The Importance of Nutrition in Reducing Pressure Ulcers

It is estimated that more than 2.5 million patients in the United States are being treated for pressure ulcers/injuries in acute care facilities each year and that 60,000 die from their complications.¹ Patients admitted to the hospital are typically sicker with increased comorbidities, and most likely have poor nutrition in the first place. We see these types of patients already in our outpatient clinics—living longer, sedentary lives, with obesity. The cost of treating a single full-thickness pressure ulcer/injury can be as high as $70,000, and the total costs for the treatment of pressure ulcers/injuries in the U.S. are estimated at $11 billion annually.² 

Preventing pressure ulcers/injuries has always been a challenge for healthcare providers from both a quality-of-care and economic standpoint. The Centers for Medicare and Medicaid Services (CMS) began Medicare non-payment for hospital-acquired conditions in October 2008 and finalized a rule in June 2011 that prohibits Medicaid payments for the additional cost of services that result from certain preventable healthcare-acquired illnesses or injuries.³ Pressure ulcers/injuries fall into this “Medicare and Medicaid preventable condition” bucket. The Hospital-Acquired Condition Reduction Program, in an effort to improve quality of care, penalizes the worst-performing hospitals by reducing their payments and rewards the top performers with financial incentives. Additional penalties include loss of reimbursement, an increased length of stay, and possible litigation. 

Addressing and maximizing a patient’s nutritional status is the key to preventing pressure ulcers/injuries as well as managing the ulcers when they do occur. Inadequate nutrition will increase the risk of a pressure ulcer/injury and will negatively affect the wound healing process if not addressed with chronic wound patients.

Peer Pressure

Our acute care hospital is located in a rural setting and is comprised of 96 beds. Over the years, our nosocomial pressure ulcer rate was decreasing, but as our hospital began a “zero patient harm” culture, the focus was to meet national benchmarks and hardwire a proven process. In 2016, I was recruited to assist our acute care hospital with decreasing our inpatient pressure ulcer occurrence, at the request of our chief executive officer and quality director. My efforts were to be evaluated based on actual outcomes, a challenge that I wanted to be part of to prove that having a multidisciplinary team can have a significant impact in reducing hospital-acquired injuries—and by team, I truly mean team involvement and impact. Often, hospitals discuss having a team but fail to include other disciplines, or there seems to be a territorial issue that diminishes the strengths of staff members of various disciplines. I’ve had first-hand experience with this issue as a physical therapist in the wound care world. 

Everyone at our organization understands the known statistics regarding patient malnutrition during admission and during hospital stay. As an example, the admitting nurse does a skin and nutritional assessment to recognize impairments and risk factors and involves necessary team members as a plan of care is developed. A registered dietitian and a wound care consult will be automatically generated if the electronic health record (EHR) chart triggers a risk for developing a pressure ulcer, if the patient has a history of wounds or an existing wound, to guide appropriate nutritional interventions. When swallowing problems exist, a speech therapist is consulted to assist patients with strategies implementing necessary treatments. Occupational therapy will assist with patients’ activities of daily living (ADL), utilizing devices to help patients become as independent as possible with feeding, meal preparation, and home strategies. A physical therapy screen will be generated if mobility impairment is triggered on admission while encouraging transfers to a chair for meals if not medically contraindicated. 

Our CNA, probably one of the most important team members, assists patients with feeding, inspects skin daily, and communicates with the team if the patient’s nutritional status begins to deteriorate. Physicians recognize the importance of implementing supplements promptly to avoid complications, decrease patients’ length of stay, and decrease readmission rates. Wound care nurses and dietitians reassess interventions and outcomes frequently while making adjustments based on objective data. The purchasing director stores an adequate amount of supplies and is open to new products based on collected and suggestive data. Case management leads a daily multidisciplinary huddle to discuss admitted patients and team concerns and address barriers to care. The administration supports our program financially as it promotes the zero patient harm ideology. 

