July/August 2012 The Future of Skin By Jessica Girdwain Aging Well Vol. 5 No. 4 P. 18 Biosynthetic skin substitutes offer a promising solution for older adults’ wound care. When a patient’s leg ulcer or surgical wound just won’t heal, it’s frustrating for both the patient and the physician. Now with a growing number of biosynthetic skin products available, physicians are harnessing the latest in biotechnology for wound care—and it’s paying off. Biosynthetic skin substitutes assist in the restoration of the skin bed, giving wounds the chance to heal at an accelerated rate and with less pain and discomfort for the patient. Restoring the skin bed is vital to prevent infection and maintain skin function as well as minimize scarring. Reconstructing skin and caring for wounds can present a challenge, but these skin substitutes offer easy application, provide quicker wound healing, and cost less than traditional dermal grafts. The new guard of biosynthetic skin substitutes available today are superior when treating elders, notes Tania J. Phillips, MD, a dermatology professor at Boston University School of Medicine who specializes in wound healing and biologic skin substitutes. “The old way we treated wounds was to take a piece of skin from an area of healthy tissue and put it over the wound, also called a skin graft. Many times in the elderly, this was the thigh, which would cause a lot of pain and was often difficult to heal,” Phillips says. “With the skin substitutes of today, the procedure is akin to having a dressing put on a wound. It’s a simple procedure done in a doctor’s office that is pain free and comfortable for the patient.” The total time for treating a leg or foot ulcer may be 30 minutes. (One exception is burn patients, who are treated in an operating room, which takes longer.) Biosynthetic skin basically acts as a temporary wound covering. Many of these skin substitutes contain foreign cells (eg, synthetic or natural materials, such as bovine or shark cartilage, or human cells) that provide a scaffolding material. Then the body’s own cells “migrate in, heal the wound, and replace the skin substitute,” Phillips explains. Dramatic Results Consider Integra Bilayer Matrix Wound Dressing, for example. The product is considered a bilevel dressing consisting of a single layer of material a couple millimeters thick that sits on a silicone backing, with a stiff plastic on the other side, says Mary Maloney, MD, chief of the division of dermatology and a professor of medicine at the University of Massachusetts Medical School in Worcester and an expert in Integra. How it works highlights just how simple it is for health practitioners to use and why it is a good, gentle treatment for elderly patients: The doctor wets the dressing and peels off the plastic, placing the dressing into the wound. If the wound is deep, the doctor removes the silicone layer and places another dressing on top of it. “The patient’s blood vessels will grow through all of these layers to help regenerate skin tissue,” Maloney explains. “Integra is particularly useful at stimulating blood vessel and collagen growth into an open wound,” she says. It’s used on large wounds where a vascular bed is needed, particularly when there’s exposed bone or cartilage. After it’s been in place for two to three weeks, doctors can then graft over it. However, sometimes a graft may not be needed. “With certain patients that have had smaller wounds, I’ve waited an extra week. That was enough time for them to completely heal by themselves,” Maloney says. Additionally, in the case of deep wounds, biosynthetic skin grafts offer a better aesthetic after healing. As the skin graft is applied, it lies flush with the skin, which diminishes scarring, she adds. “Our offices use them about once every few weeks—and we do a lot of surgery. … It’s been really helpful for our patients in terms of improving healing and minimizing scarring. I call it a ‘surgeon-in-a-box,’” Maloney says. “If I’m doing surgery for skin cancer and there’s exposed bone or a deep wound, I will use a biosynthetic skin substitute,” says Maloney. In addition, she notes that products like Integra can be used “absolutely anywhere” on the body. (Integra itself is FDA approved for various indications and is not restricted to certain body parts.) “I’ve applied it to the bottom of a patient’s foot who had skin cancer, and the wound healed dramatically.” If it is used in a tough-to-apply spot, Maloney notes that physicians can suture it into place, which Maloney does for every application. “You don’t have to do this step, but it is more comfortable for the patient and [the skin substitute] can’t get wiped off somehow,” she explains. Depending on the skin substitute, doctors utilize a variety of sutures. Maloney uses Vicryl when applying Integra patches. It’s comprised of a mesh of Vicryl and skin cells from the dermis. As skin fibroblasts grow over the mesh, it forms a material that’s partly human cells and partly Vicryl, she notes. When placed within the wound, the sutures eventually disintegrate as the patient’s own cells grow into the matrix. It’s important for healthcare practitioners to know that each type of biosynthetic skin product is FDA approved only for certain indications (eg, burns, diabetic foot ulcers, venous leg ulcers). However, many providers use them off label for other body sites. But when they’re used off label, the skin product can’t be guaranteed to result in a successful outcome. “A lot of biosynthetic skin grafts are delicate and may be destroyed by pressure. Maybe the graft is in an area that the patient sits on, for example. It can be affected, but right now the success rate with off-label sites is purely anecdotal. We just don’t have enough data to say whether, aside from what they’re FDA approved for, the grafts work better on one body site vs. another,” Phillips says. Ensuring Success To improve a patient’s chances of success with a biosynthetic skin graft, a few things need to happen. Practitioners should be aware that the patient must have the wound for at least one month before treatment with a biosynthetic skin graft can be considered. “We have to try traditional therapies first,” Phillips says. For a venous leg ulcer, for example, Phillips notes a patient would receive a compression wrap and follow up with local dressing for one month. In treating a diabetic foot ulcer, the practitioner would clean the wound, treat the infection, and instruct the patient to keep weight off the wound for at least three to four weeks. Negative pressure therapy should also be considered prior to a biosynthetic procedure. Only after