Presented by: Vivian Cheng, Dietetic Intern 17 July 2008

1. 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

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

3. 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)

4. Pressure Ulcers Localized injury to the skin and/or underlying tissue usually over a bony prominence Risk factors

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

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

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

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

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

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

11. 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

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

13. Braden Scale

14. 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)

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

16. 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.

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

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

19. 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)

20. 42 Met Inclusion Criteria 147 Charts Reviewed 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

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

22. Nutritional InterventionsStage I Ulcers

23. Nutritional InterventionsStage II Ulcers

24. Nutritional InterventionsStage III Ulcers

25. Nutritional InterventionsUndefined-Stage Ulcers

26. What nutritional wound care interventions are implemented? Dietitian Consult Pressure Ulcer Nutritional would care interventions as usually provided as recommended by the literature and practice guidelines when dietitians were involved 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

27. 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

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

29. 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

30. 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.

31. Thank You Questions & Comments