An Insider Look at the 2014 NPUAP Nutrition Recommendations Protection Status
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by Mary Ellen Posthauer RDN, CD, LD, FAND

For the past two years I have been involved in the research and development of the second edition of the Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Members of the Pan Pacific Pressure Injury Alliance joined National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) in producing a document that could be used by health professionals around the world.

Small work groups (SWG) comprised of representatives from each organization were assigned to review and evaluate the research for a particular area. I was privileged to represent NPUAP as chair of the bariatric SWG and co-chair of the nutrition SWG. The majority of our deliberation was conducted electronically, but there were a few conference calls. It was interesting to chat with a colleague in Australia who was just arriving at the office while in Indiana I was wrapping up my day.

New Pressure Ulcer and Nutrition Recommendations

Nutrition interventions for pressure ulcer prevention and treatment are combined and expanded in the second edition. The recommendations focus on nutrition and malnutrition risk, noting the impact these factors have on both prevention and healing. The focus in any health care environment is on the risk factors for pressure ulcer development including turning, positioning, support surfaces, etc. Who screens for malnutrition risk? Are you using a validated nutrition-screening tool? How is the screening information communicated to the registered dietitian? A cross-sectional study investigating the role of clinical guidelines found that adapting a facility-wide nutrition guideline that included regular nutritional screening reduced the barriers to providing nutritional support.

In this edition, a consensus voting process (GRADE) involving all of the experts formally engaged in the guideline development was used to assign the strength to each recommendation, which is an important addition to the rigorous guideline process. The strength of recommendation identifies the importance of the recommendation statement based on the potential to improve individual outcomes. It includes consideration to the overall measure of harm versus benefits (including side effects, hazards, cost effectiveness, feasibility) if the recommendation was implemented. The strength of recommendation provides an indication to the practitioner of the confidence they can have that the recommendation will improve patient outcomes and do more good than harm.

The Evidence Supporting the NPUAP Guideline

Many recommendations with strength of evidence C are supported by indirect evidence or by studies in healthy humans or individuals with other types of chronic wounds. However, clinicians would agree that many of the recommendations are essential. For example, "assess renal function to ensure that high levels of protein are appropriate for the individual" has strength of evidence C but a strong positive strength of recommendations. Clinicians should consider the individual’s co-morbidities, renal status and ability to tolerate high levels of protein.

The guideline "refer individuals screened to be at risk of malnutrition and individuals with an existing pressure ulcer to a registered dietitian or an interprofessional nutrition team for a comprehensive nutrition assessment" has a strength of evidence C and a strength of recommendation of weak positive or probably do it. Considering that clinicians throughout the world may implement these guidelines, the work group had to consider the feasibility of implementation. Some countries have limited access to and/or a limited number registered dietitians and utilize an interprofessional team to assess nutritional status.

The guideline is available as a Quick Reference Guide and a Clinical Practice Guideline, which contains the detailed analysis and methodology used to reach consensus plus the references. Visit the NPUAP website for additional details.

About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Advisory Panel and the American Dietetic Association's Unintentional Weight Loss work group.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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