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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. Agenda. Prevalence of pressure ulcers

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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

agenda
Agenda
  • Prevalence of pressure ulcers
  • Pressure ulcer risk factors
  • Pressure ulcer stage classification
  • Braden scale
  • Nutrition and wound healing
  • Study Results
  • Relevance to Practice
prevalence of pressure ulcers
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)
pressure ulcers
Pressure Ulcers

Localized injury to the skin and/or underlying tissue usually over a bony prominence

Risk factors

cost of treatment
Cost of Treatment
  • Cost to heal one ulcer:
    • $5000-$25,000 USD
  • Anuual cost:
    • over $5 billion USD

Bennet et al., 2004

pressure ulcer staging system
Pressure Ulcer Staging System
  • Blancheable Erythema (BE)
  • Stage I
  • Stage II
  • Stage III
  • Stage IV
  • Stage X
blancheable erythema
Blancheable Erythema
  • A reddened area of unbroken skin over a bony prominence.
stage i ulcer
Stage I Ulcer
  • Non-Blanchable Erythema
    • A red discoloration of unbroken skin over a bony prominence

NPUAP, 2008

stage ii ulcer
Stage II Ulcer
  • Stage II Ulcer
    • Partial thickness skin loss involving the epidermis and/or dermis

NPUAP, 2008

stage iii ulcer
Stage III Ulcer
  • Stage III Ulcer
    • Full thickness skin loss over a boney prominence, involving damage of the subcutaneous tissue

NPUAP, 2008

stage iv ulcer
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

stage x ulcer
Stage X Ulcer
  • Stage X Ulcer
    • Cannot be accurately stage due to the presence of necrotic tissue covering the wound base

NPUAP, 2008

nutrition and wound healing
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)
nutrition status wound healing
Malnourished IndividualNutrition Status & Wound Healing
  • Well-Nourished Individual

Adapted from Furguson et al., 2000

study aims objectives
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.
study methods
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
variables explored
Variables Explored
  • Presence/ reason for dietitian consultation
  • Nutritional intervention
  • Age, room location
  • Ulcer site/ stage
  • Lab data
    • Serum protein albumin
    • Total lymphocyte count
study results and discussion
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)
slide20

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

were rd appropriately referred
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

what nutritional wound care interventions are implemented
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

study conclusions
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
study limitations
Study Limitations
  • Data not always complete
    • Variables explored
    • Undocumented Braden score
  • Small Sample Size
  • Pressure ulcers with undefined stage
relevance to practice
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
references
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.
thank you

Thank You

Questions & Comments