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Merrilyn Banks, PhD Advanced Accrediting Practicing Dietitian NHMRC Health Professional Research Training Fellow & Director of Nutrition & Dietetics, Royal Brisbane Women’s Hospital delivered this presentation at the Reducing Avoidable Pressure Injuries Conference. For more information about this annual event, please visit: www.healthcareconferences.com.au
Citation preview
NUTRITION : A Bed Fellow with
Pressure Injury
Merrilyn Banks PhD AdvAPD
NHMRC Health Professional Research Training Fellow
Director Nutrition & Dietetics, Royal Brisbane & Women’s Hospital
Topics
Nutritional status and
association with PI
Nutrition in the prevention of PI
Nutrition in the healing of PI
Malnutrition Hoffer (2001) CMAJ
Background Thomas et al (1996):
29% malnourished elderly on hospital admission.
At 4 weeks ….
well-nourished group: 9% had PI
malnourished group: 17% had PI
Patients malnourished at admission were twice as likely to develop PI
(Relative Risk=2.1; 95% CI 1.1-4.2)
Number of other studies cite association between nutrition risk factors and PI eg. Weight loss, poor intake.
Malnutrition in Qld Hospitals and
aged care facilities; and its
association with PI
AIM: To determine the
independent effect of
nutritional status on the
presence of PI in hospitalised
patients and residents of aged
care homes
Malnutrition in Qld Hospitals and
aged care facilities; and its
association with PI
Cross sectional point prevalence audits of
PI in Queensland public hospitals and
residential aged care facilities in
2002/2003
Dietitians independently determined
nutritional status using Subjective Global
Assessment (SGA) in a convenience sub
sample
Subjective Global Assessment
Subjective Global Nutrition Assessment (SGA)1. History
Weight Change Dietary Intake
change
GI symptoms,
for >2 weeks
Functional impairment
(nutrition related)
In 6 mths
_ kg _ %No change Change Duration : _ wks
Overall:
None Moderate Severe
In last 2 wks :
No change
Type of change:
solid Full liquid
liquid Starvation
None Nausea Anorexia Vomiting Diarrhoea Change in past 2 wks:
Improved No change Regressed
2. Physical (A = normal, B = mild - moderate, C = severe)
Subcutaneous fat loss: Muscle Wasting: Oedema : Ascites:
OVERALL RATING A = Well Nourished Signature: ….………………
B = Moderately malnourished Designation: Dietitian-Nutritionistor at risk of malnutrition
C = Severely malnourished Date: :…../…../…..
Malnutrition in Qld Hospitals
and aged care facilities; and its
association with PI
Data were pooled for each audit for acute
and residential facilities:
Percentage of well nourished, moderately
and severely malnourished was
determined.
Effect of nutritional status on presence of
PI determined by logistic regression,
controlling for age, gender, medical
specialty and facility location.
Facility type Moderately
malnourished
%
Severely
malnourished
%
Total Malnourished
% + SD
Acute 2002 (n=
774) (8)
28 7 35 + 4
Acute 2003
(n=1434) (16)
26 5 31 + 9
Residential
care 2002
(n=381) (5)
42 8 50
Residential
care 2003
(n=458) (5)
35 14 49
Banks et al Nutr Diet 2007;64:172-8
Prevalence of malnutrition in Qld
hospitals and racfs in 2002/2003
Results – Effect of nutritional status on
presence of PI Facility Malnutrition Adjusted OR
(95% CI)
p= Wald Chi
Square
Acute
(n=2208)
(16 hospitals)
Moderate
Severe
Total
2.2 (1.6-3.0)
4.8 (3.2-7.2)
2.6 (1.8-3.5)
<0.001
<0.001
<0.001
33.3 (2)
P=<0.001
14.8 (1)
P=<0.001
Residential
Audit 1
(n=381)
(5 racf)
Moderate
Severe
Total
1.7 (1.2-2.2)
2.8 (1.2-6.6)
1.9 (1.3-2.7)
<0.001
0.02
<0.001
12.2 (2)
P=0.002
13.4 (1)
P<0.001
Residential
Audit 2
(n=458)
(5 racf)
Moderate
Severe
Total
2.0 (1.4-2.8)
2.2 (1.5-3.1)
2.0 (1.5-2.7)
<0.001
<0.001
<0.001
28.5 (2)
P<0.001
24.6 (1)
P<0.001
Summary: Malnutrition occurs in about 30% of
acute and 50% of residential patients
Being malnourished increases the odds risk of having a PI by greater than 2 times
