HEALING FROM THE INSIDE OUT: THE ROLE OF NUTRITION AND WOUNDS. Hayley Cosh, RD Abbott Nutrition Adult Clinical Nutriton

Transcription

1 HEALING FROM THE INSIDE OUT: THE ROLE OF NUTRITION AND WOUNDS Hayley Cosh, RD Abbott Nutrition Adult Clinical Nutriton 1

2 DISCLOSURE STATEMENT Support for this program is provided by Abbott Nutrition This program is not intended for continuing education credits for any healthcare professional 2

3 PROGRAM AGENDA Highlight key issues in today s healthcare environment related to wounds Discuss principles of nutrition therapy and updated NPUAP Guidelines for prevention and treatment Review updated data on the use of HMB, arginine and glutamine in wound healing 3

4 TODAY THERE ARE NEW CONCERNS IN HEALTH CARE Stage 3 and 4 pressure injuries that occur after admission to a healthcare facility are not reimbursed by CMS 1 76% of 30-day readmissions have been identified as potentially preventable; more than half of the nation s hospitals a total of 2,597 will be penalized this year 2,3 Patient lawsuits are increasingly common in both acute and longterm settings with judgments as high as $312 million in a single case Accessed 8/9/2016, 2. Accessed 8/9/ Accessed 8/9/ Legal issues in the Care of pressure Ulcer Patients. Accessed 8/9/

5 SCOPE OF THE WOUND PROBLEM 1 Types of chronic wounds in the US are pressure injury, diabetic ulcer, venous ulcer, arterial ulcer, sickle cell ulcer, burns, traumatic wounds, and surgical wounds Stage 1 Stage million patients in the US are affected $25 billion is the current annual cost of chronic non-healing wounds in the US Stage 3 Stage 4 1. Sen CK, et al. Wound Repair Regen. 2009;17(6):

6 COMPARATIVE DIRECT MEDICAL COSTS OF CHRONIC, NON-HEALING WOUNDS Disease/Condition Annual Direct Medical Costs in the US Hospital Acquired Infections 1 Chronic, Non-Healing Wounds 2 CHF 3 Hypertension 4 Diabetes 5 $9.8 billion $25 billion $35 billion $42.9 billion $176 billion 1. Hospital Infections Cost Billions, Study Shows. Accessed 8/8/ Sen CK, et al. Wound Repair Regen. 2009;17(6): CDC Heart Failure Fact Sheet. Accessed 8/8/ Health Care Spending and Hypertension: The Cost of High Blood Pressure. Accessed 8/8/ The Cost of Diabetes. Accessed 8/8/

7 COMPARATIVE DIRECT MEDICAL COSTS OF CHRONIC, NON-HEALING WOUNDS Disease/Condition Annual Direct Medical Costs in the US Hospital Acquired Infections 1 Chronic, Non-Healing Wounds 2 CHF 3 Hypertension 4 Diabetes 5 $9.8 billion $25 billion $35 billion $42.9 billion $176 billion 1. Hospital Infections Cost Billions, Study Shows. Accessed 8/8/ Sen CK, et al. Wound Repair Regen. 2009;17(6): CDC Heart Failure Fact Sheet. Accessed 8/8/ Health Care Spending and Hypertension: The Cost of High Blood Pressure. Accessed 8/8/ The Cost of Diabetes. Accessed 8/8/

8 PRESSURE INJURY CAN INCREASE LENGTH OF STAY AND HOSPITAL READMISSIONS 1 51,842 hospitalized fee-for-service Medicare patients (1/1/2006 to 12/31/2007) Data extracted from the Medicare Patient Safety Monitoring System (MPSMS) 4.5% developed at least one new PI during their hospitalization LOS for those who developed a PI was 11.2 days vs 4.8 days for those who did not Odds ratio for readmission for those who developed a PI was 1.33 (p<0.001) 1. Lyder CH et al. J Am Geriatr Soc 2012; 60(9):