Previously, in 1993, I was asked to help a hospital system with its wound care problems, and in 1994, I was sought after to start a multidisciplinary skin/wound care program at a large facility in another state. I’m proud to say that both programs were successful, but only because they were multidisciplinary and everyone had an important role that added up to total multidisciplinary care. The focus was early recognition of factors that could place patients at risk for developing complications and prompt interventions. At our facility, our team decided that adequate nutrition was the one important factor that will influence maintaining health and preventing diseases. The team met often to discuss patients who were at risk for pressure ulcers and/or were identified as malnourished followed by educating everyone on how they can intervene with proper nutritional strategies, and coordinating care.

At our hospital, the acute care wound department consists of a director and a nurse, both of whom are knowledgeable and hold multiple roles, including non-wound-care-related duties. They are utilized as wound care educators and consultants throughout the hospital while our bedside nurses perform daily treatments. This organizational structure is partly due to limited resources, and some clinicians may have hybrid positions to help our patients meet their needs. As the wound care service line director, it was important for me to recruit a multidisciplinary team to tackle nutrition. I wanted the program to revolve around education first and foremost while utilizing best practices. 

This was the beginning of a long journey, and what we continue to accomplish has been unimaginable. To determine success, we were looking at decreasing the number of nosocomial pressure ulcers/injuries from past collected data, maintain a record of consecutive days without the onset of a pressure ulcer, and reviewing charts to determine if consults and implementation strategies were deployed per policies.  

Where We Came From and Where We Are Going

The route to effective traditional care was to review current pressure ulcer preventative processes, collect/interpret data, and determine what was working and what was hindering progress. The major changes were educating everyone on how optimal nutrition or lack of impacts patient outcomes, nutritional best practices including how to properly determine the level of malnutrition, early recognition, and prompt deployment of nutritional interventions. We began utilizing available resources such as allowing the EHR to trigger consults upon admission and revamped our policies to give everyone the “rule book” including nutritional supplementation. Promoting the consistency of this established process based on findings by promoting education and accountability allowed our organization to achieve a zero pressure ulcer/injury, no-harm culture. 

Once we fully understood current nutritional protocol, the hospital’s acquired skin injury committee, a multidisciplinary team, was assembled. This team consisted of supervisors and directors from all units, nurses, dietitians, therapists, office managers, and quality directors. Environmental services and medical directors were also part of the team, but due to logistics, they were included as needed while being kept abreast of matters. This team met monthly with the same goal of eliminating nosocomial pressure ulcers/injuries. Once we identified the initial building blocks needed to support good nutrition—for example, risk assessment, guidance to current and future employees (policies and procedures, orientation, yearly skills validation), providing necessary tools to the bedside clinician (revamping the formulary and adding necessary equipment), proper education, a documentation platform, and accountability—the focus turned to the contributing factors for pressure ulcer/injury development, highlighted by nutrition.  

After reviewing and interpreting collected data, the one identified risk factor that we could immediately address and make an impact on was the recognition of patients who were malnourished upon admission and those who became malnourished during their stay. In other words, the idea was to concentrate in early recognition and deployment of a pressure ulcer/injury prevention program emphasizing a concurrent nutritional strategy. Early recognition by performing a nutritional screening at admission, identifying those patients at risk for pressure ulcers/injuries, and determining who is malnourished to perform an in-depth nutritional assessment were prioritized to promptly address malnutrition and nutritional supplementing as needed. We also began reviewing known statistics to determine where we stood pre-program deployment. Consider these findings in the literature on patient malnutrition: 