Severe malnutrition was associated with an even higher odds risk of having a PI in hospital (OR = 4.8)
Malnutrition is also associated with an increased number of PI and worst stages of PI for individuals
Comparison to previously published studies Nutrition factor Independent association
(statistically significant) Author (year) Setting, Country
Malnutrition (no definition provided)
OR = 1.9 (95% CI 1.4-2.6) for presence of PU
(Maklebust and Magnan, 1994) Acute setting,USA
Malnutrition (defined by objective measures)
RR = 2.1 (95% CI 1.1-4.2) for development of PU
(Thomas, 1996) Acute setting, USA
Poor food intake Data not provided (Ek et al., 1991) Acute setting, Sweden
Poor food intake
OR = 2.3 (95% CI 1.5-3.5) for presence of PU in males (not significant in females)
(Fisher et al., 2004) Acute setting, Canada
Food intake (not poor)
OR = 0.5 (95% CI 0.3-0.9) for development of PU
(Lindgren et al., 2005) Acute surgical setting, Sweden
Oral eating problems
OR = 1.4 (95% CI 1.1-1.8) for development of PU, compared to high risk residents that didn’t develop PU
(Horn et al., 2004) Aged care setting, USA
Weight loss OR = 1.4 (95% CI 1.1-1.9) for development of PU, compared to high risk residents that didn’t develop PU
(Horn et al., 2004) Aged care setting, USA
Weight loss OR = 2.2 (95% CI 1.1-4.5) for development of PU (stage 2 or greater)
(Allman et al., 1995) Acute setting, aged with activity limitation, USA
Body weight <54 kg OR = 1.3 (95% CI 0.7-2.4) >95 kg OR = 2.2 (95% CI 1.3-3.1) of development of PU
(Schoonhoven et al., 2006) Acute setting, Netherlands
BMI OR = 0.94 (95% CI 0.92-0.97) for presence of PU
(Casimiro et al., 2002) Aged care setting, Spain
Hypoalbuminaemia OR = 3.0 (95% CI 1.3-7.1) for presence of PU
(Allman et al., 1986) Acute setting, USA
Hypoalbuminaemia Data not provided (Ek et al., 1991) Acute setting, Sweden
Shanin et al (2010) Germany
Malnutrition
indicator
OR (95% CI) of
presence of PI
p=
Hospitals
n=4067
(22 hospitals)
Weight loss:
5-10%
BMI <18.5
Poor intake
3.3 (1.3-8.7)
4.0 (1.6-10.0)
4.0 (1.3-12.4)
0.014
0.003
0.015
Nursing
Homes:
n=2393
(29 NHs)
Weight loss:
5-10%
>10%
BMI <18.5
Poor intake
Probable
inadequate
intake
5.2 (2.3-11.9)
5.0 (1.1-23.0)
2.5 (1.5- 4.3)
2.5 (1.1-5.90)
1.4 (1.1-1.8)
<0.001
0.041
<0.001
0.03
0.006
Iizaka et al (2010) Japan Case controlled study of home care patients
290 with home acquired PI vs 456 without
Comprehensive assessment of factors associated with PI development:
Significant differences in:
Malnutrition status
Caregiver knowledge of nutrition
Mean Calorie intake
Adequacy of meal intake (3 per day)
Health professionals conducting nutritional assessments and adequacy of intake
Malnutrition significantly associated with PI development (OR=2.3 95%CI= 1.5-3.4)
Prevalence of malnutrition in Queensland
public hospitals - 2008
69.1%
26.7%
4.1%
Well nourished Moderately malnourished Severely malnourished
n= 2800 patients across 40 facilities
OR of developing PI = 2.2
No change since 2002 and 2003!
Australasian Nutrition Care Day Survey (Agarwal et al 2010)
N=3125 from 56 hospital across Australia and NZ
Co$ts of PU attributable to malnutrition
Data from 2002/2003 Qld public hospitals:
– Number of separations
– Incidence rate for pressure ulcer
– Effect of malnutrition in the development of pressure ulcer
– Effect of PU on length of stay
– Cost of a bed day
Economic cost of PU attributable to malnutrition in QH in 2002/2003 predicted as:
⇒ 3666 + 555 PU cases
⇒ 16050 + 5672 bed days lost to PU
⇒ $13 + 5 million – opportunity costs
Cost benefits of nutrition in
prevention of PI
Economic model was developed to predict:
– Number of cases of PU AVOIDED
– Number of bed days NOT LOST to PU
– The associated economic costs
IF an intensive nutrition support intervention was provided to all nutritionally at risk patients compared to standard care
+ Extra food and supplements
+ Extra FTE to assist with nutrition care
= Extra cost of $ 3.5 – 5.5 million per year!
