Click here for the Wounds UK Home Page September 2005

European Pressure Ulcer Advisory Panel Guideline on Nutrition and Pressure Ulcers How up to date are you? Pressure ulcers and nutrition Poster presentations at the European Society for Parenteral and Enteral Nutrition 2005.	Welcome Back From Summer! It's now Bank Holiday Monday but rather than lazing at home I find the slow months of the Summer have ended and the Autumn conference season is now open. So here I am in Brussels at the 27th Annual Meeting of the European Society for Parenteral and Enteral Nutrition (ESPEN) to give a lecture of the epidemiology and economics of pressure ulcers. Pressure ulcers are not a large part of the agenda of ESPEN but in any discussion of the effects of nutrition and malnutrition they cannot be ignored. Two satellite symposia here have included presentations on pressure ulcers with Nutricia hosting discussion of a new systematic review on the links between pressure ulcers and nutrition. While this paper perhaps added little to the recent Cochrane review by Langer and colleagues on pressure ulcer prevention and pressure ulcers it was positive to find a multi-national group working on the intricate relationships between inadequate nutrition and pressure damage. This new review is expected to be published later this year and this newsletter will cover the report in greater detail when it enters the public domain. Along with Nutricia, Nestle have entered the area of nutrition and pressure ulcers and later today my session on the scale of the problem of pressure ulcers is intended to set the scene for new clinical data. It will be good to see these manufacturers of products and services aimed at improving the nutritional state of people vulnerable to pressure damage attend and support UK wound care and tissue viability events. This issue of the newsletter will look at other pressure ulcer and nutrition initiatives reported during the poster sessions of the ESPEN meeting to bring you the latest information on the links between pressure ulcer development, their management and malnutrition. Michael Clark Editor	Keeping up to date with pressure area care Recent publications

Do You Know the European Pressure Ulcer Advisory Panel Guideline on Nutrition and Pressure Ulcers? In 2004 the European Pressure Ulcer Advisory Panel (EPUAP) released a clinical practice guideline on nutrition in pressure ulcer prevention and management. This guideline is available in eight languages and has been widely disseminated at wound care conferences and other events. But have you read this guideline? The EPUAP Nutrition Working Group is in the process of finding out how well the dissemination of the guideline has been with a simultaneous initial exploration of its implementation into practice. Over the autumn of this year all Trusts in England, all public health care institutions in the Netherlands and 300 health professionals in Germany will receive a questionnaire from EPUAP to find out the extent of the nutrition guideline dissemination and barriers to its implementation. Look out for this questionnaire and help EPUAP to find out how well its nutrition guideline has been disseminated in England. The next issue of this newsletter will contain further details of this survey and the results will be covered in a future issue early in 2006. Keep reading for: Pressure ulcers and nutrition - poster presentations at the European Society for Parenteral and Enteral Nutrition 2005. Keeping up to date with pressure area care Download this newsletter in PDF format Pressure ulcers and nutrition - poster presentations at the European Society for Parenteral and Enteral Nutrition 2005. This year three posters were presented at the ESPEN conference specifically related to pressure ulcers and nutrition. The format of this conference means that each poster is only displayed for a few hours to be then replaced the next day with a new poster allowing the conference to display 388 posters over its duration! The three pressure ulcer posters covered an experimental study of the effects of arginine, vitamin C and zinc on pressure ulcer healing (Crowe and colleagues, Australia), the cost savings that could be obtained through use of oral nutritional supplements in pressure ulcer healing (Elia and Stratton, UK) and the links between the prevalence of malnutrition and pressure ulcers in Dutch health care (Meyers and colleagues, Netherlands). Elia and Stratton proposed cost savings per patient of £5 for a grade 1 pressure ulcer rising to £460 for a grade 4 pressure ulcer following the use of oral nutritional