Critique: Effects of a Comprehensive Nutritional Program on Pressure Ulcer Healing, Length of Hospital Stay, and Charges to Patients

Problem Statement

Through extensive introductory and background information, Allen (2012) presents a compelling argument of the need for more effective strategies for decreasing the morbidity, poor quality of life, mortality, and high costs associated with pressure ulcers in older adults. The premise that pressure ulcers constitute a serious health issue is bolstered by sound empirical evidence. Malnutrition heightens the risk, thus “Adequate nutrition is an important factor in the prevention and management of pressure ulcers” (Allen, 2012, p. 187). The study was designed to investigate the effects of a comprehensive, interdisciplinary nutritional program among older patients (>60 years), focusing on pressure ulcer wound healing, duration of hospital stay (directly associated with the pressure ulcer), and charges related to managing pressure the pressure ulcer.

Literature Review

A weakness of Allen’s (2012) article is that there is no formal literature review. At the same time, the introduction is quite comprehensive and relevant information from credible sources is cited throughout the article. Allen noted that there is minimal research on the use of a comprehensive interdisciplinary nutritional program for patients with pressure ulcers (p. 190) and few current studies on financial charges related to pressure ulcers (p. 200). She briefly mentions techniques commonly used to promote wound healing, which have limited results. (pp. 189-190). However, she might have expanded more on the current state of intervention.

Hypothesis

Allen (2012) does not present either a formal research question or formal hypothesis. Inferring from the purpose of the study, the hypothesis is that a comprehensive, interdisciplinary nutritional protocol would be more effective than standard wound care for improving healing of pressure ulcers, decreasing hospital length of stay (LOS) directly related to pressure ulcers, decreasing symptoms of gastroesophageal reflux disease,  and decreasing charges directly related to pressure ulcers.

Methodology

Sample

The sample was composed of 100 hospital patients (50 experimental and 50 control group) ranging in age from 65 to 96 years, with a mean age of 79.42 years (Allen, 2012, p. 195). All patients had to be at least 60 years and admitted with or developed a pressure ulcer from Stage 2 to Stage 3 while hospitalized. The two groups were matched on gender, age, Braden Scale scores, and pressure ulcer stage. Comorbidities were assessed but not used for matching.

Data Collection Procedures

The first 50 patients whose hospital records showed they met the researcher’s inclusion criteria were chosen to be part of the experimental group (Allen, 2012, p. 191). Fifty matching (control group) patients were identified on the basis of chart data. Data from both patient groups were collected from hospital records after the patients’ discharge.

Research Design

Allen (2012) utilized a quasi-experimental pretest and posttest design (p. 190). The experimental group received the nutritional intervention from an interdisciplinary team consisting of a chief nursing officer (CNO), physician, dietitian, wound care nurse and other nursing staff, pharmacist, and an occupational, speech, and physical therapist. The experimental protocol and the standard care protocol were both described in detail.

Data Collection Instruments

The tools used to assess pressure ulcer development were the Braden Scale and the Bates-Jensen Wound Assessment Tool (BWAT; Allen, 2012, p. 193). Both have documented reliability and validity. LOS was assessed via hospital days directly related to pressure ulcers, and charges were based on wound care supplies (dressings, lotions, and creams), nursing time, and equipment (special beds) as recorded daily. Caloric intake was calculated on a 25% incremental scale and serum albumin was analyzed weekly. Demographic data were gathered from hospital records.

Data Analysis

The techniques used for data analysis were descriptive statistics, frequencies, t-tests, and chi-square tests (Allen, 2012). These techniques are specified in the abstract (p. 186), in tables showing Pressure Ulcer Healing (p. 196) and Charges for Pressure Ulcer Care (p. 197), and the presentation of results for pressure ulcer healing, LOS, and charges for care. However, the modes of data analysis would have been clearer if the techniques were presented in a specific section.

Results and Findings

The quantitative results for the effects of the nutritional intervention on pressure ulcer healing, LOS, and charges for care were each presented in detail prior to being discussed in relation to the relevant literature. The results showed that the nutritional intervention effectively improve pressure ulcer wound healing and decreased the duration of hospital stay in terms of total LOS as well as directly related to pressure ulcers (Allen, 2012). The intervention did not decrease financial costs, but did not increase them either. The findings suggest that the nutritional protocol is a promising intervention for improving the healing of pressure ulcers, which are not only damaging but potentially life-threatening, and can be unavoidable (Allen, 2012, p. 201). The study was rigorously conducted and the results merit further study.

Reference

Allen, B. (2012). Effects of a comprehensive nutritional program on pressure ulcer healing, length of hospital stay, and charges to patients. Clinical Nursing Research, 22, 186-205.  doi:10.1177/1054773812457673.