Strategies for Managing Incontinence
Challenges and Related Wound Care
Management
Presented by Steve Salomon, RN, MBA
Principle Business Enterprises, Inc.
NASVH Winter Conference 2012
Does the cheapest product give
you the best outcome ?
WHO WOULD BUY A TIRE FOR $10 ?...AND IF YOU DID…
WHAT WOULD YOU EXPECT ???
Objectives:
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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.
Growth in Aging Population…
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1998, 2007
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1998
1990
2007
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Overweight and obesity are known
risk factors for:
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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
Wound Care/ Present
on Admission (POA)
POA Indicator
General Requirements
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Present on admission (POA) is defined as present at the time the order
for inpatient admission occurs
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Conditions that develop during an outpatient encounter, including
emergency department, observation, or outpatient surgery, are
considered POA
POA indicator is assigned to
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Principal diagnosis
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Secondary diagnoses
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External cause of injury codes (Medicare requires reporting only if Ecode is reported as an additional diagnosis)
Present on Admission
Wound Care
F-Tag 314
Intent of Tag F314
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Predicated on the LTC facility providing adequate
care and services to:
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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
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
F-Tag 314: Assessment
Prompt admission evaluation helps identify:
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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
F-Tag 314: Assessment
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Deep Tissue Injury
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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.
F-Tag 314:
Factors that increase susceptibility to
develop or not heal pressure ulcers:
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A healed ulcer
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History of a healed ulcer is important.
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Areas of healed Stage III or IV pressure ulcers are more
likely to have recurrent breakdown.
Assess Nutrition Status
Prevention
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Place at risk individuals on a pressure
reduction surface
Reduce pressure for chair-bound individuals
Gel or air is more effective than foam
Relieve pressure under heels using pillows
or other devices
Use incontinence skin barriers
Treatment of Pressure Ulcers
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Reduce friction and shear
Reduce/relieve pressure
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Low air loss/air fluidized may improve healing
rates
Shift immobile patients in chair every hour and
limit out of bed time
Ensure adequate nutritional and fluid intake
Product selection is critical
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
Incontinence
F-Tag 315
Why did CMS revise the standards ?
F Tag 315 Requirements
Understand how Incontinence can
impact wound care/ skin care/ slips
and falls and related risk
management…
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.
Slips and Falls…
Slips and Falls…
According to the American Academy of Orthopedic
Surgeons:
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30% of all people over the age of 65 fall each year.
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50% of older adults hospitalized with a hip fracture are unable to
return home or live independently again.
Slips and Falls…
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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.
Prevent Falls with a good Exercise
Program….
Slips and Falls
Understand related costs of care when
dealing with a patient with
incontinence and it’s impact on wound
care
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…
Address new clinical studies to use when
implementing an incontinence program and
looking at how product selection can
impact quality of care…
Associated costs of care…
The Iceberg Theory…
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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 ?
Linking Incontinence with Wound Care…
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New studies completed
New studies in progress
Collaboration between wound and skin care
clinicians
Looking at Skin Barrier Function…
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.
Contact Information…
Steve Salomon, RN, MBA
305 South Ladd Court
Daniel Island, SC 29492
843-737-1053
ssalomon@pbenet.com