Nutritional status among patients with hip fracture in relation to pressure ulcers

doi:10.1016/j.clnu.2007.06.003

Clinical Nutrition

Volume 26, Issue 5, October 2007, Pages 589-596

https://doi.org/10.1016/j.clnu.2007.06.003 Get rights and content

Summary

Background & aims

Patients with a hip fracture often have a poor nutritional status that is associated with increased risk of complications, morbidity and mortality. The aim of this study was to investigate the effects of an improved care intervention in relation to nutritional status and pressure ulcers. An intervention of best practices for patients with hip fracture was introduced, using the available resources effectively and efficiently with a not too complicated or expensive intervention.

Methods

A quasi-experimental study of 478 patients consecutively included between April 1, 2003 and March 31, 2004. A new evidence-based clinical pathway was introduced on October 1, 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article.

Results

The total number of patients with a hospital-acquired pressure ulcer was in the intervention group, 19 patients, and in the control group, 39 patients (p=0.007). No patient younger than 65 years developed a pressure ulcer. There were no statistical significant differences between the groups with respect to blood biochemical variables at inclusion. Patients in the control group had higher arm muscle circumference (AMC) (p=0.05), calf circumference (CC) (p=0.038) and body mass index (BMI) (p=0.043) values. Abnormal anthropometrical tests of BMI, triceps skin fold (TSF) <10th percentile and AMC <10th percentile were found in 12 patients in the control group and in 4 patients in the intervention group. None of the 4 patients in the intervention group developed pressure ulcers. However, 2 of the 12 patients in the control group were affected.

Conclusions

It is possible to reduce the development of hospital-acquired pressure ulcers among elderly patients with a hip fracture even though they have poor prefracture nutritional status. Results in this study indicate the value of the new clinical pathway, as number of patients who have developed pressure ulcers during their stay in hospital has been reduced by 50%.

Introduction

Despite a growing awareness of the dramatic impact on quality of life and treatment costs1, 2 the occurrence of pressure ulcers (PUs) is still an abundant problem among hip fracture patients. Patients with a hip fracture often have a poor nutritional status³ which is associated with increased risk of complications, morbidity and mortality.4, 5, 6, 7, 8 Especially protein energy malnutrition (PEM) which is an important determinant of clinical outcome, is seen more often in patients with a hip fracture than in age-matched control subjects.3, 8, 9 Carpintero et al.¹⁰ noted higher mortality in men than in women with hip fracture related to nutritional status. Patients with a hip fracture may also have poor food intake in hospital.¹¹ Adequate nutrition is essential in the care of the hip fracture patients in order to achieve recovery without complications.

The aim of this study was to investigate the effects of an improved care intervention in relation to nutritional status and PU. An care intervention of best practices for patients with hip fracture,¹² not too complicated or expensive, but only using the available resources effectively and efficiently.

Section snippets

Subjects and methods

The study was conducted at the University Hospital in Lund, Sweden. The subjects were 478 patients with a hip fracture consecutively included between April 1, 2003 and March 31, 2004. On October 1, 2003 a new evidence-based clinical pathway was introduced. The transition period for implementing the new pathway was 44 days and the 58 patients from this period are not included here. Comparisons are here made between the 210 first patients in the control group (CG) and the 210 last patients in the

Patient characteristics

There was no significant differences between the groups with regard to age, sex, lucidity, smoking, ASA-grade, hip fracture type, time to operation, time on operation—table, prefracture living conditions, length of stay at hospital or mortality (Table 3). However, the co-morbidity was higher in the IG. At admission 36% of the patients in the IG had a diagnosis of three or more diseases, versus 20% (p=0.003) of the patients in the CG.

Biochemical variables

There were no significant differences between the groups with

Discussion

Although there is awareness that malnutrition must be recognised, there are no golden standard of a screening system assessing nutritional status and no consensus regarding absolute criteria for malnutrition. In this study we used a sample of biomedical and anthropometric variables together with a questionnaire. Hedströms et al.²¹ stated, that patients with a hip fracture in general have a low body mass index (BMI), and low biochemical nutritional markers on admission to hospital, signs that

Limitations of the study

This study has limitations. First we did not design the study as a randomised controlled study, which is accepted as being the most reliable method for assessing effectiveness. We selected a quasi-experimental design for two reasons. The first reason was that the intervention started already in the ambulance and since five different ambulance stations were involved, we could not assure that patients were randomised and cared for in a proper way. The second reason was that even if we had tested

Acknowledgements

We wish to thank all patients included in the study. All staff involved in this study at the University Hospital, the local hospital and at all the different homes for elderly people is gratefully acknowledged for their help in conducting this study. The study was supported by the Swedish National Board of Health and Welfare and the Swedish Association of County Councils.