Cost effectiveness of nutrition support
in prevention of PI in Qld 2002/2003
Cases of Pressure Ulcers Avoided versus Cost
-30,000,000
-25,000,000
-20,000,000
-15,000,000
-10,000,000
-5,000,000
0
5,000,000
0 1,000 2,000 3,000 4,000 5,000 6,000
Cases of Pressure Ulcers Avoided
Eco
no
mic
Co
st
($)
Mean economic cost SAVING: -AU$5.4+3.9 million
Causes of Malnutrition
Disease associated malnutrition is caused by:
Physiological factors, including:
Anorexia
Dysphagia
Malabsorption
Increased nutrient loss
Increased nutrient requirements
Wasting due to immobility
Compounded by inadequate nutritional intake….
Significant proportion of patients do not consume
enough food (Allison 2000, Sullivan et al 1999, Dupertiuis et al
2003)
How good is our nutrition care?
The HUNGER study - RBWH Mudge, Ross, Young, Banks
134 elderly medical patient:
Only 41% met estimated resting energy requirements
Poor intake due to:
• Poor appetite
• Higher BMI
• Having infection or cancer
• Delirium
• Need for assistance
No improvement was seen in intake between day 3 and day 7
Meals vs. requirements vs. intake
Energy reqt: 127kJ/kg (BMI<21); 110kJ/kg (BMI ≥21), Alix et al. (2007) Protein reqt: 1g/kg, Gaillard et al. (2008)
*
* Paired samples t-test p<0.001
Australasian Nutrition Care Day Survey:
% 24 hour food intake (Agarwal et al 2010)
}
N=3125 from 56 hospital across Australia and NZ
Summary Malnutrition at least doubles the risk of having PI
Malnutrition is also largely preventable, like PI
Patients at risk of PI and malnutrition ARE
OFTEN THE SAME !
Prevalence of PI decreasing but no change in
prevalence of malnutrition!
The incidence and prevalence of malnutrition
should also be regarded as a quality issue
similarly to PI
More action is required regarding the
identification of risk, prevention and treatment of
malnutrition, as it is for PI
Food and
Nutrition
Stat!
Extrinsic Factors
moisture friction shear temperature
poor nutrition age illness hypotension anaemia genetic/anatomy oedema peripheral circulation metabolic demand
IntrinsicFactors
Decreased Activity
Sensory Perception Decreased
Mobility
Risk factors
Stratton et al 2003
Overnutrition (obesity) and PI
Nutrition in the PREVENTION of PI
Nutrients and role in PI Protein Cell growth and repair,
turnover
Evidence for increased
needs in wound healing
Energy
(Calories)
Maintain weight, tissue
repair, spare protein
Evidence for increased
needs in inflammation
Arginine Promotes protein and
collagen formation;
stimulates immune system
Some evidence may
promote wound healing –
not definitive
Glutamine Fuel source for rapidly
dividing cells
Limited studies
Vitamin C Cofactor in production of
Collagen
Deficiency associated with
impaired immune function.
Higher doses of no benefit
Vitamin A Integrity of epithelial
surfaces.
No evidence greater than
NRVs required
Zinc Cellular proliferation and
immune function
No evidence greater than
NRVs required
Prevention - Literature
Cochrane Review (Langer et al 2008)
4 RCTs – mixed nutritional supplements
Other studies of poor methodological quality
Largest study (672 elderly patients) found nutritional
supplements reduced number of new PIs
Other 3 demonstrated lower incidence of PI in the
supplemented group but were too small to detect
clinically important differences as statistically significant.
Implications for Practice:
Elderly people recovering from acute illness appear
to develop fewer PI when given 2 daily supplement
drinks
Nutrition and prevention of PI – meta analysis
Delmi et al 1990 0.19 (0.01-4.09) 27
Ek et al 1991 0.81 (0.44-1.49) 472
Bourdel- Marchesson
et al 2000 0.72 (0.52-0.98) 971
Houwing et al 2003 0.83 (0.38-1.8) 160
Hartgrink et al 1993 0.72 (0.31-1.65) 168
Meta-analysis:
Stratton et al 2005
0.74 (0.62-0.88) 1798
Systematic review and meta-
analysis – Stratton et al 2005
Meta-analysis showed oral nutrition support
(4RCTs) and enteral tube feeding (1RCT),
particularly with high protein, were
associated with significantly lower
incidence of PU development in at risk
patients compared to routine care (by 25%)
Evidence to justify nutrition support,
especially high protein, in patients at
risk of PI
Recent studies:
Theilla et al (2007): A diet rich in EPA, GLA and
Vitamins A,C and E is associated with a
significantly lower occurrence of new PI in
critically ill patients with acute lung injury.
