The National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance’s 2019 Clinical Practice Guideline for Prevention and Treatment of Pressure Ulcers/Injuries (CPG)1 was developed by a team of 181 academic and clinical experts, the Guidelines Governance Group (GGG), a methodologist, and 168 small working group members using a rigorous methodology.2 It includes recommendations and evidence summaries and two new features: good practice statements (GPSs) and implementation considerations. Each recommendation was written based on a body of supporting evidence and given a level of evidence, strength of evidence (SoE), and strength of recommendation (SoR) rating. The level of evidence was based on the study design, and the SoE rating was based on the evidence quantity, levels, and consistency. The SoR rating was determined by consensus voting and reflects the extent to which a clinician can be “confident that adherence to the recommendation will do more good than harm.” The GPSs were not rated by SoE or SoR.
The criteria for SoE ratings used in the 2014 CPG3 are compared with the criteria used in the 2019 CPG1 in Table 1. One key change is that recommendations based on expert opinion were considered an SoE designation of C in the 2014 CPG,3 whereas in the 2019 CPG,1 all statements based on expert opinion were designated GPSs or included under implementation considerations. This change in methodology affected a number of the 2014 nutrition recommendations. However, it is important to note that not all clinical nutrition questions can be ethically examined in randomized controlled trials. Therefore, the nutrition GPSs and implementation considerations should be incorporated into clinical practice and not considered of lesser value than the other recommendations to achieve patient care goals.
Table 2 outlines the criteria for the SoR designations. The criteria for the SoR did not change in the 2019 CPG,1 but the icons were updated.
To assist clinicians in incorporating the 2019 CPG1 into their current practice, implementation considerations are provided for each recommendation and GPS. It is important to note that the recommendations and GPSs were written to apply to many nutrition-related medical conditions, but may not be appropriate in all contexts, settings, and circumstances. Moreover, all practitioners must use clinical judgment in each individual case regarding the patient’s preferences and available resources.
Realigning a healthcare organization’s clinical practices to be consistent with the most current evidence-based clinical practice guidelines and good practice recommendations is a process. Effective change requires an implementation plan with reasonable timelines.
MAJOR CHANGES IN THE NUTRITION CHAPTER
Clinicians familiar with the nutrition recommendations from previous editions of the CPG will note that there are fewer recommendations in the new edition (29 recommendations in 2014 CPG vs 10 recommendations and five GPSs in 2019 CPG).1,3
The SoE ratings for the 2019 CPG1 nutrition recommendations are of higher quality and consistency than the 2014 CPG; all but one of the recommendations were based on either B1 or B2 level of evidence. There are no nutrition recommendations supported by level A evidence. All of the nutrition recommendations received a positive SoR as determined by consensus voting of small working group and GGG members. The supplemental table (http://links.lww.com/NSW/A35) summarizes and compares the 2014 and 2019 nutrition recommendations and GPSs. In addition, the importance of nutrition is noted in chapters on growth factors, biologic dressings, wound dressings, biophysical agents, and pressure injury surgery. These chapters do not include specific nutrition recommendations or GPSs.
Major Changes in Nutrition Recommendations for Pressure Injury Prevention
One of the major changes in the 2019 CPG1 is specific to nutrition recommendations for pressure injury prevention. Older editions of the CPG included specific and prescriptive recommendations for energy and protein intake for adults at risk of a pressure injury and malnutrition. Indirect evidence demonstrates that providing nutrition supplements to individuals at risk of pressure injuries who are malnourished results in improved energy intakes.4,5 The 2019 CPG methodologists’ literature review found one study that demonstrated an association between consumption of high-protein nutrition supplements and a significant reduction in the incidence of pressure injuries.6 Another smaller study reported favorable but nonsignificant results.7 However, other studies showed no significant effect in reducing the incidence of pressure injury with high-calorie and high-protein nutrition supplements.8,9
The nutrition small working group and GGG agreed that adequate energy and protein intake is essential for skin health. However, the small working group did not find high-quality research evidence to indicate that a higher consumption of energy and protein reduces the incidence of pressure injuries in individuals assessed to be malnourished or at risk of malnutrition who were also at risk of a pressure injury. Recommendation 4.4 and GPS 4.5 address the importance of nutrition in pressure injury prevention:
- 4.4: Optimize energy intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition.
- 4.5 Adjust protein intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition.