supplements. However these cost savings were calculated using the projected costs of different grades of pressure ulcer published by Bennett and colleagues in 2003. In this cost model the treatment of a grade 1 pressure ulcer was over £1000 while the treatment cost of a severe pressure ulcer exceeded £10000. From these estimates the cost savings associated with the provision of oral nutritional supplements appear to be relatively small in the case of superficial pressure ulcers. Cost models such as that presented at ESPEN by Elia and Stratton do focus the mind upon the economic consequences of decisions to use (or not to use) specific interventions however the main weakness of such models is their reliance on imperfect background information upon the 'standard' cost of treatment - for example does it really cost over £1000 to treat a grade 1 pressure ulcer? Meyers and colleagues reported a national audit of the prevalence of malnutrition in Dutch health care organizations, with malnutrition defined as a Body Mass Index below 18.5 or unintentional weight loss greater than 6kg in the past six months or 3kg in the month preceding the audit. Malnutrition was also present if the BMI fell between 18.5 and 20 with no nutritional intake for three days or where the likelihood existed that no intake would occur for more than 10 days. Based on this definition then 28.8% of university hospital patients were malnourished in 2005 with 17.4% of nursing home patients also malnourished. The audit covering 258 health care organizations with 36354 patients also collected prevalence data upon pressure ulcers and incontinence but these parts of the audit were not reported in the poster presentation so we must wait for a future event to find out the links between the prevalence of malnutrition and pressure ulcers! Keep reading for: Keeping up to date with pressure area care Download this newsletter in PDF format Latest References In keeping with the nutrition and pressure ulcers theme of this issue of the newsletter here are a selection of publications retrieved from MEDLINE by combining the terms 'pressure ulcer', 'nutrition' and 'decubitus ulcer'. Dowsett J. Nutrition--module 1: Part 4--The importance of nutrition in wound healing. World of Irish Nursing 1996;4(4):15-8. Chernoff R. Policy: nutrition standards for treatment of pressure ulcers. Nutrition Reviews 1996;54(1 Pt 2):S43-4. Finucane TE. Rating long-term care facilities on pressure ulcers.[comment]. Annals of Internal Medicine 1996;125(6):520. Defloor T. [From accepted myths to proven action--decubitus prevention in home care].[see comment]. TVZ: Het Vakblad voor de Verpleging 1997;107(23):715-22. Anonymous. Study may produce new best practices. Healthcare Benchmarks 1997;4(11):161-2. Thomas DR. Specific nutritional factors in wound healing. Advances in Wound Care 1997;10(4):40-3. Hofmann-Rosener M. [Prevention of decubitus ulcers]. Pflege Aktuell 1998;52(2):111-5; quiz 116-7. Kamphausen U. [Decubitus ulcers--without end]. Krankenpflege Journal 1999;37(6):213-7. Adam S, Forrest S. ABC of intensive care: other supportive care. BMJ 1999;319(7203):175-8. Dolynchuk K, Keast D, Campbell K, Houghton P, Orsted H, Sibbald G, et al. Best practices for the prevention and treatment of pressure ulcers. Ostomy Wound Management 2000;46(11):38-52; quiz 53-4. Brown C. Building bridges to healthy skin. Treatment teams maximize healing. Provider 2000;26(5):suppl 4-6. Thomas DR. Issues and dilemmas in the prevention and treatment of pressure ulcers: a review. Journals of Gerontology Series A-Biological Sciences & Medical Sciences 2001;56(6):M328-40. Saltzman E. Nutrition in disease prevention & treatment. Caring 2002;21(8):22-4. Finucane TE. "Quality," nutrition, and pressure ulcers.[comment]. Archives of Internal Medicine 2002;162(1):100. Thomas DR. Are all pressure ulcers avoidable? Journal of the American Medical Directors Association 2003;4(2 Suppl):S43-8. Buchanan RJ, Wang S, Huang C. Profiles of nursing home residents with traumatic brain injury using the Minimum Data Set. Brain Injury 2003;17(6):507-23. Lyder CH. Pressure ulcer prevention and management.[see comment]. JAMA 2003;289(2):223-6. Clark M, Schols JM, Benati G, Jackson P, Engfer M, Langer G, et al. Pressure ulcers and nutrition: a new European guideline. Journal of Wound Care 2004;13(7):267-72. Horn SD, Bender SA, Ferguson ML, Smout RJ, Bergstrom N, Taler G, et al. The National Pressure Ulcer Long-Term Care Study: pressure ulcer development in long-term care residents. Journal of the American Geriatrics Society 2004;52(3):359-67.   Download this newsletter in PDF format