Funding: The Swedish National Board of Health and Welfare and the Swedish Association of County Councils.

Authorship: A.H.,

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Finnish and Swedish prehospital emergency care providers’ knowledge and attitudes towards pressure ulcer prevention
2021, International Emergency Nursing
Despite the knowledge that transportation by emergency medical services may increase the risk of pressure ulcers (PU), there is still lack of knowledge about the possibility of prehospital emergency care providers to be a part of preventing and reducing the risk of PUs.
A survey was carried out during 2017 in Finland and Sweden. Validated questionnaires were used.
A total of 179 (72.7%) Finnish and 188 (28.8%) Swedish prehospital emergency care providers participated in the study. The overall rate of correct answers and the mean total knowledge score was 58.8% (SD 21.8), 20/34, in the Finnish group and 70.5% (SD 15.7), 24/34, in the Swedish group (p < 0.000). The percent of the total and the mean attitude score was in the Finnish group 71.3% (SD 0.48), 37.1/52, and in the Swedish group 69.4% (SD 0.77), 36.1/52 (p < 0.813). Half of the Finnish and most of the Swedish participants felt they needed more education about PUs (Fin 50.2% & Swe: 76.0%).
Prehospital emergency care providers don’t see themselves as responsible for PU prevention. Therefore, there is a need for increasing the level of knowledge on PU prevention and classification among prehospital emergency care providers. They could play a key role in developing methods to improve PU prevention and identifying patients in risk of developing PUs.
Concomitant Malnutrition and Frailty Are Uncommon, but Significant Risk Factors for Mortality and Complication Following Primary Total Knee Arthroplasty
2020, Journal of Arthroplasty
Total knee arthroplasty (TKA) demand continues to rise, but we are also gaining greater insight into patient risk factors for postoperative complications and excess resource utilization. There has been growing interest in frailty and malnutrition as risk factors, although they are often mistakenly used interchangeably. We aimed at identifying the incidence of their coexistence, and the magnitude of risk they confer to TKA patients.
We queried the American College of Surgeons-National Surgery Quality Improvement Program database to identify 4 patient cohorts: healthy/normal serum albumin, healthy/hypoalbuminemic patients, normoalbuminemic/medically frail patients (defined by modified frailty index), and hypoalbuminemic/frail patients. We performed both univariate and multivariate analyses to quantify the risk conferred by each condition in isolation, and in coexistence.
Of 179,702 elective TKA cases from 2006 to 2018, 18.6% of patients were frail only, 3.0% were hypoalbuminemic -only, and just 1.2% were both frail and hypoalbuminemic. The raw rate of any complication was highest in frail/hypoalbuminemic patients (8.7%), 5.2% in hypoalbuminemic patients, 4.8% in frail patients, and just 3.4% in healthy patients (P < .001); the multivariate model revealed odds ratio of a complication in frail/hypoalbuminemic group of 2.40 (95% confidence interval = 1.27-1.63; P < .001). Mortality within 30 days was highest in the frail/hypoalbuminemic cohort (1.0%), and just 0.1% in healthy patients, and the multivariate model noted an odds ratio of 9.43 for these patients (95% confidence interval = 5.92-14.93; P < .001). The odds of all studied complications were highest in the frail/hypoalbuminemic group.
Frailty and hypoalbuminemia represent distinct conditions and are independent risk factors for a complication after TKA. Their coexistence imparts a synergistic association with the risk of post-TKA complications.
Combined Malnutrition and Frailty Significantly Increases Complications and Mortality in Patients Undergoing Elective Total Hip Arthroplasty
2020, Journal of Arthroplasty
The demand for total hip arthroplasty (THA) continues to rise. While prior work has examined frailty and malnutrition independently, the additive effects of these conditions are unknown. Therefore, the purpose of this study was to evaluate the individual and combined influence of malnutrition and frailty in the elective THA patient.
This is a retrospective cohort study. Patients undergoing elective, primary THA were identified from the American College of Surgeons-National Surgery Quality Improvement Program database. Patients with hip fracture were excluded. Preoperative serum albumin levels (malnutrition = albumin <3.5 g/dL) and 5-item modified frailty index scores (≥2 = frail) were collected. Four cohorts were created: (1) Healthy (N), (2) Frail-only (F), (3) Hypoalbuminemia-only (H), and (4) Hypoalbuminemia and frail (HF). Demographic and complication data were collected, and statistical analysis was performed comparing complications between cohorts.
105,997 patients undergoing THA were identified for inclusion. The majority (82%) of patients were healthy (14% F, 3% H, and 1% HF). The HF group was found to have higher odds of complication compared with all other groups (HF vs N; odds ratio [OR] 3.7, 95% confidence interval [CI] 3.07-4.46, P < .001). Notably, patients in the HF cohort had a 1.9% 30-day mortality rate (HF vs N; OR 12.66, 95% CI 7.81-20.83, P < .001). Additionally, HF patients had higher odds of increased resource utilization when compared with all other groups (P < .001).
Frailty and malnutrition both represent physiologically compromised states but are only weakly correlated. The concurrent presence of frailty and malnutrition in the THA patient has significant detrimental impacts. Further research will be needed to delineate to what degree these risk factors are modifiable.
The International Collaboration of Orthopaedic Nursing (ICON): Best practice nursing care standards for older adults with fragility hip fracture
2019, International Journal of Orthopaedic and Trauma Nursing
Citation Excerpt :
