A New European Guideline
Joseph Schols, Michael Clark, Giuseppe Benati, Pam Jackson, Meike Engfer, Gero Langer, Bernadette Kerry, and Denis Colin
Introduction
Given that the occurrence of pressure ulcers is increasingly viewed as one indica- tor of the quality of care delivered to patients, the development, dissemination, and implementation of appropriate guidelines and policies covering aspects of pres- sure ulcer prevention and treatment have been of growing interest across all healthcare sectors.1Despite this focused attention upon pressure ulceration these wounds remain common, with almost 20% of hospital inpatients exhibiting some form of pressure-induced damage.2The development of pressure ulcers is admit- tedly complex, depending upon a wide variety of extrinsic and intrinsic risk factors. Extrinsic risk factors such as mechanical loads on the skin and soft tissues have been frequently discussed in the literature3 while intrinsic factors have recently been explored in a number of studies that have used logistic regression techniques to identify independent risk factors4–7with the following factors asso- ciated with the presence of pressure ulcers—age, sex, limitation in activity, need for assistance with the activities of daily living, bowel and/or bladder incontinence, elevated Braden scale score, anemia, infection, and nutritional status. However, the relative influence and importance of each of these factors remains unclear.
Interventions to correct many of the intrinsic risk factors are difficult. However, nutritional status is a factor that can be readily influenced by patients, their carers, and health professionals. Previous studies have indicated that poor nutritional status, a low body weight, and poor oral food intake are all independent risk factors for pressure ulcer development.8–15However, the exact causal relationships between nutrition and pressure ulceration remain unclear while there is also confusion regarding the precise role of various macronutrients and micronutrients in pres- sure ulcer prevention and healing.10,11Regardless of this uncertainty it is widely assumed that an adequate nutritional intake may help protect vulnerable patients from developing pressure ulcers.16,17Moreover, intake of oral supplements or tube feeding with a high content of protein may also improve the rate of wound healing.18More recently, a positive effect on wound healing was found following protein and energy supplementation, together with the use of arginine, trace ele- ments, and vitamins with antioxidant effects.19
Such assumptions need to be treated with some caution for they are based on relatively small studies, typically heterogeneous with regard to type of participants and intervention.20
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Regardless of the ambiguous nature of the evidence base implicating poor nutrition and pressure ulcers, the majority of healthcare professionals regard malnutrition as one of the main causal factors contributing to pressure ulcer devel- opment and delayed healing.21However, despite this conviction not only do most patients receive only limited nutritional attention; but even where this is given intervention is often started too late.22Perhaps one reason for the lack of inter- vention, or its delay, might be the relative lack of focus on nutrition within current clinical practice guidelines devoted to pressure ulcer prevention and management.
A recent study on the treatment of nutrition within pressure ulcer guidelines devel- oped across 13 countries identified a wide variation in their content related to nutrition and pressure ulcers.23If nutrition was mentioned at all, then the major- ity of guidelines focused on the need to prevent malnutrition, but were rather unspecific regarding how this was to be achieved. Most guidelines did not cover the full nutritional cycle from nutritional assessment, through nutritional inter- vention, to evaluation and follow-up of nutritional status; and it was also surpris- ing how seldom referral to a dietician was recommended. Furthermore, most of the reviewed guidelines paid little attention to the possibility of providing either nutritional supplements or tube feeding, which is surprising because, in practice, many patients with pressure ulcers or at elevated vulnerability may have difficulty in obtaining sufficient nutrients entirely from their normal food intake.
In 2002 the European Pressure Ulcer Advisory Panel (EPUAP) formed a working group to develop specific clinical guidance on the role of nutrition in pressure ulcer prevention and management. This project was initially led by Professor Gerry Bennett who sadly died in 2003. The entire working group would like to pay tribute to Gerry for his enthusiasm for and support of this EPUAP initiative. The objec- tive of the guideline development group was to prepare a clinical guideline that elaborated upon the comments about nutrition and pressure ulcers within the EPUAP’s existing guidelines on pressure ulcer prevention (1998) and treatment (1999). This chapter describes the process of constructing the guideline, its content stressing the importance of nutritional assessment and intervention, and subse- quent actions to enhance the practical implementation of the guideline.
Guideline Development Process
A multidisciplinary working group, with relevant healthcare professionals from six different countries, was established by Professor Bennett and subsequently facili- tated by Dr Clark. This working group met in Amsterdam to agree their objectives, after which all contact was by email and telephone. Previous literature that linked nutrition and pressure ulcers was identified through a search of Medline with hand-searching of relevant conference proceedings; this identified over 400 publi- cations. The abstracts were circulated to the working group and key papers identified for further review. In addition, the conclusions of, and studies reviewed within, a recent Cochrane Review on nutrition and pressure ulcer prevention and management were reviewed.20
Several drafts of the guideline were discussed within the working group with an advanced draft presented to delegates who attended the annual conference of the EPUAP held in Tampere, Finland in September 2003. Concurrently the draft was published within the EPUAP Review. Both the presentation and publication gen- erated comments which were used to guide the final version of the text. The final
text was published in the EPUAP Review early in 200324and the full guideline was launched at the 2nd World Union of Wound Healing Societies Conference held in Paris in July 2004; at the time of the launch the guideline had been translated into eight languages.
