Chronic wound healing has been identified as a growing problem in my health region and across Canada. It’s a problem that contributes to health care costs and, more importantly to me, to the suffering of patients.
I began investigating the latest research in nutrition therapy to address this problem in January 2014. A nurse I work with, Roberta Moore, had asked me to help her understand the nutritional aspects of chronic wound healing and to help her with a difficult case. I was able to share my findings with my team thanks to the support of my supervisor, Chantelle D’Andrematteo, RD, who recognized the importance of this area of nutrition therapy.
The Canadian Association of Wound Care estimates that:
My research process
the average cost of treating a chronic wound in Canada is $10,3761
diabetes-related foot ulcers cost our Canadian health care system $150 million annually1
1) I started with Practice-Based Evidence in Nutrition (PEN). I reviewed the “Wound Care” and “Wound Care – Pressure Ulcer” knowledge pathways.5
2) Then, I searched for position papers. These were great resources because they gave practical ideas on how to apply current knowledge.
3) Finally, I did a Google Scholar search for literature published since 2011, and conducted a regular Google search.
This retrieved one of my best Canadian resources: “Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury.”2
This resource, produced by the Rick Hanson Institute, was a two-year project done by a panel of experts, including Pamela Houghton, TP, PhD, Chris Fraser, HBSc, RD and 12 others from various disciplines. It included a great chapter on nutrition that confirmed many of my previous findings.
A summary of my findings (illustrated in flow chart below)
The nutritional recommendations that are suggested have a “strength of evidence” letter attached to them. These letters are determined using the guidelines discussed in the National Pressure Ulcer Advisory Panel White Paper. 3 You can find the criteria for the “strength of evidence” ratings here (on page nine).
If a client is at nutritional risk:
Increase energy intake to 30-35kcal/kg, protein to 1-1.5g/kg (strength of evidence = A)2 and start a multivitamin/mineral supplement (strength of evidence = B).2
If there is no wound improvement in 15-20 days, supplement with collagen hydrolysate3 (no strength of evidence rating) and/or arginine could be considered2 (strength of evidence = lower B).
Vitamin C supplementation above recommended levels does not have any clear evidence of efficacy.2
Omega-3 fatty acid supplementation is not recommended because this may inhibit collagen synthesis. 4
A case study
Vitamin E supplementation is not recommended because it may enhance the inflammatory response (strength of evidence =C).2
Zinc supplementation above recommended levels has no clear evidence of efficacy and may cause gastrointestinal distress and a secondary copper deficiency.2
Provide 1ml fluid/kcal consumed (strength of evidence = C).2
The difficult case that the nurse had asked me to help with was a client that had been a paraplegic for 20 years and had developed a large chronic wound on his gluteus maximus. His wound had not healed for 12 months. He was using negative pressure wound therapy (a sealed wound dressing attached to a vacuum pump), however, nothing had been working.
His fluid intake and protein support were sufficient but he had run out of his multivitamin six months ago. He did mention that he had taken salmon collagen years ago and it had helped heal a previous wound.
I helped him source salmon collagen, reminded him of the importance of good protein support and suggested he start taking a multivitamin again. Roberta Moore, RN also made some nursing treatment changes using a risk assessment tool called the Braden Scale.
In three weeks, his wound began to heal and, after six weeks, there was marked improvement. Working together with Roberta, and using the latest evidence in chronic wound nutrition therapy was essential in treating this complex health problem.
Supply the fuel
Healing a wound is like doing renovations on your house after it has been damaged. Good nutrition supplies the fuel and building materials. Good nursing and medical care clears out debris, encourages the building of the foundation (granulation tissue), prevents further damage by looters (infection), and promotes good finishing carpentry (skin reconstruction).
Sharing my findings
After conducting the literature search and summarizing my main findings, I developed a protocol and nutritional intervention flow chart (below) for wound healing. We use the Malnutrition Screening Tool to determine if an RD referral is indicated.
Three months later, I presented the protocol, “Nutritional Therapy in Chronic Wound Treatment,” to the Southern Health dietitians in Manitoba. Many dietitians since then have said the protocol has been a valuable tool for them. Teaching other dietitians about this protocol provided a great opportunity to discuss the specific nutritional challenges we have faced in this area.
Going through this process from conducting research, to protocol development, to educating others was an exceptional experience. I would do it again in a heartbeat! It was great seeing nutrition play a key role in easing a client’s suffering and I enjoyed the synergy of working with another health care professional.
I am currently working on a pamphlet for our health region, which will be used by home care nurses, to provide practical information to clients with chronic wounds. This pamphlet discusses the rationale behind increased energy and protein intake, and provides some simple, high protein, milkshake and smoothie recipes. I hope it will become a valuable tool for caregivers who provide day-to-day nutritional care.
It is my hope that my experience will inspire you to update the protocols in your organization. I continue to be called into difficult cases and, having done this research, I feel much more confident in the nutritional therapy I recommend. Nutrition is often forgotten in chronic wound healing, but I think in the future it will become one of the first considerations.
Canadian Association of Wound Care. (n.d.) Statistics. Retrieved from http://cawc.net/index.php/public/facts-stats-and-tools/statistics/
Rick Hansen Foundation. (2013, Feburary). Canadian best practice guidlines for the prevention and managment of pressure ulcers in people with spinal cord injury. Retrieved from http://onf.org/system/attachments/168/original/Pressure_Ulcers_Best_Practice_Guideline_Final_web4.pdf
Dorner, B., Posthauer, M., & Thomas, D. (2009, May). The role of nutrition in pressure ulcer prevention and treatment: National pressure ulcer advisory panel white waper. Retrieved from http://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf
Boulom, V., & Barbul, A. Advances in wound care: Volume 2 omega-3 fatty acids modulate wound healing. Retrieved from http://online.liebertpub.com/doi/abs/10.1089/9781934854280.301
Dietitians of Canada. (2010). Wound Care - Pressure Ulcers Evidence Summary. Retrieved from Practice-based Evidence in Nutrition [PEN]: http://www.pennutrition.com/KnowledgePathway.aspx?kpid=7871&trid=7859&trcatid=42
Editor’s note: It is great to see Kim’s research and experience in this area benefiting so many others and improving patient care. Kim is happy to share the pamphlet that she has developed when it is available. Please email her for further details if interested.
Malnutrition affects the healing of wounds, length of hospital stay and much more. Check out DC’s detailed paper, “An Inter-professional Approach to Malnutrition in Hospitalized Adults,” to find out how dietitians can lead the way in this area!
Is there anything missing from Kim’s findings that you have used to help chronic wounds heal? Is there additional research that you would suggest referring to?
Please share your experiences, comments or questions for Kim below.