It is important to note that evidence-based clinical guidelines have been published for older adults, adults with acute or chronic diseases, and critically ill adults who do not have a chronic wound. These clinical guidelines recommend higher energy requirements and protein intake of at least 1 g protein/kg body weight per day. Table 3 outlines nutrition recommendations for older adult and critically ill adult populations. These individuals are likely to be malnourished and at risk of pressure injuries because of aging, impaired cognition, impaired ability to perform activities of daily living, chronic or acute conditions, and other factors.10–18
The 2019 CPG1 acknowledges that there are no apparent negative effects of providing increased energy and protein to adults at risk of pressure injuries. Moreover, there are quality economic analyses that report cost-savings and reduced lengths of hospital stay associated with increasing energy and protein intake in adults at risk of pressure injuries who are malnourished or at risk of malnutrition.19–21
It is vital for nutrition and wound care professionals to recognize the prevalence of malnutrition in all care settings. The results from a 2009 to 2015 survey using the Malnutrition Screening Tool reported that the prevalence of malnutrition risk was about 33% of non-ICU acute care patients in the US.22 Moreover, it is important to actively screen individuals for indicators of declining nutrition status if the individual's clinical condition worsens and to provide nutrition supplementation as part of achieving the individual’s clinical goals.1 To this end, the 2019 CPG nutrition chapter provides implementation considerations specific to screening for malnutrition, the characteristics of malnutrition in children and adults,23,24 components of a comprehensive nutrition assessment, and individualized nutrition care planning.25 The 2019 CPG recognized that individuals identified as malnourished, with pressure injuries/at risk of developing pressure injuries, or with any significant change in condition should be referred to a registered dietitian/nutritionist for an in-depth nutrition assessment.23
The 2019 CPG1 focuses on individualized assessment of energy and protein requirements for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition. The change reflects the shift in clinical nutrition care interventions to provide malnourished and frail adults with prehabilitation prior to surgery and more aggressive nutrition support services upon discharge.26–30 Moreover, implementation of enhanced recovery after surgery recommendations including carbohydrate beverages up to 2 hours prior to surgery has significantly improved overall clinical outcomes including reduced lengths of hospital stay, fewer complications, lower rates of wound infections, and reduced postoperative insulin resistance.31–34 Future research may demonstrate that addressing malnutrition proactively prior to surgery will reduce the risk of hospital-acquired pressure injuries.
Major Change in Nutrition Recommendation for Adult Nutrition Supplements
The recommendation for high-calorie, high-protein oral nutrition supplements (ONSs) containing arginine, zinc, and antioxidants has been expanded to include Stage 2 pressure injuries:
- 4.10: Provide high-calorie, high-protein, arginine, zinc, and antioxidant oral nutritional supplements or enteral formula for adults with a Category/Stage 2 or greater pressure injury who are malnourished or at risk for malnutrition.
The new recommendation is supported by evidence from a high-quality randomized controlled study concluding that disease-specific ONSs are related to significant pressure injury healing. Moreover, findings demonstrated more than three times greater likelihood of a pressure injury healing when patients consume a high-calorie, high-protein, disease-specific ONS containing arginine, zinc, and antioxidants for more than 4 weeks.35 A quality/cost analysis demonstrated that the use of disease-specific ONSs is associated with cost savings in healing pressure injuries compared with standard ONSs.36
BRIDGING RECOMMENDATIONS TO PRACTICE
One of the most common situations clinicians struggle with is how to successfully increase energy and protein intake in individuals with early satiety, poor appetite, impaired cognitive status, impaired functional status (ie, dependent on others to assist at meals), illness, emotional distress,37,38 impaired sense of taste and/or smell,39–41 and/or limited understanding of the importance of nutrition in maintaining skin integrity and promoting wound healing. The 2019 CPG1 nutrition chapter includes many implementation considerations to guide clinical practice and communicate that nutrition intake matters in the prevention and treatment of pressure injuries.
Medical orders for prolonged and often unnecessary fasting prior to diagnostic testing and other surgical procedures are another contributor to poor appetite.42 Whereas short periods of fasting increase appetite, lengthy periods of fasting reduce appetite.43
Further, individuals at risk of or with pressure injuries make choices about what they are willing to eat. Chefs and clinicians strive to provide culturally appropriate foods to meet their nutrient requirements. Food service systems are rapidly evolving to meet both customer expectations and clinical nutrition goals.44
Fortified foods and ONSs are interventions that offer nutrient-dense choices to individuals at risk of or with pressure injuries. Nursing and medical staff can be invited to rate or score the food attributes, that is, taste, aroma, and texture of the fortified foods and ONSs provided in the facility to identify preferred products. (See the Figure for a simple score card to rate these attributes.) In some healthcare settings, it may be possible to invite individuals at risk of malnutrition to participate in product taste tests.45 The taste test feedback can be used as a quality indicator of nutrient-dense products. Recipes of fortified foods that are deemed unacceptable may be modified. New products with more favorable food attributes may be considered after evaluating the acceptability of the current nutrition supplements in the formulary.
It is vital that nutrition interventions are successful in light of common practices in healthcare settings for fasting orders, the impact of illness and treatment on food intake, and the consequences for pressure injury risk among malnourished individuals. Practitioners should emphasize the importance of meal intake during family and patient education. Everyone has an opinion about the food and the ONSs served; these opinions are often voiced on patient satisfaction surveys.
Decision-makers need to be involved and committed to making changes in food service systems and nutrition formularies to successfully implement the 2019 CPG nutrition recommendations. The financial implications of unpalatable food and ONSs for hospital-acquired pressure injuries or worsening pressure injuries are considerable. The Supplemental Table includes some ideas to help generate an action plan that is consistent with each organization’s goals and objectives.
- Nutrition matters before, during, and after illness, injury, medical interventions, or surgery.
- The RDN is a key member of the medical team to identify individuals at risk of malnutrition and those who are malnourished.
- Individualized nutrition care optimizes clinical outcomes.
- Explore ways to improve outcomes using innovative nutrition interventions, for example, prehabilitation programs.
- Invest in quality nutrition products and use disease-specific ONSs to optimize healing.
- Remember that assimilating the nutrition recommendations and practice statements is a process. Thoughtfully develop an implementation plan and establish reasonable timelines for change.
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