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

http://media.photobucket.com/image/obesity/goodbyetoallfat/OBESITY.jpg?o=7

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!