Applied nutritional investigationNutritional intakes of patients at risk of pressure ulcers in the clinical setting
Introduction
Malnutrition is a common and costly problem in the hospital setting, affecting as many as 20% to 50% of patients [1], [2]. Its consequences are severe and include impaired immunity, delayed recovery and healing, loss of muscle mass and function, and poorer quality of life [3]. Malnutrition increases hospital length of stay (LOS) and hospital costs among various groups of patients [4], [5], [6], and is also directly associated with the development and severity of pressure ulcers (PUs) [7], [8].
PUs place a large burden on both the patient and the health care system. The prevalence of PUs ranges from around 5% to 30% of all hospitalized patients [7], [9]. For the patient, PUs result in numerous medical complications, including increased risks for infection and mortality, and lengthy healing times [3], [10]. Other problems arising from PUs include pain, discomfort, decreased mobility and independence, wound exudates and odor, and social isolation [11], [12]. PUs result in severe consequences to the health care system, including increased hospital costs and LOS [13], [14].
Malnutrition has been associated with at least twice the odds ratio of having a PU [7]. Mechanisms by which malnutrition increases PU risk may be related to body composition, skin and tissue integrity, and mobility [3], [11], [15]. Low body weight may be associated with PU as a result of an increase in bony prominences and less fat tissue to distribute pressure [11]. Malnutrition also may result in impaired skin integrity and resistance to pressure owing to decreased nutrient availability for tissue maintenance and repair [3]. Furthermore, malnutrition is associated with decreased mobility, which is an independent risk factor for PUs [3], [15].
Oral or enteral nutritional supplementation in groups of older patients deemed at risk for PUs may contribute to PU prevention [16]. Although most studies have failed to reach statistical significance individually, likely because of small sample sizes, a meta-analysis found that the provision of oral or enteral nutrition support resulted in a 26% lower incidence of PUs in high-risk patients compared with routine care [16].
To our knowledge, no hospitals in Australia routinely prescribe oral nutrition support (ONS) to at-risk patients for the prevention of PUs. Given this, understanding the oral intake of patients at risk for PUs and factors determining oral intake in routine care is important if we are to ensure those at risk for PUs are eating adequately. Although investigations of dietary intakes of hospitalized patients have been conducted [17], [18], [19], [20], to our knowledge, no studies have described nutritional intakes among a group of patients at risk for PUs. Therefore, it is unknown whether the current knowledge about the intakes of hospital patients in general can be applied to patients at risk for PUs. The aim of this study was to describe the nutritional intakes of hospitalized patients at risk for PUs, and predictors of inadequate energy and protein intakes.
Section snippets
Study overview
A multisite, observational study was undertaken, consisting of two components: 24-h observations and chart audits. Ethical approval was gained through Queensland Health (reference no. HREC/11/QTHS/111) and Griffith University (reference no. NRS/40/11/HREC).
Setting
Data collection was conducted in four medical wards (renal, immunology, respiratory medicine, and general medicine) at two public metropolitan hospitals in Southeast Queensland, Australia. A randomized data collection schedule was used to
Results
A total of 241 patients were recruited and participated in the study; however, complete data was available for only 184 patients. Patient characteristics for these 184 patients are summarized in Table 1. There were significant differences between sites regarding LOS and serum albumin. The most common diagnoses were infection (22.3%), respiratory disease (16.3%), and gastrointestinal disease or condition (6.5%). The most common comorbidities were hypertension (48.9%), chronic obstructive
Discussion
This study directly observed the oral intakes of hospital patients in an attempt to understand factors associated with improving dietary intake in patients at risk for PUs. Predictors of eating inadequately (i.e., intake of <75% EER and EPR) were being on the renal ward, and the absence of any intake of ONS.
Mean energy and protein intakes in this study are comparable to previous studies describing the intakes of general hospitalized patients [17], [19], [20], [32]. Many patients at risk for PUs
Conclusion
Many hospitalized patients at risk for PUs have insufficient oral intakes to meet their requirements. Predictors of eating inadequately were being on the renal ward and lack of ONS intake. Nutritional interventions targeting PU prevention should focus on ONS and consider other factors that may influence oral intake.
Acknowledgments
The authors acknowledge Sharon Latimer for her role in data collection. This research received funding from the Area of Strategic Investment Health and Chronic Diseases, Griffith University.
References (38)
- et al.
