EUROPEAN PRESSURE ULCER ADVISORY PANEL

NUTRITION POLICY FOR PATIENTS WITH PRESSURE ULCERS IN DUTCH NURSING HOMES

J.M.G.A. Schols, MD, PhD, Medical Director, Nursing Home De Riethorst, Geertruidenberg, the Netherlands; and Department of Nursing Home Medicine, University of Nijmegen, the Netherlands, and C.N. Kleijer, RD, MSc, Healthcare Scientist/Dietitian, Nutricia Nederland B.V., the Netherlands.

The Netherlands has approximately 330 nursing homes, mainly intended for the (long term) care, treatment and support typically of elderly patients who may present with complex problems. These nursing homes are probably best compared to ‘long term care hospitals’ in the UK, although in several respects they are further advanced. Approximately 35,000 patients are admitted to nursing homes every year and most of them remain for extended periods of time; many even until death. In addition to the most frequent main diagnoses of CVA (Cerebrovascular Accident) and dementia, a considerable degree of comorbidity and polypharmacy is often present. The need for care is usually considerable for both the mobility and physical condition of patients are often poor. In addition to these health problems, patients in nursing homes are regularly confronted with the problem of complicating pressure ulcers. Pressure ulcers, however, are seldom the primary reason for admission1. According to the National Nursing Home Registration System (SIVIS)1, only in 0.4% of cases are pressure ulcers listed as the primary diagnosis for admission to a nursing home while in a further 2% of all cases, pressure ulcers are listed as being the second or third diagnosis. SIVIS, however, records only the most severe stages (Grades 3 and 4) of pressure ulcers. Furthermore, only a maximum of three diagnoses can be coded in this registration scheme, so where multiple pathologies exist the selection of the second and third coded diagnosis may under-represent the prevalence of pressure ulcers.

Since 1998, the annual ‘Dutch Prevalence of Pressure Ulcers Study’ records a point prevalence of pressure ulcers across various types of health care institution. From this study the prevalence of pressure ulcers in nursing homes was 32.4% in 1998 and 28.9 % in 1999 (these prevalence rates include all stages of pressure ulcers and not just the most severe)2,3. Additionally almost 77% of the encountered pressure ulcers had developed within the nursing homes.

While many nursing homes have operated their own anti-pressure ulcer committees and anti-pressure ulcer protocols for several years, empirical findings suggest that until recently, the primary aim of these protocols was to ensure uniformity of pressure ulcer treatment. A common observation was that wound care comprised the greatest part of the local protocols with less attention given to preventive interventions with often only indirect or brief mention made of such interventions. Furthermore, the local guidelines also paid little attention to the roles and responsibilities of caregivers with similar scant regard paid to the evaluation or registration of pressure ulcers. More recently this situation has begun to change with the importance of an integrated approach to both pressure ulcer prevention and treatment recognised in an increasing number of nursing homes. In addition, the role of nutritional support in pressure ulcer prevention and treatment is also becoming increasingly evident in local protocols. Perhaps this greater attention to nutrition is partly a consequence of the 1998 recommendations by the government and the healthcare inspectorate that both nutritional and fluid intakes of nursing home patients had to be specifically and properly monitored4. Such policy recommendations stemmed from both public and professional debate regarding the administration of food and fluids to nursing home patients who were close to death; this debate arising following the reporting of a nursing home patient who was starved.

Currently in light of the 1998 recommendations regarding food and fluid intake, many nursing homes are reviewing their nutritional policies. While the main purpose of such reviews lies in the development of clear guidance for managing patients who have poor nutritional and fluid intakes, this attention also benefits pressure ulcer prevention. Frequently pressure ulcer patients present with a poor nutritional status and often a compromised physical condition. Adequate nutritional intake has been associated with good healing of pressure ulcers and may also be a component of successful pressure ulcer prevention5,6.

In order to discover what general nutrition policies covering nursing home patients with, or at risk of, pressure ulcers were now in place, a survey of all Dutch nursing homes was conducted in 1999. The current report summarises the main findings of this survey, which themselves were presented at the EPUAP Third Open Conference held in September 1999 and subsequently published in a Dutch magazine for nursing home practitioners7.

Method

The survey was conducted by sending a structured questionnaire to the head of medical services of every nursing home (n = 330) in The Netherlands. This questionnaire could be completed by the head of medical services themselves or delegated to another nursing home physician or the nursing home’s dietician (if present).

Three separate areas were highlighted in the questionnaire. The first section concerned the nursing home and its pressure ulcer activities. For example, did the home have an anti-pressure ulcer committee? Other issues raised in the first section of the questionnaire related to the home’s definition of pressure ulcers and the methods adopted to identify patients’ nutritional status. The second section concentrated upon the prevention of pressure ulcers; asking how was risk assessed, what preventive care was initiated and whether a formal protocol/policy for prevention was followed. Finally the last section considered pressure ulcer treatment. For example, was a specific pressure ulcer treatment policy/protocol followed, what nutritional support was provided for those with pressure ulcers and were logistical ‘bottle-necks’ encountered when following local policies and protocols. a ‘prevention’ section concerning questions about the presence or absence of a prevention protocol, the methods used for estimating the risk of pressure ulcer formation and the currently used prevention measures. The last section concerning ‘treatment’ focused on the existence of a treatment protocol, on nutritional measures taken in case of pressure ulcers and on possible bottlenecks in the carrying out of an anti-pressure ulcer policy in the institution.