Gunnarsson et al (2009): Patient with hip
fractures receiving nutrition according to
guidelines developed fewer PIs (18% cf 36%).
Kalava et al (2011): No association between
Vitamin D and pressure ulcers in older
ambulatory adults.
Nutrition in the TREATMENT of PI
Nutrition and Treatment of PU Cochrane review 2003 (Langer et al):
Vitamin C - 2 RCTs – effects of Vitamin C
unclear
Protein - 1 RCT – some evidence about
effects of very high protein increasing rate of
healing
Zinc - 1 RCT – very small numbers – no
significant effects
All studies small and generally of poor
methodological quality – not possible to draw
any firm conclusions on the effect of nutrition
in treatment of PU
What about the specialised wound
healing formulas?
Studies comparing standard nutrition support
formula with disease-specific (PU) formula ie
enriched with arginine, ascorbic acid and
zinc:
All studies show trend towards enhanced
healing, especially with use of high protein
formula, but sample sizes or methodological
quality of studies still too small.
Wound healing formula studies:
Desneves et al
(2005)
Australia
Hospital
n=16 Standard vs +2
ONS vs +2 WHNS
Improved PI
healing in
treatment group
Small nos.
Tx group
malnourished?
Heyman et al
(2008)
Belgium
Long term care.
N=245
9 weeks WHNS
Improved PI
healing.
No control
Cereda et al
(2009)
Italy
Long term care
n=28 Standard vs
WHNS
Increased rate of
healing
Small nos.
Higher protein
Brewer et al
(2010)
Australia
Community SI
n=18 vs 17 historical
controls
Increased rate of
healing
Historical
controls
Van Anholt et al
(2010)
Netherlands
n=43 WHNS vs non-
caloric ONS
8 weeks
Increased rate of
healing
Non-caloric
control?
Chapman et al
(2011)
Australia
Community SI
n=43 WHNS – 14
non-compliant
Increased rate of
healing
Non-compliant
with other Tx?
Nutritional intake of patients
with PU
Studies show that protein
and energy intake, as well
as micronutrient intake do
not meet nutritional
requirements, and many
patients appear to need
(complete) nutritional
supplementation (Drambach
et al 2005; Raffoul et al 2006)
Guidelines: Nutrition in PI prevention
EPUAP/NPUAP
1. Screen and assess nutritional status of individuals at risk of PU
Use a valid nutrition risk screening tool
Nutrition risk screening policy and procedures
2. Refer individuals at nutrition risk and PI risk for nutritional assessment and support – dietitians, MDT etc.
Specifically:
Offer high protein mixed oral nutritional supplements and/or tube feeding in addition to usual diet (Strength of evidence = A)
Guidelines: Nutrition in PI treatment
EPUAP/NPUAP
1. Screen and assess nutritional status for individuals with PI (Evidence = C)
Refer for early assessment and intervention
Assess weight status
Assess ability to eat
Assess adequacy of nutritional intake
2. Provide sufficient Calories (Evidence = C)
Provide 30-35 Calories/kg
Liberalize dietary restrictions
Provide HPE foods or supplements
Consider tube feeding if intake inadequate
Guidelines: Nutrition in PI treatment
EPUAP/NPUAP 3. Provide adequate protein for positive nitrogen
balance
1.25-1.5g protein/kg/day
4. Provide and encourage adequate daily fluid intake for hydration
Monitor fluid status
Provide additional fluid if high losses
5. Provide adequate vitamins and minerals
Encourage intake of balanced diet
Offer supplements if intake poor or deficiencies confirmed or suspected (consider mixed nutritional supplement!)
? Consider arginine supplements – more research?
Summary:
Prevention is better than treatment!
Prevention and treatment of malnutrition and nutrient deficiencies
Identify patients at risk of malnutrition and provide extra nutrition.
If nutritional supplementation required:
Mixed nutritional supplements
Ensure good protein and energy intake
No evidence for supplementation of micronutrients beyond normal levels
Jury still out on use of specialised formula.
Acknowledgements: Research and work colleagues
Let them Eat Cake!
Prevent Malnutrition
to Reduce Preventable
Pressure Injuries!