9 COSTS FOR STAGE 4 HOSPITAL ACQUIRED PRESSURE INJURY 1 A retrospective chart analysis of patients with stage 4 PI (19 pts 11 acute care, 8 community acquired) Costs included both treatment and secondary complications $127,185 during one hospital stay $124,327 for community acquired Stage 4 1. Brem et al. Am J Surg 2001:200 (4):

10 AVERAGE COST ASSOCIATED WITH STAGE 4 PRESSURE INJURY 1 Cost Component Average Cost/Episode ($) Hospital Accommodation 94, Laboratory 2, Radiology 4, Operating Room Services 5, Pathology 1, Ancillary Services 11, Consultation Services 1, Miscellaneous TOTAL COST 127, Brem et al. Am J Surg 2001:200 (4):

11 TRANSITIONS OF CARE Acute Post Care Hospital Home 11

12 CHARACTERISTICS OF AT RISK PATIENTS 1 Underlying medical condition(s) e.g. diabetes, renal disease, arterial disease Bedfast or immobile Incontinent Lack of sensory perception Nutritional compromise e.g. malnutrition, dehydration, underweight or overweight 1. Braden Risk Assessment Scale. Accessed 8/9/

13 NORMAL WOUND HEALING PROCESS Three predictable, overlapping phases Inflammation Proliferation Remodeling 1. Midwood K.S., Williams L.V., and Schwarzbauer J.E J Biochem cell Bio 36 (6): Chang H.Y et al., (2004). Gene Expression Signature of Fibroblast Serum Response Predicts Human Cancer Progression: Similarities between Tumors and Wounds. Public Library of Science 2 (2). 3. Thompson et al, NCP, 2005;20:

14 THE CHRONIC, NON-HEALING WOUND PROCESS Wound gets stuck in the inflammatory phase Inflammation Proliferation Remodeling 1. Midwood K.S., Williams L.V., and Schwarzbauer J.E J Biochem cell Bio 36 (6): Chang H.Y et al., (2004). Gene Expression Signature of Fibroblast Serum Response Predicts Human Cancer Progression: Similarities between Tumors and Wounds. Public Library of Science 2 (2). 3. Thompson et al, NCP, 2005;20:

15 FACTORS AFFECTING WOUND HEALING Intrinsic Systemic disease Perfusion/oxygenation Infection process Nutrition/hydration Medications Age Extrinsic Mobility Wound bed environment Bacterial burden Soft tissue/bone infection Devitalized tissue Nutrition/hydration is one of the most modifiable factor affecting wound healing 15

16 RELATIONSHIP BETWEEN LOSS OF LEAN BODY MASS (LBM) AND WOUNDS 1 LBM loss of >10% LBM loss of >20% Risk of wound development Wound healing ceases Wound healing is Impaired Risk of new wound development 1. Nutrition, Anabolism, and the Wound Healing Process: An Overview. eplasty. 2009;9: Available at Accessed 7/30/

17 BED REST, AGE AND HOSPITALIZATION INCREASE LOSS OF MUSCLE 0 Healthy Young 28 Days Inactivity 1 Healthy Elders 10 Days Inactivity 2 Elderly Inpatients 3 Days Hospitalization lb loss of muscle 2.2 lb loss of muscle 2.2 lb loss of muscle 1. Paddon-Jones D et al. J Clin Endocrinol Metab. 2004;89: Kortebein P et al. JAMA. 2007;297: Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, Ohio. 17

18 NUTRITION FOR PREVENTION AND TREATMENT OF PRESSURE ULCERS 1 Selected Recommendations from NPUAP 2014 Guidelines Nutrition Screening: Screen nutritional status at admission to a health care setting Care Planning: Develop an individualized nutrition care plan Follow relevant and evidence-based guidelines on nutrition Energy Intake: Provide individualized energy intake. Provide 30 to 35 calories/kg body weight Protein Intake: Provide adequate protein Offer 1.25 to 1.5 grams protein/kg body weight daily for adults Hydration: Provide and encourage adequate daily fluid intake for hydration Vitamins and Minerals: Provide/encourage a balanced diet that includes good sources of vitamins and minerals. Provide/encourage vitamin and mineral supplements when dietary intake is poor 1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia;