the failure of these traditional methods would a skin graft be considered. It’s also critical to address individual concerns and how a patient’s health problems or specific conditions may impact the graft’s success. For example, diabetic patients will experience better results if their diabetes is already well controlled. For that reason, when a patient initially seeks wound treatment, it’s important that the physician addresses the diabetes before considering biosynthetic skin treatment. “Treatment considerations really depend on the patient’s general health and any comorbidities,” says Robert A. Norman, DO, MPH, a board-certified dermatologist in Tampa, Florida. After trying traditional therapies and considering any comorbidities, providers should understand that the wound will accept the graft only if it has been cleaned and shows no signs of infection. The time it takes for a patient to heal is variable so it’s important not to give patients a one-size-fits-all expectation. “When you look under a microscope, it typically takes four to six weeks for your body’s own cells to repopulate and heal a wound. But depending on the depth of the wound and if you need several applications of dressing, it can take longer for certain patients,” Phillips notes. A patient’s health is a vital factor in how quickly—or slowly—a patient goes through the healing process. “If the person continues to participate in unhealthy behaviors like smoking or eating a poor diet, this will slow healing and impair the chance for treatment success,” Norman says. “It’s important that doctors know that they want to take on patients that have a good chance to heal. “As with anything in medicine, it’s about maximizing what you have left,” he adds. If a patient is older and has comorbidities, for instance, the provider must first consider the patient’s general health. “The problem is that some people in the healthcare world think that biosynthetic skin grafts are magic wands, like you can take a patient who has smoked for 20 years and has severe diabetes and give them one of these new grafts and they’ll be fine,” Norman says. “A patient can’t expect that they can cure anything with a graft. They need to be advised to take the proper steps to good health and managing disease in order for the outcome to be successful in the long term. The patient’s body needs to have a good foundation to heal.” Another important consideration is postprocedure nutrition. Many elder patients do not consume adequate amounts of protein, a critical factor in wound healing. Talking to them about their nutritional needs is key. Physicians should also consider recommending patients consult a registered dietitian who can ensure they are eating properly. According to Norman, while it’s important to take on patients who will most likely experience a positive outcome following a biosynthetic skin graft, physicians should not assume that this treatment will be successful for everyone. “That said, I like where the future of skin is going. Biosynthetic skin is intriguing and offers up a promising path for the future,” he says. Superior Treatment for Elders Biosynthetic skin substitutes are particularly useful for treating older adults. “I think it’s particularly good for elders who may not be equipped to deal with more surgery,” Maloney says. “If I remove a big tumor in the operating room, an older patient may be at the end of his or her rope and not be able to tolerate a dermal skin graft right away. We can put on a product like Integra and, if necessary, plan for a dermal skin graft or an additional procedure when they’re feeling more robust again.” While biosynthetic skin procedures are less expensive than traditional split- or full-skin grafts, they are still expensive. FDA-approved treatments are about $1,000 per application, depending on the extent of usage. Some wounds require multiple applications, according to Phillips. However, Medicare covers most treatments if a patient meets requirements to obtain a graft. In addition, Maloney notes that prices should begin to decrease as more biosynthetic skin products enter the market. And while it is a relatively simple in-office treatment, Maloney suggests that physicians recognize they can teach office assistants to do skin grafts but, for safety reasons, shouldn’t have them perform the procedure unsupervised. For physicians, it’s important to keep skin substitutes in mind as a course of treatment and not allow wounds to go unchecked for a long period of time, assuming that they will heal on their own. “These biosynthetic skin grafts are excellent for accelerating the healing process. Practitioners should not wait and sit on the wound for six months before getting the patient in. If the wound is not healing in a month or two, doctors should think about this as the next step,” Phillips says. “When a wound is more recent, it’s easier to heal than one that a patient has had for months or even years. When you accelerate the healing process, like biosynthetic skin does, you prevent painful and potentially dangerous complications down the road.” — Jessica Girdwain is a Chicago-based freelance writer who has contributed health-related articles to several national magazines. Guide to Biosynthetic Skin Many companies offer biosynthetic skin substitutes. Here’s a closer look at four of them, based on information from their respective websites: • Apligraf: A living bilayered cell-based product FDA approved to heal diabetic foot ulcers and venous leg ulcers, Apligraf combines bovine type 1 collagen and human dermal cells, which produce matrix proteins. The upper layer is created by promoting human epidermal cells to form a layer that mimics the human epidermis. • Biobrane: This is a biosynthetic wound dressing constructed of a silicone film with a nylon fabric partially embedded into the film. It is suggested for use on clean partial-thickness burns and donor sites. A recent study in Dermatologic Surgery found that Biobrane may be a good tool for use in dermatologic surgery. • Dermagraft: Manufactured from human fibroblast cells derived from newborn foreskin tissue, it is composed of fibroblasts, extracellular matrix, and a bioresorbable scaffold. Dermagraft is designed for the treatment of full-thickness diabetic foot ulcers. • Integra Bilayer Matrix Wound Dressing: Integra is an artificial skin covering composed of two layers. The bottom is a matrix of bovine collagen and a sugar molecule. The upper layer is made of medical-grade silicon. It is indicated for the management of wounds, including those caused by ulcers, surgery, and trauma. — JG 2 week CNA class Salt Lake City Utah