Results

While the questionnaire was distributed to all nursing homes, responses were received from 89 homes, representing 27% of Dutch nursing homes. Nursing home physicians completed seventy-four per cent of the questionnaires, with only 6% completed by dieticians. The 89 nursing homes that completed the questionnaire cared for 15,941 patients, of these 57.5% (n = 9,161) were described as presenting with cognitive problems associated with advanced age. Nine hundred and sixteen patients were undergoing physical rehabilitation and were patients only on a temporary basis.

Most of the nursing homes respondents (63%) regarded pressure ulcers to be a co-morbidity superimposed upon the primary diagnosis. Figure 1 summarises the respondents’ opinions about the primary causes of pressure ulcers among nursing home patients with immobility the most commonly reported reason for ulcer development. Poor nutritional status was the second most common reason offered for the development of pressure ulcers in nursing homes.

The method through which nutritional status was determined is shown in Figure 2. Measurement of body weight was the most commonly reported assessment tool (reported by 86% of respondents). Dieticians were consulted to ascertain nutritional status by less than half (47%) of the responding nursing homes. Only a limited number of nursing homes used specific nutritional screening tools such as the MNA (Mini Nutritional Assessment Scale8). For most nursing homes (70%) determination of nutritional status is a standard procedure performed upon admission. Repeated assessments were scheduled bi-annually (10% of nursing homes), quarterly (6%), every month (27%) and in 4% of homes at weekly intervals. However over 50% of nursing homes only re-assessed their patients’ nutritional status upon changes in their medical condition.

Local policies and protocols for pressure ulcer prevention and treatment were common, with 84% of respondents having a systematic approach to pressure ulcer prevention (prevention policies were frequently combined with strategies for treatment). Frequently these local policies had been developed by local anti-pressure ulcer committees (reported by 74% of respondents). The most common professional groups upon these committees were physicians (74%), (tissue viability) nurses (71%), physiotherapists (57%), occupational therapists (53%), in only 24% of nursing home committees were dieticians represented. While local policies existed, 13% of nursing homes stated that their policy was never used, with a further 16% stating that the policy was only occasionally used. Typically local policies were only used by the professional groups (and by the individuals) represented on the anti-pressure ulcer committees.

Most respondents (87%) reported that pressure ulcer risk assessment was primarily based upon the judgements of the nurses in daily contact with patients, and in 58% of nursing homes the opinions of the physicians were also used to assess vulnerability. A judgement that a patient was vulnerable to developing pressure ulcers was frequently based upon the patient’s level of mobility (85% of nursing homes) or poor nutritional status (78% of homes). Other important cues used by the nursing homes included inspection of the skin (77% of homes) and consideration of the patient’s physical condition (65% of nursing homes).

Most of the nursing homes considered that the key interventions they adopted to prevent pressure ulcers were use of a special bed or mattress (97% of homes), regular changes of position (95%) and nutritional support (88%). Physical and Occupational therapists were commonly consulted; the physical therapist to advise on repositioning and the occupational therapist to adjust patients’ wheelchairs and guide the selection of seat cushions.

Turning to the nutritional intake of nursing home patients with pressure ulcers: most nursing homes that participated in this survey (70%) considered such intake to be inadequate. Despite this opinion, only ad hoc attempts were made to provide extra nutrients, primarily by enriching meals with additional protein, or by giving supplemental sip feeds. Sometimes patients were tube fed but this was rare for reasons related to funding rather than clinical need. While the nursing homes did consult dieticians (83% of respondents) and relevant nurses and care assistants (56% of homes) once the decision had been made to offer nutritional support, this consultation appeared not to be systematically conducted. Generally, nutritional interventions appeared to be restricted to those patients with the most severe pressure ulcers.

Finally, logistical problems that prevented the implementation of an effective institutional anti-pressure ulcer policy were reported. Financial problems were highlighted by 39% of the respondents. The limited budgets of many nursing homes hampered the use of both specific nutritional interventions (for example supplemental sip feeds) or the use of the latest wound dressings. Other logistical challenges were reported by 58% of nursing homes and included the increasing workload of the nursing home staff, the current shortage in nursing home personnel, and the limited knowledge of pressure ulcers among nursing home professionals.

Discussion

This study of course has limitations – it is merely descriptive rather than explanatory and the low response rate limits the extent to which the results can be generalised. In addition, responder bias may be present, perhaps only nursing homes with a particular interest in pressure ulcers could have responded. Nevertheless, our findings tend to agree with the conclusions of earlier studies.

