Nutrition: A Key Link in Clinical Decision Trees

Advances in Skin & Wound Care, Nov/Dec 2004 by Posthauer, Mary Ellen

In 2003, Novartis Medical Nutrition, Fremont, MI, commissioned a panel of experts to develop a comprehensive pressure ulcer program for long-term-care facilities. As a result, the panel of physicians, nurses, dietitians, and physical therapists designed a unique series of decision trees intended to help guide clinicians working with elderly residents at risk for or currently being treated for pressure ulcers. Pressure ulcers are used as a quality indicator by the Centers for Medicare & Medicaid Services.

Decision trees are a systematic approach that reminds staff of the essential steps in approaching a unique clinical problem. Each individual tree expands on its components and develops that particular discipline's contribution to the overall care.

Panel Objectives

The panel's goal was to address the serious consequences of pressure ulcers, including lifestyle limitations, reduced selfesteem, altered body image, pain, delay in rehabilitation, and increased morbidity and mortality.1,2 To that end, the panel established these objectives:

* encourage a team approach to the care of chronic wounds such as pressure ulcers

* bring a cohesiveness to current facility wound care programs already in use

* offer guidelines to facilities without formal wound care protocols.

The panel developed a medical decision tree for the prevention and treatment of pressure ulcers. The physician uses this tree to refer the resident's care to the appropriate interdisplinary team member, such as nursing, nutrition, and physical therapy. Each discipline has its own decision tree to utilize in determining care for the resident.

Decision Tree in Action

After appropriate staff training, 5 Autumn Care long-term-care facilities in Virginia and North Carolina implemented the decision tree program (Figure 1, page 476). The new program was evaluated after 3 months. Nineteen residents who had either documented wounds or were at high risk for pressure ulcer development had been assessed.

In Group 1,12 residents were identified as being at high risk for pressure ulcers. Six residents did develop pressure ulcers during the 3-month period, with the wounds healing for 5 of the 6 residents during this time.

In Group 2, 7 residents had documented wounds at the start of the program: 5 had pressure ulcers, 1 had a stasis ulcer, and 1 had a surgical wound. At the conclusion of the 3-month trial period, wounds had healed in 5 of the 7 residents.

Implementing the decision tree process promoted collaboration between departments, especially nursing and dietary, and led to identification of nutrition and hydration issues that may not have been considered.

References

1. Clay M. Pressure sore prevention in nursing homes. Elder Care 1999 Dec-Jan 2000;11:19-24.

2. Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospital-acquired pressure ulcers and risk of death. J Am Geriatr Soc 1996; 44:1435-40.

3. Bergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992;40:747-58.

4. Pinchcofsky-Devin GD, Kaminski M Jr. Correlation of pressure sores and nutritional status. J Am Geriatr Soc 1986;34:435-40.

5. Chernoff R, Milton K, Lipschitz D. The effect of a very high protein liquid formula on decubitus ulcers healing in long-term tuhe fed institutionalised patients. Am Diet Assoc 1990;Octsuppl:A-130.

6. Breslow R, Hallfrisch J, Guy D, Crawley B, Goldberg AR The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc 1993;41:357-62.

7. Mullholland JH, Tui C, Wright AM, et al. Protein metabolism and bedsores. Ann Surg 1943;118:1015-23.

8. Position of the American Dietetic Association, Liberalized diets for older adults in longterm care. J Am Diet Assoc 2002;102:1316-23.

9. Thomas D, Ashmen W, Morley JE, Evans WJ. Nutritional management in long-term care: development of a clinical guideline. Council for Nutritional Strategies in Long Term Care. J Gerontol A Biol Sci Med Sci 2000;55:M725-34.

10. Thomas D. The role of nutrition in prevention and healing of pressure ulcers. Clin Geriatr Med 1997;13:497-511.

Mary Ellen Posthauer, RD, CD, LD

Mary Ellen Posthauer, RD, CD, LD, is a registered and licensed dietitian and CEO of M.E.P. Healthcare Dietary Services, Inc., in Evansville, Ind. Her company provides clinical and food service management to long-term-care facilities and group homes. She is a member of the National Pressure Ulcer Advisory Panel. The author has disclosed that she is on the speaker's bureau for Novartis Laboratories.