Common risk factors for PU/PI in patients with fragility hip fracture include: advanced age, prolonged time on the operating table (Houwing et al., 2004) and delay to surgery, specifically delay between admission to the hospital and time to surgery (Haleem et al., 2008). Patients operated on within 24 h of admission develop significantly fewer PU/PIs (Al-Ani et al., 2008; Hommel et al., 2007). Additional risk factors include, co-morbidities such as diabetes (Wei et al., 2017), respiratory disease, low hemoglobin, low systolic blood pressure, altered mental status (Lindholm et al., 2008; Moore and Cowman, 2009; Campbell et al., 2010) and poor nutritional status (Dreyfus et al., 2017).
Nonpharmacologic Interventions to Prevent Pressure Ulcers in Older Patients: An Overview of Systematic Reviews (The Software ENgine for the Assessment and optimization of drug and non-drug Therapy in Older peRsons [SENATOR] Definition of Optimal Evidence-Based Non-drug Therapies in Older People [ONTOP] Series)
2016, Journal of the American Medical Directors Association
Citation Excerpt :
The intervention included adequate oxygen therapy, intravenous fluids, and pain drugs, organizational changes in the workflow, maximizing the use of AP mattresses, and providing nutritional support. They found a significant reduction in hospital-acquired PUs (9.0% vs 18.6%, P = .007), but the results of the first 58 patients were excluded without a sound reason, and baseline comorbidities among the groups were different.83 Moody et al86 conducted a BA trial; the 2 periods of data collection were separated by 3 months, in a community hospital.
Pressure ulcers (PUs) are frequent in older patients, and the healing process is usually challenging, therefore, prevention should be the first strategic line in PU management. Nonpharmacologic interventions may play a role in the prevention of PUs in older people, but most systematic reviews (SRs) have not addressed this specific population using convincing outcome measures.
To summarize and critically appraise the evidence from SRs of the primary studies on nonpharmacologic interventions to prevent PUs in older patients.
SR and meta-analysis of comparative studies.
PubMed, Cochrane Database of Systematic Reviews, EMBASE, and CINHAL (from inception to October 2013) were searched. A new search for updates in the Cochrane Database was launched in July 2014.
SRs that included at least 1 comparative study evaluating any nonpharmacologic intervention to prevent PUs in older patients, in any healthcare setting, were selected. Any primary study with experimental design was then identified and included.
From each primary study, quality assessment was undertaken as specified by the Cochrane Collaboration and the Grading of Recommendations Assessment, Development and Evaluation working group. Interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis, using the incidence of new pressure ulcers as the main outcome measure.
One hundred ten SRs with 65 primary studies satisfied the inclusion criteria. The most frequent interventions explored in these trials were support surfaces (41 studies), repositioning (8), and nutrition interventions (5). High quality of evidence was not found for any intervention, mainly because of a high risk of bias and imprecision. There is moderate quality evidence to support the use of alternating pressure support mattresses over usual hospital mattresses in medical and surgical inpatients, low quality evidence to support constant low pressure devices and Australian medical sheepskin over usual mattresses, and very low quality evidence to support nutrition interventions in hospital settings. No recommendations on hydration, repositioning, standardized risk assessment, or multicomponent interventions can be done.
In older patients at high risk to suffer PUs, high-technology and low- technology support surfaces can significantly reduce the incidence of PUs. Nutrition intervention may also have a role in preventing PUs in hospital settings. More evidence is needed to support other recommendations, which is specially lacking for repositioning.
Prevalence of pressure ulcers in hospitals in Brazil and association with nutritional status-A multicenter, cross-sectional study
2013, Nutrition
Citation Excerpt :
This finding is certainly due to the common dorsal position patients assume in bed [14–16,20,27,28]. Furthermore, well known patient risk factors such as immobility, age, and nutritional status increased the probability of presenting with PU [4,19,20,27,29,30]. Our data showed that 30.4% of the patients were bedridden, and the probability of having pressure ulcers was 75 times higher than that of nonbedridden individuals.
Pressure ulcers (PU) represent a widespread, painful, and expensive health care problem directly associated with increased morbidity, mortality, and length of hospital stay. The aim of this study was to determine the prevalence of PU in hospitalised patients in public and private Brazilian institutions and the ulcers’ associations with nutritional status and other risk factors.
A multicenter, cross-sectional, quantitative and qualitative study was carried out in hospitals in different geographic regions of Brazil from March 2009 to February 2011. The prevalence and characteristics of PU, the nutritional status and the association between the presence of PU, and the nutritional status and other study variables were evaluated. The association of the presence of PU with the study variables was performed by univariate analyses and multivariate logistic regression models. The final multivariate model was one in which all variables were significant at the 0.05 level.
According to the subjective global assessment (SGA), the prevalence of PU was 16.9%, and 52.4% of patients were malnourished. PU and their severity were directly associated with malnutrition (P < 0.05). Patients who are bedridden, who are elderly, who have neurological disorders or cancer, who are staying at a public or private institution, and who are staying at the hospital between 8 d and 15 d had an increased risk of PU (P < 0.05).
The prevalence of PU in Brazilian general hospitals is high, and the prevalence of malnutrition is extremely high. Malnourishment is one of the most important risk factors associated with the development and severity of PU in hospitals. Patients who are malnourished are more prone to developing PU.

