1. 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

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
Pressure
Shear
Friction
Moisture
Host Factors
Mobility
Incontinence
Nutritional Status
Skin Perfusions
Neurological Diseases

5. Cost of Treatment Cost to heal one ulcer: Anuual cost:
$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. Nutrition Status & Wound Healing
Malnourished Individual
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 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

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
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

21. 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.

22. 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 mL/kg
Cannot be determined
N/A
Multivitamin

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

24. Nutritional Interventions Stage III Ulcers
Incidence of treatment
Nutrition assessment 4
100%
Energy kcal/kg 3
75%
PRO g / kg
Fluid mL/kg
Cannot be determined
N/A
Multivitamin 2
Vitamin C mg/d
50%
Elemental Zinc mg/d

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

26. 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

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 Small Sample Size
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:
National Pressure Ulcer Advisory Panel [Internet]. [Toronto, ON]: Updated Staging System. [cited July 3]. Available from:
Bennett G, Dealy C, Posnett J. The cost of pressure ulcers in the UK. Age and Ageing (3):

31. Thank You
Questions & Comments