Presented by: Vivian Cheng, Dietetic Intern 17 July 2008 Are clinical dietitians appropriately consulted and what nutritional interventions are implemented for patients identified at risk for skin breakdown with a nutritional deficit at QCH? Presented by: Vivian Cheng, Dietetic Intern 17 July 2008

Agenda Prevalence of pressure ulcers Pressure ulcer risk factors Pressure ulcer stage classification Braden scale Nutrition and wound healing Study Results Relevance to Practice

Prevalence of Pressure Ulcers A major health problem Financial burden to healthcare system Canadian Association of Wound Care estimates: 25% Acute care 30% Non-acute care 15% Community care QCH Pressure Ulcer Prevalence Study 17% Point prevalence all stages (2007) 20% Point prevalence all stages (2006) 19% Point prevalence all stages (2005)

Pressure Ulcers Localized injury to the skin and/or underlying tissue usually over a bony prominence Risk factors Pressure Shear Friction Moisture Host Factors Mobility Incontinence Nutritional Status Skin Perfusions Neurological Diseases

Cost of Treatment Cost to heal one ulcer: Anuual cost: $5000-$25,000 USD Anuual cost: over $5 billion USD Bennet et al., 2004

Pressure Ulcer Staging System Blancheable Erythema (BE) Stage I Stage II Stage III Stage IV Stage X

Blancheable Erythema A reddened area of unbroken skin over a bony prominence.

Stage I Ulcer Non-Blanchable Erythema A red discoloration of unbroken skin over a bony prominence NPUAP, 2008

Stage II Ulcer Stage II Ulcer Partial thickness skin loss involving the epidermis and/or dermis NPUAP, 2008

Stage III Ulcer Stage III Ulcer Full thickness skin loss over a boney prominence, involving damage of the subcutaneous tissue NPUAP, 2008

Stage IV Ulcer Stage IV Ulcer Full thickness skin breakdown involving complete loss of the epidermis, dermis, subcutaneous tissue and possibly extending into muscle, bone and joint. NPUAP, 2008

Stage X Ulcer Stage X Ulcer Cannot be accurately stage due to the presence of necrotic tissue covering the wound base NPUAP, 2008

Braden Scale

Nutrition and Wound Healing Nutrition to promote optimal wound healing Positive nitrogen balance Adequate total calories Nutrition risk indicators Low albumin (<3.5 mg/dL) Low body weight (<85% ideal body wt) 5-10% significant wt loss over one month Low serum transferrin (<170 mg/dL)

Nutrition Status & Wound Healing Malnourished Individual Well-Nourished Individual Adapted from Furguson et al., 2000

Study Aims & Objectives Determine whether dietitians are being appropriately referred for consultation to provide nutritional care for patients at risk for skin breakdown with a nutritional deficit as identified by the Braden Scale. Describe the nutritional interventions currently implemented for patients at risk for skin breakdown with a nutritional deficit.

Study Methods Data Collection: Nov to Dec 2007 Cluster Sampling Patient medical charts Cluster Sampling Inclusion criteria Documented Braden Score <18 – indicative for pressure ulceration Nutritional Deficit 2 or less on the nutrition subscale

Variables Explored Presence/ reason for dietitian consultation Nutritional intervention Age, room location Ulcer site/ stage Lab data Serum protein albumin Total lymphocyte count

Study results and Discussion 147 charts reviewed 42 (28.6%) met the inclusion criteria 15 males 27 females Mean age: 78 Mean documented Braden score: 14.6 (indicative of pressure ulceration)

42 Met Inclusion Criteria 147 Charts Reviewed 42 Met Inclusion Criteria Dietitian Consult Pressure Ulcer 10 11 10 Poor intake x9 Skin breakdown x5 Diet teaching x2 Nutrition support x1 Other x4 Stage I x10 Stage II x3 Stage III x5 Stage IV x0 Undefined x3 11

Were RD appropriately referred? Dietitian Consult Pressure Ulcer 10 11 10 Poor intake x9 Skin breakdown x5 Diet teaching x2 Nutrition support x1 Other x4 11 Only half of the identified high risk patients in this study were appropriately referred to the dietitian for nutrition care.

Nutritional Interventions Stage I Ulcers Incidence of treatment Incidence rate of treatment Nutrition assessment 2 100% Energy 30 kcal/kg PRO 1.2g / kg Fluid 27-30 mL/kg Cannot be determined N/A Multivitamin

Nutritional Interventions Stage II Ulcers Incidence of treatment Incidence rate of treatment Nutrition assessment 2 100% Energy 30-35 kcal/kg PRO 1.2g / kg 1 50% Fluid 25-30 mL/kg Cannot be determined N/A Multivitamin

Nutritional Interventions Stage III Ulcers Incidence of treatment Nutrition assessment 4 100% Energy 30-35 kcal/kg 3 75% PRO 1.5-2.0 g / kg Fluid 35-40 mL/kg Cannot be determined N/A Multivitamin 2 Vitamin C 25-1000 mg/d 50% Elemental Zinc 25-50 mg/d

Nutritional Interventions Undefined-Stage Ulcers Incidence of treatment Nutrition assessment 3 100% Energy 30-35 kcal/kg 2 66.7% PRO 1.5-2.0 g / kg 1 33.3% Fluid 35-40 mL/kg Cannot be determined N/A Multivitamin Vitamin C 25-1000 mg/d Elemental Zinc 25-50 mg/d

What nutritional wound care interventions are implemented? Dietitian Consult Pressure Ulcer 10 11 10 Poor intake x9 Skin breakdown x5 Diet teaching x2 Nutrition support x1 Other x4 Stage I x10 Stage II x3 Stage III x5 Stage IV x0 Undefined x3 11 Nutritional would care interventions as usually provided as recommended by the literature and practice guidelines when dietitians were involved

Study Conclusions Half were appropriately referred Pt most often received nutritional intervention when dietitians involved Consequently, high risk patients not receiving appropriate nutritional care Development of pressure ulcers Delayed wound healing

Study Limitations Data not always complete Small Sample Size Variables explored Undocumented Braden score Small Sample Size Pressure ulcers with undefined stage

Relevance to Practice Nutrition is an important factor to promote wound healing Dietitians are key players in multidisciplinary team More effective referral system Anticipated changes in Wound and Skin Care Policy Acknowledge the importance of nutrition in wound healing process document nutrition risk indicators

References Canadian Association of Wound Care [Internet]. [Toronto, ON]: Pressure ulcer awareness: prevent pressure ulcers. [cited 2008 June 14]. Available from: http://www.preventpressureulcers.ca/decision-maker/decision-maker.html. National Pressure Ulcer Advisory Panel [Internet]. [Toronto, ON]: Updated Staging System. [cited July 3]. Available from: http://www.npuap.org/ Bennett G, Dealy C, Posnett J. The cost of pressure ulcers in the UK. Age and Ageing. 2004. 33(3):230-235.

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