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^☆: Poster presentation at the ESPEN Conference in Istanbul in October 2006.

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ORIGINAL ARTICLENutritional status among patients with hip fracture in relation to pressure ulcers☆

Summary

Background & aims

Methods

Results

Conclusions

Introduction

Section snippets

Subjects and methods

Patient characteristics

Biochemical variables

Discussion

Limitations of the study

Acknowledgements

Clin Geriatr Med

Lancet

Clin Nutr

Clin Nutr

Clin Nutr

Clin Nutr

Prim Care

Clin Nutr

Fourth national pressure ulcer prevalence survey

Adv Wound Care

Serum albumin level on admission to as a predictor of death, length of stay, and readmission

Arch Int Med

Protein depletion and metabolic stress in elderly patients who have a fracture of the hip

J Bone Jt Surg (Am)

Nutritional status in elderly female hip fracture patients: comparison with an age-matched home living group attending day centres

Br J Nutr

Differences in body composition between female geriatric hip fracture patients and healthy controls: body fat is more important as explanatory factor for the fracture than body weight and lean body mass

Aging (Milano)

Men with hip fracture have poorer nutritional status and survival than women; a prospective study of 165 patients

Acta Orthop

Best practices for elderly hip fracture patients

J Gen Intern Med

ORIGINAL ARTICLE
Nutritional status among patients with hip fracture in relation to pressure ulcers☆