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Fun with TED hose

Having some fun with compression stockings at CNA class.

Salt lake City Two week CNA program student "look at me mom!:

CNA class students practice TED hose

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CNA student "hey half my patient's body is missing."

CNA students "hey this is a little strange"


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I went to a creature encounter party with my son and got to hang out with some creepy critters.

Scorpion eek. The guy that brought the critters put it in his mouth. Yuck

A tarantula on my hand. Soft and fuzzy but I wouldn't want to find on e in my bed.

Oh the fun we have. I am a brave CNA teacher! Carol

Salt Lake City CNA Class

We have a great winter break Salt Lake City CNA class coming up. The CNA class starts on December 17, 2012. All students should be able to finish their clinical and be done with the CNA class before SLCC and the U start up for spring classes.
Join us, we will have a great time and learn new stuff.
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Use Restraints With Caution

By Maura Keller
Aging Well
Vol. 4 No. 4 P. 8
Walking down any hallway in a nursing home or hospital in 1981, you were likely to see residents restrained in wheelchairs and beds throughout the facility. Fast-forward 30 years, and you’re unlikely to see the use of restraints in these same facilities, as today’s physicians and regulatory bodies have devised alternate methods for handling agitated, violent, and disruptive individuals.
Historically Speaking
The use of physical restraints for “uncooperative” patients has declined in recent years. As Cheryl Phillips, MD, senior vice president for advocacy at LeadingAge in Washington, D.C., explains, prior to 1987 and the regulations for nursing reform as part of the Omnibus Budget Reconciliation Act 0f 1987, the use of restraints was common in nursing homes. The belief was that they prevented falls and injuries and helped staff by preventing wandering and disruptive behavior.
“However, increasing evidence has shown that physical restraints led to higher risks of injury and did not prevent falls,” Phillips says. “Furthermore, they contributed to depression, immobility, increased agitation, and confusion.” Most states report fewer than 4% of patients on average in nursing home settings are physically restrained, but use varies considerably across states and settings—with the most commonly restrained group being individuals with dementia or other cognitive impairments.
Over the past decade other care settings have also recognized the harms of physical restraints, including acute care hospitals and rehabilitation centers.
“There are still areas for improvement in both nursing home and other care settings,” Phillips says. “While many have moved to a ‘restraint-free’ commitment to care, there is still a need for better understanding of what a physical restraint is and how it can negatively impact the person restrained. Families themselves need to be educated about the real risks of routine use of physical restraints.”
Here are some things we know: Restraints are associated with death by strangulation; they are associated with increased weakness if used for long periods of time; and they contribute to increased confusion, increased risk of pressure ulcers, depression, and agitation.
“As knowledge regarding the adverse effects of both physical and chemical restraints has accrued, the utilization of restraints is now considered only as a last resort,” says Mark A. Supiano, MD, executive director at the University of Utah Center on Aging, chief in the division of geriatrics at the University of Utah School of Medicine, and director of the VA Salt Lake City Geriatric Research, Education, and Clinical Center.
In fact, according to Supiano, most long term care facilities are now entirely restraint free. “In the inpatient hospital setting, physical restraints are occasionally justified,” Supiano says. “For example, agitated patients in an ICU are at risk from pulling out life-supporting breathing tubes or other invasive devices.”
Supiano stresses that data clearly show that physical and chemical restraints are associated with adverse outcomes, including fatalities. “In turn, there is absolutely no data to report that restraints have any effect to decrease fall risk—a common justification for their use,” Supiano says. “In fact, when carefully studied, the risk for fall-related injury increased in patients who were restrained relative to those who were not.”
Jacob DeLaRosa, MD, chief of cardiothoracic surgery at Portneuf Medical Center in Pocatello, Idaho, says restraints can be humane when used appropriately and in the correct setting. “When patients are in the transition from being anesthetized to awake can be a dangerous time when patients do not understand what is happening and can be a danger to themselves,” DeLaRosa says. “This is the only indication that I feel restraints should be used.”
