Nutrition: A Bed Fellow with Pressure Injury

1,426 views

Published on

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

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,426
On SlideShare
0
From Embeds
0
Number of Embeds
344
Actions
Shares
0
Downloads
19
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Nutrition: A Bed Fellow with Pressure Injury

  1. 1. 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
  2. 2. Topics  Nutritional status and association with PI  Nutrition in the prevention of PI  Nutrition in the healing of PI
  3. 3. Malnutrition Hoffer (2001) CMAJ
  4. 4. 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.
  5. 5. 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
  6. 6. 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
  7. 7. 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-Nutritionist or at risk of malnutrition  C = Severely malnourished Date: :…../…../…..
  8. 8. 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.
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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)
  15. 15. 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!
  16. 16. Australasian Nutrition Care Day Survey (Agarwal et al 2010) N=3125 from 56 hospital across Australia and NZ
  17. 17. 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
  18. 18. 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!
  19. 19. 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 EconomicCost($) Mean economic cost SAVING: -AU$5.4+3.9 million
  20. 20. 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)
  21. 21. How good is our nutrition care?
  22. 22. 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
  23. 23. 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
  24. 24. Australasian Nutrition Care Day Survey: % 24 hour food intake (Agarwal et al 2010) } N=3125 from 56 hospital across Australia and NZ
  25. 25. 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
  26. 26. Food and Nutrition Stat!
  27. 27. 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
  28. 28. Stratton et al 2003
  29. 29. Overnutrition (obesity) and PI
  30. 30. Nutrition in the PREVENTION of PI
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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.
  36. 36. Nutrition in the TREATMENT of PI
  37. 37. 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
  38. 38. 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.
  39. 39. 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?
  40. 40. 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)
  41. 41. 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)
  42. 42. 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
  43. 43. 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?
  44. 44. 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.
  45. 45. Acknowledgements: Research and work colleagues Let them Eat Cake! Prevent Malnutrition to Reduce Preventable Pressure Injuries!

×