• Malnutrition is common in hospitalized patients in the U.S. and is associated with unfavorable outcomes, including higher infection rates, poor wound healing, longer lengths of stay, and higher frequency of readmission.⁴  
• Studies suggest between 24%-53% of hospitalized patients were malnourished; others estimate higher rates.^5,6
• Length of stay for malnourished patients was 12.6 days versus no malnutrition diagnosis of 4.4 days. Total cost of malnourished patient was $26,944 compared to $9,485.⁷  
• Malnourished patients have more than 50% higher rates of admissions within 30 days compared with those who are better nourished.⁷ 
• Evidence suggests 20%-50% of all patients are at risk for or are malnourished at the time of hospital admission, and yet a recent study shows that only 7% of patients are typically diagnosed with malnutrition during their hospital stay, leading to millions of cases left undiagnosed and potentially untreated.⁸ 
• Up to 31% of these malnourished patients and 38% of well-nourished patients experience nutritional decline during their hospital stay.⁹ 
• A 2016 analysis of U.S. hospital discharges reported average hospital costs for all non-neonatal and non-maternal hospitals stays were $12,500, while patients diagnosed with malnutrition had hospital costs averaging up to $25,200, depending on the type of malnutrition indicated.⁸  

After studying and dissecting our data, it was established that malnutrition was not a common diagnosis, nutritional supplements were not consistently administered, and we had an opportunity to improve our processes. Armed with knowledge, as a team our nutritional strategy was adopted by our medical board and our hospital staff in an effort to do no patient harm.

Outcomes Focused

It’s been more than three years since we started this journey to prevent pressure ulcers/injuries. Addressing nutrition is one aspect of the overall pressure ulcer program, but having adequate nutrition plays a monumental role in the overall health, healing process, and hospital stay of the patient. After rolling out our strategic plan throughout the organization, we achieved 252 consecutive pressure ulcer-free days before encountering a stage 2 ulcer, followed by approximately 170 days before finding a deep tissue injury. As of this writing, we are 185 days and counting days with no pressure ulcer/injury incidence. Coincidentally, our length of stay improved overall during this time period. Also, by recognizing and documenting malnutrition properly, we were able to capture additional reimbursement on our hospitalized patients. n

Frank Aviles Jr. is wound care service line director at Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapy (PT)/wound care consultant at Louisiana Extended Care Hospital, Natchitoches; and PT/wound care consultant at Cane River Therapy Services LLC, Natchitoches.

1. Strategies for preventing pressure ulcers. Joint Commission Perspectives on Patient Safety. 2008;8(1):5–7. Available at https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_25_July_20161.pdf. Published July 2016.  

2. Cuddigan J, Ayello EA, Sussman C. Pressure ulcers in America: prevalence, incidence, and implication for the future. Adv Skin Wound Care. 2001; 14(4):208–15.   

3. New York State Department of Health. Provider-preventable conditions policy. Available at https://www.health.ny.gov/health_care/medicaid/quality/hac/policy/. 

4. Corkins MR, Guenter P, DiMaria-Ghalili RA, et al. Malnutrition diagnoses in hospitalized patients. JPEN J Parenter Entreal Nutr. 2014; 38(2):186–95. 

5. Pawellek I, Dokoupil K, Koletzko B. Prevalence of malnutrition in paediatric hospital patients. Clin Nutr. 2008;27(1):72-76.

6. Somanchi M, Tao X, Mullin GE. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition. JPEN J Parenter Enteral Nutr. 2011;35(2):209-216.

7. Agency for Healthcare Research and Quality. 2010 Healthcare Cost and Utilization Project. Available at https://www.ahrq.gov/data/hcup/index.html.

8. Weiss AJ, Fingar KR, Barrett ML, Elixhauser A, Steiner CA, Guenter P, Brown MH. Characteristics of hospital stays involving malnutrition, 2013. HCUP Statistical Brief #210. Available at https://www.hcup-us.ahrq.gov/reports/statbriefs/sb210-Malnutrition-Hospital-Stays-2013.pdf. Published September 2016. 

9. Braunschweig C, Gomez E, Sheean PM. Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. J Am Diet Assoc. 2000;100(11):1316-1322.