomon, RN, MBA Principle Business Enterprises, Inc. NASVH Winter Conference 2012

2. Does the cheapest product give you the best outcome ? WHO WOULD BUY A TIRE FOR $10 ?...AND IF YOU DID… WHAT WOULD YOU EXPECT ???

3. Objectives: Identify trends in patient population for incontinence issues including obesity. Understand new regulatory guidelines: Present on Admission (POA). Impact of new regulations – Present on Admission (Acute Care), F-Tags 314 and 315 – and what this means for LTC. Understand how Incontinence can impact wound care/ skin care/ slips and falls. Address new clinical studies to use when implementing an incontinence program and looking at how product selection can impact quality of care. Understand related costs of care when dealing with a patient with incontinence.

4. Growth in Aging Population…

5. 1998 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2007 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2007 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

6. Overweight and obesity are known risk factors for: diabetes coronary heart disease high blood cholesterol stroke hypertension gallbladder disease osteoarthritis (degeneration of cartilage and bone of joints) sleep apnea and other breathing problems some forms of cancer (breast, colorectal, endometrial, and kidney) Obesity is also associated with: stress incontinence (urine leakage caused by weak pelvic floor muscles) psychological disorders, such as depression increased surgical risk increased mortality

7. Wound Care/ Present on Admission (POA)

8. POA Indicator General Requirements Present on admission (POA) is defined as present at the time the order for inpatient admission occurs – Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA POA indicator is assigned to – Principal diagnosis – Secondary diagnoses – External cause of injury codes (Medicare requires reporting only if E- code is reported as an additional diagnosis)

9. Present on Admission

10. Wound Care F-Tag 314

11. Intent of Tag F314 Predicated on the LTC facility providing adequate care and services to: Predicated on the LTC facility providing adequate care and services to: – Promote the prevention of pressure ulcer development – Promote the healing of pressure ulcers that are present – Prevent development of additional pressure ulcers – A “paper trail” can follow intent

12. The “Bottom” Line…. The care process should include efforts to stabilize, reduce or remove underlying risk factors To monitor the impact of the interventions To modify the interventions as appropriate. CMS Guidelines

13. F-Tag 314: Assessment Prompt admission evaluation helps identify: – The resident at risk of developing a pressure ulcer – The resident with existing pressure ulcers – Areas of skin at risk for skin breakdown – Pre-existing signs of deep tissue damage

14. F-Tag 314: Assessment Deep Tissue Injury Deep Tissue Injury – Purple or very dark areas that are surrounded by profound redness, edema, or induration suggest that deep tissue damage has already occurred and additional deep tissue loss may occur.

15. F-Tag 314: Factors that increase susceptibility to develop or not heal pressure ulcers: – A healed ulcer History of a healed ulcer is important. History of a healed ulcer is important. – Areas of healed Stage III or IV pressure ulcers are more likely to have recurrent breakdown.

16. Assess Nutrition Status

17. Prevention Place at risk individuals on a pressure reduction surface Place at risk individuals on a pressure reduction surface Reduce pressure for chair-bound individuals Reduce pressure for chair-bound individuals Gel or air is more effective than foam Gel or air is more effective than foam Relieve pressure under heels using pillows or other devices Relieve pressure under heels using pillows or other devices Use incontinence skin barriers Use incontinence skin barriers

18. Treatment of Pressure Ulcers Reduce friction and shear Reduce friction and shear Reduce/relieve pressure Reduce/relieve pressure Low air loss/air fluidized may improve healing rates Low air loss/air fluidized may improve healing rates Shift immobile patients in chair every hour and limit out of bed time Shift immobile patients in chair every hour and limit out of bed time Ensure adequate nutritional and fluid intake Ensure adequate nutritional and fluid intake Product selection is critical Product selection is critical

19. Summary Employ Standards of Care Communicate to residents, providers, family Demonstrate competency Treat underlying etiology If patient fails 2-4 weeks therapy, consider referral Prevention is key –reduce mechanical forces, ensure adequate nutrition and hydration Keep educated on products

20. Incontinence F-Tag 315

22. Why did CMS revise the standards ?

23. F Tag 315 Requirements

24. Understand how Incontinence can impact wound care/ skin care/ slips and falls and related risk management…

25. Incontinence…and it’s Impact on Wound Care… Urinary incontinence affects 38% of women and 17% of men age 60 and older. Perineal skin damage secondary to incontinence has been reported to occur in 31% of acute care patients and 41% of long-term care patients. Perineal dermatitis has been reported to increase risk for UTIs, microbial skin infections, and pressure ulcers. Fecal incontinence has been documented as one of the most common risk factors for pressure ulcer development.

26. Slips and Falls…

27. According to the American Academy of Orthopedic Surgeons: 30% of all people over the age of 65 fall each year. 50% of older adults hospitalized with a hip fracture are unable to return home or live independently again.

28. Slips and Falls… In 2003, 1.5 million people 65 and older lived in nursing homes. If current rates continue, by 2030 this number will rise to about 3 million. About 5% of adults 65 and older live in nursing homes, but nursing home residents account for about 20% of deaths from falls in this age group. Each year, a typical nursing home with 100 beds reports 100 to 200 falls. Many falls go unreported. As many as 3 out of 4 nursing home residents fall each year. That’s twice the rate of falls for older adults living in the community. Patients often fall more than once. The average is 2.6 falls per person per year. About 35% of fall injuries occur among residents who cannot walk.

29. Prevent Falls with a good Exercise Program….

30. Slips and Falls

31. Understand related costs of care when dealing with a patient with incontinence and it’s impact on wound care

32. Cost of Care… % of the population with UI & OAB Over 200 Million dollars in expense due to Skin Irritation, UTI and Falls because of UI and OAB…

33. Address new clinical studies to use when implementing an incontinence program and looking at how product selection can impact quality of care…

34. Associated costs of care… The Iceberg Theory… Dressings/ Tape ? Gloves ? Skin Breakdown ? Creams/ Lotions ? Pain Medications ? Sleep Medications ? Reporting/ Legal ? Physician/ Hospital ? Rest/ Sleep through the night ? Patient Dignity ? Caregiver time ? Product Cost/ Frequency of Care Linen and Trash ?

35. Linking Incontinence with Wound Care… New studies completed New studies in progress Collaboration between wound and skin care clinicians

36. Looking at Skin Barrier Function…

37. Objectives: Identify trends in patient population for incontinence issues including obesity. Understand new regulatory guidelines: Present on Admission (POA). Impact of new regulations – Present on Admission (Acute Care), F-Tags 314 and 315 – and what this means for LTC. Understand how Incontinence can impact wound care/ skin care/ slips and falls. Address new clinical studies to use when implementing an incontinence program and looking at how product selection can impact quality of care. Understand related costs of care when dealing with a patient with incontinence.

38. Contact Information… Steve Salomon, RN, MBA 305 South Ladd Court Daniel Island, SC 29492 843-737-1053 ssalomon@pbenet.com