DeLaRosa says restraint use is restricted to patients coming out of heart surgery during their resuscitation. “The restraints are put on to protect each patient from reaching up and pulling out lifesaving catheters and intravenous and interarterial lines,” he says. “Once the patient is conscious and following commands, the restraints are removed.”
Alternate Restraint Methods
Chemical restraints have also played a role in healthcare management of older adults. “In the past, people were medicated with the sole intent of causing them to stop moving, but those days are gone,” Phillips says. “What is the challenge now is how to manage the kind of behaviors that are difficult for caregivers and for the individuals themselves to cope with. Problems such as yelling out, striking, resisting care, [and] delusional thinking are all examples of these kinds of responses to negative stimuli—most often occurring in people with dementia or other cognitive impairments. Because these are the best medications—we often have to address disturbing delusions and psychotic behaviors—they are thought of as a ‘fix’ for other distressing actions by people with dementia, by families, caregiving staff, and often physicians.”
Phillips says the solution is not to eliminate the drugs from ever being used but rather to improve understanding of what alternatives exist and, when they are used, information on how to use them safely and at the lowest dose for the shortest time.
Experts agree that healthcare professionals should prevent the need for restraints—either physical or medication—and change the care facility’s culture to adopt a restraint-free approach. One step is delirium prevention, which mitigates the need to restrain agitated patients. The Hospital Elder Life Program (HELP) at the University of Utah Health Care Hospital offers an effective approach to preventing delirium in older, at-risk patients. “Trained volunteers support patients with standardized protocols proven to decrease delirium risk factors such as maintaining hydration, ambulation, orientation, vision, hearing,and promoting sleep,” Supiano says.
In the last year since launching HELP, the incidence of delirium in patients enrolled in the program has decreased to 7% from a baseline of 33%. “Restraints should never substitute for a lack of staffing to provide adequate patient supervision,” Supiano says. “Alternatives to nursing supervision include involving family members or having close supervision by trained sitters to be with the patient at all times.”
Partners in Progress
Concerned family members who may have objections to having parents or spouses restrained often question physicians. That’s why it’s imperative you understand the reason you are ordering a restraint.
“I think it is essential that physicians discuss why restraints are placed and when they will be removed,” DeLaRosa says. “Also, discuss the alternatives that can be used instead of having the restraints as well as the complications that can arise if the restraints are not being used.”
Phillips adds that physicians should work with direct care providers for other interventions to behaviors that create concern. “Think about factors that could be contributing to the need for a restraint,” Phillips says. “Is the confused person striking out because they are in pain? Are they agitated because they are hungry or because there is too much stimulation in the environment?”
Then look to the least restrictive device and when ordering, use it only for the shortest possible period of time. Work with your physical therapists to look for physical conditioning in lieu of physical restraints to prevent falls. Work with your nursing staff to identify other options for addressing disturbing behaviors.
“Physicians should provide a daily written order to indicate the nature of the restraint (using the least restrictive possible), the indication for the restraint, and a time-limited duration not to exceed 24 hours,” Supiano says. “In addition, analogous to any other procedure or treatment that carries significant risks, patients’ families should complete an informed consent agreement to approve of restraint use once the risks and benefits of their usage have been thoroughly explained.”
In the rare situations where restraints are justified, their use should be governed by strict adherence to the rules of The Joint Commission, a private sector U.S.-based not-for-profit organization that accredits and certifies more than 15,000 healthcare organizations and programs in the country. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
There also are various regulations requiring provider settings of care to create policies regarding when restraints are used, how they are ordered, how restrained patients should be monitored, and what documentation must be present. If a physician has a question, he or she should first ask the director of nursing services or the facility administrator to explain the policies in that setting of care.
— Maura Keller is a Minneapolis-based writer and editor.UTAH CNA STUDENTS
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How much fun can you have in a CNA course?

Utah CNA teachers being seriously silly

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CNA Student hanging out in a walker

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