19 2014 NPUAP CLINICAL PRACTICE GUIDELINES FOR ENERGY 1 Offer high protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet, to individuals with nutritional risk and pressure ulcer risk because of acute and chronic disease, or following a surgical intervention. - Strength of Evidence: A 1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media:Osborne Park, Western Australia;

20 NUTRITION FOR TREATMENT OF WOUNDS 1 Selected Recommendations from NPUAP 2014 Guidelines Nutrition Screening: Screen nutritional status at admission to a health care setting Care Planning: Develop an individualized nutrition care plan Follow relevant and evidence-based guidelines on nutrition Energy Intake: Provide individualized energy intake. Provide 30 to 35 calories/kg body weight Protein Intake: Provide adequate protein Offer 1.25 to 1.5 grams protein/kg body weight daily for adults Hydration: Provide and encourage adequate daily fluid intake for hydration Vitamins and Minerals: Provide/encourage a balanced diet that includes good sources of vitamins and minerals. Provide/encourage vitamin and mineral supplements when dietary intake is poor 1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media:Osborne Park, Western Australia;

21 2014 NPUAP CLINICAL PRACTICE GUIDELINES FOR TREATMENT OF PRESSURE ULCERS 1 When an adult patient with a pressure ulcer Category/Stage III or IV or multiple pressure ulcers cannot meet nutritional requirements with traditional high-calorie and protein supplements, supplement with high protein, arginine and micronutrients. - Strength of Evidence: B 1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler, ed. Osborne Park, Western Australia: Cambridge Media;

22 INTRODUCING JUVEN : TARGETED NUTRITIONAL THERAPY HMB Week 1 Week 2 Juven clinically shown to support wound healing in as little as 2 weeks Week 0 Arginine Glutamine 22

23 B-HYDROXY- B-METHYLBUTYRATE (HMB) human clinical trials over the past 30 years Metabolite of amino acid leucine Occurs naturally in human muscle cells Found in small amounts in many foods (e.g., avocado, grapefruit, catfish) Inhibits intracellular protein degradation in muscle and supports intracellular protein synthesis in muscle by: Reducing the inflammatory response Protecting muscle from breakdown Protecting muscle from stress-related damage 1. Nissen SL, Abumrad NN. J Nutr Biochem. 1997;8: Wilson. Nutr Metab. 2008;5:1 3. Eley HL et al. Am j Physiol Endocrinol Metab. 2008;295:E Deutz NE et al. Clin Nutr ;32:

24 EFFECT OF HMB ON MUSCLE MASS AND STRENGTH DURING BED REST 1 Objective: To investigate the effect of HMB on muscle mass and strength that occur during 10 d bed rest To investigate the effect of HMB (+ exercise) on muscle recovery following the bed rest period Study Design: Randomized, double-blinded, controlled study Healthy elderly subjects (60 to 77 yrs; Average= 68 yrs) Ca-HMB (3 gm/d) versus Control 24 subjects (20 women; 4 men) Outcomes: Decline in muscle mass and function 1. Deutz NE et al. Clin Nutr Oct;32(5):

25 EFFECT OF HMB ON MUSCLE MASS AND STRENGTH DURING BED REST 1 Kg Change in Total Lean Mass (Female) 1. Deutz NE et al. Clin Nutr Oct;32(5):

26 3 MAJOR FUNCTIONS OF ARGININE IN WOUND HEALING 1 Arginine is a Key Amino Acid for Metabolic Pathways: Stimulant for Wound Healing Protein biosynthesis Enhances IGF-1 Mediates growth hormone Nitric Oxide production for intracellular signaling Vasodilates blood vessels Increases vascular permeability Support immune function Is directly bactericidal Used by macrophages and leukocytes to destroy pathogens 1. Patel JJ, Miller KR, Rosenthal C, Rosenthal MD. Nutr Clin Pract. 2016;31(4):