The Guideline
The essentials of the guideline are summarized below. To assist the implementa- tion of this new guideline additional work has been undertaken to draw out the essential elements of the guideline within a decision tree to aid practitioner deci- sion-making (Figure 10.1). The view of the EPUAP is that all people vulnerable to developing pressure ulcers or with established ulcers should undergo nutritional screening and that this screening should take place within the context of all other appropriate interventions and assessments relevant for the overall management of pressure ulceration. Where the nutritional screening (which may include the outcome from a validated nutritional assessment tool) indicates that the individ- ual may be malnourished then a comprehensive nutritional assessment should be performed by a dietician or member of a local nutritional team. Where patients are not considered to be vulnerable to malnutrition at the initial screening they should be monitored regularly, to identify any change in nutritional behavior.
Where assessment of nutritional status indicates that malnutrition may be present, nutritional interventions need to be initiated, taking into account patient choice and the expected outcome of treatment. Nutritional intervention should be imple- mented in combination with all other appropriate interventions including load management.
The primary goal of nutritional intervention is to correct protein-energy mal- nutrition, ideally through oral feeding. If enhanced oral feeding is not possible, protein-energy rich oral supplements should be considered14,15,17,19,25and in those cases where both normal feeding and oral supplementation fail to resolve appar- ent malnutrition then tube feeding may be undertaken although the potential risks associated with this intervention should be considered.
Where patients already have established pressure ulcers their nutritional demands may be greater. There are a number of observational studies which suggest that protein and calorie supplementation, along with the use of arginine, vitamins and trace elements with antioxidant effects, have a positive effect on pres- sure ulcer healing.14,15,17,19,25
The nutritional plan of care, as well as the criteria for monitoring its success should be clear to the patient, caregivers, and to the healthcare professionals regardless of the care setting.26How is success to be monitored? The outcomes of any nutritional intervention should be reviewed within ongoing regular nutritional assessments and may be indicated by such outcome criteria as increased weight, improved functional ability, and/or enhanced health-related quality of life. Suc- cessful nutritional intervention may also be measured by a reduced incidence and/or the improved healing of established pressure ulcers, although the direct attribution of these changes in the status of pressure ulcers to the nutritional inter- vention alone may be problematic given the concurrent deployment of other inter- ventions such as load management.
Where the nutritional interventions fail to meet the goals set with the pa- tient, further diagnostic tests may be required and/or the level of nutritional
Patient at risk of developing PU or with PU
NUTRITIONAL SCREENING
• clinical judgment
• weight (kg), height (m), BMI (kg/m2)
• screening tool (e.g. MUST)
NUTRITIONAL ASSESSMENT
this should be done preferably by a qualified member of a nutritional team
NUTRITIONAL INTERVENTION
Is it possible to achieve adequate oral intake with normal diet?
Can it be achieved using (specific) supplements in addition to normal diet?
Can adequate intake be achieved by partial or total enteral feeding?
Did this plan meet the goals set with the patient?
Refer to the nutrition team or reset the goals with the patient.
Plan includes patient’s choice and expected outcome
NO STEPS
FIRST
SECOND
THIRD
YES
NO YES
YES
NO YES
In association with all other appropriate
interventions according to guidelines REGULAR NUTRITIONAL FOLLOW-UP
NOT AT RISK OF
MALNUTRITION BMI (kg/m2) < 20
% weight loss > 10% in 6 months or > 5% in 1 month high risk score from screening tool
AT RISK OF OR WITH MALNUTRITION
Figure 10.1 Decision tree on nutrition in pressure ulcer (PU) prevention and treatment.
intervention may need to be increased. In these cases the goals of the interventions may need to be reset with the patient.
Discussion
The nutritional guideline presented in this chapter extends the existing EPUAP guidelines on pressure ulcer prevention and treatment. The purpose of the guide- line is to provide clinicians with specific guidance on nutritional screening, assess- ment, appropriate nutritional intervention, and follow-up within the context of pressure ulcer prevention and treatment.
The EPUAP believes that the new guideline is generally appropriate across all healthcare settings although logistical issues may prevent full compliance with all aspects of the guideline (for example access to weighing scales and dieticians may be limited). EPUAP recognizes that other clinical guidelines on nutrition exist and that the specific guidance EPUAP offers on nutrition and pressure ulcers should be considered within the context of general guidelines on nutritional manage- ment.24Moreover, it is also clear that the evidence base that underpins nutritional support in pressure ulcer prevention and management must be strengthened and that this process will lead to greater understanding of the relationship between one important intrinsic risk factor and pressure ulceration and so ultimately strengthen this new guideline.
Having produced a guideline there is no guarantee that its recommendations will be implemented—EPUAP now needs to consider how best all those involved in pressure area care can be made aware of such issues as the performance of nutri- tional screening and assessment, the preparation, presentation and delivery of attractive and appetizing meals, and the use of appropriate nutritional supple- ments or tube feeding, if required. Such education and training will be an impor- tant step towards establishing a nutritional culture within all care settings.
Acknowledgments
This guideline and the subsequent development of the decision tree were made possible by an unre- stricted educational grant from Nutricia. The full text of the guideline can be downloaded from www.epuap.org
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