Pressure ulcers are a common problem in Dutch nursing homes. The characteristics of the nursing home patients make them particularly vulnerable to developing pressure ulcers1. The reported causes for pressure ulcers offered in the current survey supports this view!

In most of the nursing homes that responded in this study, protocols for pressure ulcer prevention and treatment often developed by an anti-pressure ulcer committee, had been established. This emphasises the importance of pressure ulcer prevention and treatment in these homes. However, although the nursing homes did advocate a multidisciplinary approach, the participation of some professional groups, such as dieticians, needs to be strengthened. The expanded participation of dieticians is also highlighted by the observation that the nursing homes considered poor nutritional status to be an important factor in the development of pressure ulcers. It would appear that this belief regarding the importance of nutrition in pressure ulcer aetiology does not translate into taking appropriate actions to remedy a poor nutritional intake. Previously it has also been shown that nutritional support was offered only in a very low percentage of nursing home patients with pressure ulcers2,3. Given that most nursing homes now have access to a dietician it would be our recommendation that all anti-pressure ulcer committees have a dietician as a key member of the multi-professional team.

The advice offered to the anti-pressure ulcer committees by dieticians could include guidance upon the frequency and methods of nutritional assessment of nursing home patients. Beyond the role of the dietician there is a need for further support in the following key areas – how should vulnerability to pressure sore development be assessed, how should the progress of healing pressure ulcers be best documented and how can nursing homes better inform their staff regarding pressure ulcers and their prevention and treatment? Recently a national Steering Committee for Prevention and Treatment of Pressure Ulcers has been formed in The Netherlands12, perhaps this group will begin to offer further guidance for Dutch nursing homes.

In Dutch nursing homes patients are cared for by a multidisciplinary team drawn from the nursing home itself. Such a team typically consists of nurses/nursing assistants, one or more physiotherapists, an occupational therapist, a psychologist, a social worker/ a pastor, one or more activity leaders and a specific nursing home physician who also acts as the team leader. The availability of this internal multi-disciplinary team may distinguish Dutch nursing homes from all other long-term care institutions in the world. For every patient a separate and specific integral care plan is developed. This care plan tackles physical, psychological and social problems and also records the desired goals and interventions required to meet the goals of care. In our view nutritional problems should also be incorporated in this care plan. The incorporation of nutritional problems and solutions within patients’ care plans should be relatively straight forward given the existing organisation of Dutch nursing home care and is likely to have a minimal effect upon workload.

With respect to the cited logistical reasons hindering the implementation of effective pressure ulcer prevention and management, pressure ulcer care may benefit if issues of cost are considered in relation to the effectiveness of nutritional or wound healing products. Effective prevention and treatment of pressure ulcers should lower both the number of patients with pressure ulcers and the cost of pressure ulcer care within nursing homes (9–11).

1. SIG Jaarboek verpleeghuizen 1996. Utrecht: SIG Zorginformatie, 1997.
2. Bours GJJW, Halfens RJG, De Winter A. Landelijk prevalentie onderzoek decubitus. Resultaten eerste jaarlijkse meting 1998 op instellingsniveau. Universiteit Maastricht: Vakgroep Verplegingswetenschap. Stuurgroep Decubitus, 1998.
3. Bours GJJW, Halfens RJG, Joosten CMC. Landelijk prevalentie onderzoek decubitus. Resultaten tweede jaarlijkse meting 1999 op instellingsniveau. Universiteit Maastricht: Vakgroep Verplegingswetenschap. Stuurgroep Decubitus, 1999.
4. Staatstoezicht op de Volksgezondheid. Rapport: Zorg voor vocht, voeding en incontinentiebeleid in verpleeghuizen. Arnhem: Inspectie voor de gezondheidszorg, 1998.
5. Breslow RA. Nutritional status and dietary intake of patients with pressure ulcers: review of research literature 1943 to 1989. Decubitus 1991; 4: 16–21.
6. Breslow RA, Bergstrom N. Nutritional prediction of pressure ulcers. JADA 1994; 94: 1301–4.
7. Schols JMGA, Kleijer CN. Voeding bij verpleeghuispatienten met decubitus; weten is nog niet doen. Tijdschr Verpleeghuisgeneeskd 2000; 1: 9–12.
8. Guigoz Y, Vellas B, Garry PJ. Mini Nutritional Assessment: A practical assessment tool for grading the nutritional state of elderly patients. Facts and Research in Gerontology 1994; Suppl 2: 15–59.
9. Haalboom JRE. De behandeling van decubitus. Pharmaceutisch Weekblad 1991; 126: 82–7.
10. Haalboom, JRE. De kosten van decubitus. Ned Tijdschr Geneeskd 1991; 135: 606–10.
11. Haalboom JRE. Decubitus: een te voorkomen aandoening. Het actieplan. Medisch Contact 1997; 52: 1325–6.
12. Actieplan Stuurgroep Decubitus. Decubitus kan beter voorkomen worden! Actieplan: preventie van decubitus. Stuurgroep decubitus, Woerden: NIGZ, 1997.