27 ROLE OF GLUTAMINE IN WOUND HEALING Glutamine may become depleted in patients with 1 : Critical Illness Increased metabolic demand Protein catabolism Glutamine is the most abundant amino acid in the body: GLUTAMINE >20% total circulating Amino acids >60% intracellular Amino acids Benefits of supplemental glutamine related to wound healing include 3 : Stimulation of collagen synthesis Regulation of nitrogen metabolism in catabolic states Immune support Gut integrity 1. Manpreet S, Mundi MD, Shah M, Hurt RT. Nutr Clin Pract. 2016;;31(4): Buhaescu I, Izzedine H, Covic A. Ther Drug Monit. 2006;28(5): Escobar J, Frank JW, Suryawan A, et al. Am J Physiol Endocrinol Metab. 2005;288(5):E914-E

28 EFFECT OF HMB, GLUTAMINE, AND ARGININE ON PROTEIN SYNTHESIS AND DEGRADATION f=p<0.001 from Control degradation g=p<0.001 from Cachectic degradation h=p<0.001 from Glut+ Arg degradation, using one-way ANOVA with Tukey-Kramer Multiple Comparison Test (n=6) a=p<0.01 and b=p<0.001 from Control synthesis c=p<0.001 from cachectic synthesis d=p<0.05 e=p<0.01 from HMB, Arg + Glut synthesis using one-way ANOVA with Tukey-Kramer Multiple Comparison Test (n=6) Source: Abbott on file 28

29 RECENT JUVEN PUBLICATIONS Study Objective Subjects Duration of Intervention with Juven Outcome with Juven Use of Bioelectrical Impedance (BIA) to measure wound healing 11 patients; ave age years; various wound types 12 weeks or until the wound closed 64% of patients had closure of their wounds 46% healed within 12 weeks Retrospective examination of the use of Juven in healing of diabetic foot wounds 11 diabetic patients; ave age 66 years 4 weeks 63.6% improved wound depth (p=0.006) 72.7% improved wound appearance (p=0.001) Examined the effect of Juven on wound healing Examined 9 subjects with diabetic foot ulcer FOPR the effect of Juven on wound healing 2 weeks Significantly higher hydroxyproline content at wound site +67.8% vs -78.4% (p=0.03) Examination of the effect of Juven on healing pressure ulcers with Juven 2 cases of elderly patients with renal dysfunction and pressure ulcer case 1 = 113 days; case 2 = 72 days Juven improved pressure ulcer healing with no effect on renal function. 1. Moore M et al. Phase Angle, an Alternative Physiological Tool to Assess Wound Treatment in Chronic Nonhealing Wounds. J Am Col Cert Wound Spec 2011;3: Sipahi S et al., The effect of oral supplementation with a combination of HMB, arginine and glutamine on would healing: a retrospective analysis of diabetic hemodialysis patients. BMC Nephrology 2013;14:8. 3. Jones M et al., Targeted amino acid supplementation in diabetic foot wounds: Pilot data and a review of the literature. Surgical Infections. 2014;15: Ogura Y et al., Treatment of pressure ulcers in patients with declining renal function using arginine, glutamine and HMB. J Wound Care 2015;24:

30 JUVEN CASE STUDY: FOOT ULCER Overview Charles, a 62-year-old male, had a 20-year history of diabetes mellitus when he developed a diabetic foot ulcer with osteomyelitis. In January, Charles sought medical attention after a crack on the bottom of his foot developed into a lesion. Tissue around the lesion was inflamed and necrotic Four weeks later, his wound-care team administered a debriding treatment Ulcer worsened and Charles developed osteomyelitis Charles was treated with IV antibiotics for the next 9 months August Before Juven therapy Wound-care team decided that the ulcer required a second debridement. After the procedure, wound measured 6.35 cm (L) x 5.08 cm (W) and 2.54 cm (H). Physician directed Charles to clean the wound, change the dressing daily, and take an oral antibiotic (levofloxacin) In spite of the debridement, good home care, and adequate nutrition, the wound continued to worsen Consulting physician recommended below-the-knee amputation and wound-care team recommended hyperbaric oxygen therapy 30