Prognostic impact of disease-related malnutrition
Clin Nutr
(2008) - et al.
Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days
J Am Diet Assoc
(2000) - et al.
Malnutrition and pressure ulcer risk in adults in Australian health care facilities
Nutrition
(2010) - et al.
Prevalence of pressure ulcers in hospitals in Brazil and association with nutritional status—a multicenter, cross-sectional study
Nutrition
(2013) Pressure ulcer prevalence, incidence, risk factors, and impact
Clin Geriatr Med
(1997)- et al.
Nutritional status and associations with falls, balance, mobility and functionality during hospital admission
J Nutr Health Aging
(2011) - et al.
Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis
Ageing Res Rev
(2005) - et al.
Food intake in 1707 hospitalised patients: a prospective comprehensive hospital survey
Clin Nutr
(2003) - et al.
Incidence of nutritional risk and causes of inadequate nutritional care in hospitals
Clin Nutr
(2002) - et al.
Helping understand nutritional gaps in the elderly (HUNGER): a prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients
Clin Nutr
(2011)
Assessment of food intake in hospitalised patients: a 10-year comparative study of a prospective hospital survey
Clin Nutr
Risk assessment scales for pressure ulcers: a methodological review
Int J Nurs Stud
A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients
Nutrition
ESPEN Guidelines for nutrition in liver disease and transplantation
Clin Nutr
High food wastage and low nutritional intakes in hospital patients
Clin Nutr
Mechanisms of altered regulation of food intake in chronic kidney disease
J Ren Nutr
Handgrip strength predicts pressure ulcers in patients with hip fractures
Nutrition
The effects of enteral tube feeding and parenteral nutrition on appetite sensations and food intake in health and disease
Clin Nutr
Prevalence of malnutrition in adults in Queensland public hospitals and residential aged care facilities
Nutr Diet
Cited by (17)
Construction of a Risk Prediction Model for Intraoperative Pressure Injuries: A Prospective, Observational Study
2021, Journal of Perianesthesia NursingNutrition and healing
2020, Actualites PharmaceutiquesHealth practitioner practices and their influence on nutritional intake of hospitalised patients
2019, International Journal of Nursing SciencesCitation Excerpt :Malnutrition can also develop in hospital as a result of decreased protein-calorie intake [9]. Several reports of patients' dietary intake in hospital suggest that the majority of patients eat inadequately to meet their nutritional needs [10–13] and that patients may feel hungry and have difficulty accessing food [14]. A number of complex and interrelated barriers may prevent adequate dietary intake in the acute medical setting, including patient-related factors and aspects of the hospital environment [9] including interruptions and lack of mealtime assistance [15].
The expert's guide to mealtime interventions – A Delphi method survey
2018, Clinical NutritionCitation Excerpt :The survey of experts emphasised the importance of engendering a high level of commitment to address patient mealtimes in the acute care setting. Given that the literature has good evidence to support prioritisation of mealtimes for particular patient groups such as the elderly [33,34], those undergoing rehabilitation or who are cognitively or functionally impaired [35–38] or patients at risk of pressure areas [39–41] it was seen as important to build a case for those patients who stand to benefit the most from these types of interventions. When discussing barriers and enablers to successful mealtime interventions, the many challenges in changing mealtime processes were acknowledged by experts.
A multi-faceted, family-centred nutrition intervention to optimise nutrition intake of critically ill patients: The OPTICS feasibility study
2016, Australian Critical CareCitation Excerpt :The provision of adequate nutrition to critically ill patients is recognised as an important therapeutic strategy to improve patient outcomes during hospitalisation and following discharge. However nutrition intake in the ICU32 and other hospital settings2,33 are often suboptimal and multi-faceted interventions aimed at improving nutrition intake have not always made a strong and sustained impact on calorie and protein intake.34 At the centre of many of these interventions is a nutrition champion, typically a health care professional, whose availability may be inconsistent and where the focus is often at the organisational level.35
SR was responsible for the conception and design of the study; collection, assembly, analysis, and interpretation of data; drafting and revision of manuscript; and approval of final version of manuscript. WC and BD were responsible for conception and design of the study; analysis and interpretation of data; drafting and revision of manuscript; and approval of the final version of the manuscript. ML and MB were responsible for interpretation of the data; drafting and revision of the manuscript; and approval of the final version of the manuscript.
The authors declare no conflict of interest.