31 JUVEN CASE STUDY: FOOT ULCER October After 2 weeks of Juven therapy Faced with potential amputation and hyperbaric oxygen therapy, Charles s doctor suggested that he add 2 packets of Juven to his daily diet. Charles mixed 1 packet of Juven with 8 10 oz of water, twice a day After 2 weeks, Charles noticed his wound beginning to heal Charles continued to take Juven every morning and night for 6 weeks December After 14 weeks of Juven therapy Wound had reached remodeling phase. Charles returned to the wound care center for a follow-up visit Ulcer surface had diminished to 3.81 cm (L) x 1.27 cm (W) 31

32 NUTRITION THERAPY: A COST-EFFECTIVE INTERVENTION Add nutrition interventions to your wound care protocol Therapeutic nutrition is a highly cost-effective intervention to help prevent and treat pressure ulcers Brem et al reported cost of Stage 3/4 PI $127, If nutrition therapy costs $5/day, you could provide nutrition for 25,437 days (69 years) at an equal cost to treat one pressure injury! CONDITION One Stage 3/4 PI COST FOR CARE $127, NUTRITION COST (Equivalent) 25,437 days (69 years) 1. Brem et al. Am J Surg 2001:200 (4):

33 SAMPLE PRESSURE ULCER (PU) PREVENTION AND TREATMENT DECISION TREE WITH STANDING ORDERS Oral Nutrition Supplements (ONS) and Juven Are one or more of the following risk factors present 1? Age (over 50) 2 Surgery 3 Weight 4 Poor skin condition 5 Friction/Shear Yes Known Diabetes Mellitus or hyperglycemia 6? No Yes Diagnosis of Diabetes Mellitus or hyperglycemia present 6? Yes Standing Order 7 1. Diabetes specific meal plan 2. ONS 1-2 per day 8 For example: Patient receives 2 (8oz) Glucerna Shake per day 3. Nutrition Consult No No Standing Order No Standing Order 7 1. ONS 1-2 per day 8 For example: Patient receives 1 (8oz) Ensure Enlive or 2 (8oz) Ensure per day 3. Nutrition Consult Standing Order for PU If PU present on admission or diagnosed, add Juven 2 X day 9 Standing Order for PU If PU present on admission or diagnosed, add Juven 2 X day 9 Are one or more facility specific nutrition screening parameters present? 1. Low albumin Low protein intake Poor dietary Intake 12 Yes No Reassess every 24 hours 7 33

34 Pressure Ulcer (PU) Prevention and Treatment Decision Tree for Standing Orders Support and References 1. Risk factors. A simple prediction rule based on 5 hospital patient characteristics may help identify those at increased risk for pressure ulcer development. Age over 50, particularly age over 75, weight on admission of less than 119 lbs. and greater than 209 lbs., abnormal appearance of skin, potential for friction and shear, and surgery in the coming week were all independent predictors of PU development. Formula for calculation of risk can be found in Schoonhoven, Age. Up to 55% of patients admitted to the hospital are malnourished, particularly older individuals (McWhirter, 1994; Weekes, 1999). Older individuals have a variety of risk factors for malnutrition including polypharmacy, social isolation, depression, medical conditions, poor diet, socioeconomic factors, and dependency. Age over 50 increases risk of developing a PU (Schoonhoven, 2006). 3. Surgery. Surgical patients are at increased risk for PU development. 49% of cardiac surgery patients develop pressure ulcer in the operating room (Frankel, 2007) and 66% of orthopedic surgery patients develop PU (Versluysen, 1986). Even well-nourished patients can experience adverse outcomes if postoperative nutrition is delayed (Huckleberry, 2004). One study showed that even in patients with no risk for PU development before surgery (Braden Pressure Ulcer Risk Assessment Scale), 54.8% were observed to have a Stage I pressure ulcer within 6 days post-op. A study of 161 elderly surgical IUC patients examined risk factors for development of PU. Incidence of PU in this study was 40% and risk factors included: redness of the skin, duration of surgery, fecal incontinence and diarrhea, use of steroids and decreased total protein and albumin 1 DAY POST-OP (Versluvsen, 1986). 4. Weight. Underweight and low BMI are known risk factors for PU development. However, overweight creates risk for PU as well. Schoonhoven et al found that patients who weighed over 209 lbs had 2.2 x the risk compared to those who weighed between and 209 lbs. Those patients who weighed 119 lbs or less had 1.3 x the risk as those who weighed between 119 and 209 lbs. Underweight patients are at risk due to bony prominences placing stress on the skin. The condition is under-recognized and under-treated and can lead to decreased strength and mobility and diminished organ function. Overweight patients are at risk due to extra tissue causing stress/friction of the skin. Malnutrition under-recognized in this group and they have a greater risk for hyperglycemia, reduced circulation, and inability to reposition. Braunschweig et al found that upon admission, patients with severe malnutrition (assessed by SGA) were on the high end of normal weight (mean BMI 23.5) and at discharge, patients with severe malnutrition were overweight (mean BMI 25.7). 5. Skin condition. Characteristics include dry (particularly dry sacral skin) or unhealthy, thin skin. The skin is largest organ in the body and plays important role in preserving fluid balance, sensation, and body temperature (Scoonhoven, 2006). 6. Diabetes Mellitus/hyperglycemia. Diabetes increases risk of PU by 60% (Resnick, 2008). 4.2 million hospitalizations occur annually among people with diabetes, 1.5 million hospitalizations occur with significant hyperglycemia and no history of diabetes. Nutritional factors that increase risk include dehydration (can compromise skin integrity) and PEM (decreases collagen synthesis increases loss of lean body mass). Hyperglycemia causes tissue ischemia (decreased microcirculatory function) increasing the risk of poor skin condition (Fromy, 2005). 7. Standing orders. An immediate practice change may be necessary to efficiently provide supplemental nutrition for patients to reduce development of PU. In a pilot for the SKIN PU prevention program at Ascension Health, researchers found that 87% of the time a nutritional consult had been ordered for patients with PU, but were carried out only 35% of the time. This lead to medical-staff-approved standing orders for dietitians. Due to this comprehensive program, PU incidence was reduced to >1% with no new Stage III or IV PU (Gibbons, 2006). 8. Oral nutrition supplements (ONS). In a randomized, prospective multi-center trial of 672 acute care, older patients, 200 kcal supplements 2x day were shown to decrease the incidence of PU development (Bourdel-Marchesson, 2000) A meta-analysis of 15 studies of elderly, post-surgical, hospitalized patients showed that ONS of kcal/day significantly reduced risk of developing pressure ulcer by 25% compared to routine care (Stratton, 2005). The ESPEN 2006 guidelines for geriatrics give ONS an A rating, stating that ONS, particularly high protein ONS, can reduce the risk of developing pressure ulcers (Vulkert, 2006). 9. Juven. Juven has been clinically shown to help build lean body mass and support healing (May, 2002; Clark, 2000; Williams, 2002) 10. Albumin. Interstitial edema due to low albumin can decrease nutrient passage to damaged tissue (Wells, 1994). 75% of patients with serum albumin below 3.5 md/dl develop pressure ulcers (Holmes, 1987). Even patients admitted to a hospital who screen as adequately nourished can experience declines in nutritional status during their stay. Braunschweig et al found that 38% of patients admitted with normal nutrition status (assessed with SGA) declined in nutritional status. 11. Low protein intake. Protein intake < 93% of RDA is associated with PU development whereas protein intake of >119% is associated with no PU (Bergstrom,1992). 12. Poor dietary intake. Defined as persistently poor appetite, meals being held, or a prescribed diet of less than 1100 kcal or 50 g protein/day, shown to predict PU development (Berlowitz, 1989) 34

35 TAKE ACTION Revisit nutrition care planning for prevention and treatment of wounds including: Nutrition screening Aggressive nutrition therapy Nutrition education at discharge Implement a treatment protocol for wounds Early nutrition intervention Standing orders Discharge recommendations 35

36 DISCUSSION AND QUESTIONS The team approach to treatment: We must all work together to communicate the nutrition message /September