Okay. So, welcome everyone. I think we’ll probably have a few more people join over the next few minutes, but we’re going to go ahead and get started in the interest of time. So, this is our sixth learning network webinar. And thanks, again, for joining us. Today, we’ll just do a little housekeeping to start, like we always do, talk about, you know, the webinar utilities that you have available to you. And then we’re going to do a brief update on some of the upcoming topics that we have for the — our plan for the future webinars. And then we have, fortunately, today we have Dr. Mary Litchford, who’s going to do a presentation for us on nutrition in pressure ulcer prevention, “The Power of Nutrition in Pressure Ulcer Prevention.” And then we’ll have some time for questions and discussion at the very end of this webinar. And we hope that you’ll use some of the webinar tools to engage in the discussion. And then, finally, we’ll wrap up and adjourn for the day. So, just a little housekeeping. As a reminder, when we get to the point where we’re doing discussions, I’d like to ask you to raise your hand to let us know that you have a question or something that you want to discuss or say. You can also use the chat panel. It’s on the right-hand side of the webinar screen. You know, we encourage you guys to, you know, chat questions that you want to have asked or any comments that you have. And then please make sure that you mute your phone so we can minimize the background noise. And I’ve said a couple of times already, if you dialed in, please make sure that the computer volume is turned down or muted, otherwise there will be some background noise, kind of an echoing sound. So, you’ll want to make sure that that is turned down. Another way to keep the volume to a minimum is just to mute your phone. The key here is just to make sure that you unmute your phone or unmute yourself in the webinar system when you want to make a comment. Okay. So, now, the other thing we’re going to be doing today, and I don’t have a slide to show it, but we’re going to be doing some polling. And you’ve already seen the first poll question. We’re just asking you to tell us which hospital you represent. We have about three minutes left for that poll, so please go ahead and let us know which hospital you’re representing. All right. So, just a few updates from our team. One is to tell you about the webinars that we have planned for the future, the upcoming months. In February, this is the month where we’re going to begin the hospital update. And we currently have two hospitals who have committed to doing their presentations next month. We’ll have Hemet Valley and Roswell both do presentations on giving us just a brief update on what their — you know, some of the actions or interventions that are included in their implementation action plan. And we’ve already developed the schedule, so you’re all slated to present in one of the upcoming months, between February and May. Additionally, during — sometime between the period of March and May, we are fortunate enough that Dr. Litchford has agreed to come back and do a second part of — a second webinar on nutrition, because there’s so much to cover and so little time. So, she has agreed to come back and do another webinar for us. So, we will keep you posted on when that will be. All right. So, with that, let me just introduce you. Hi, folks. I hear some background and I’d like to ask people to please mute their phones while we’re — while Dr. Litchford does her presentation. So, let me just introduce to you Dr. Litchford. Dr. Litchford is an acclaimed speaker, author, medical and legal expert, and a consultant to healthcare providers. And along with her consulting work, Dr. Litchford has built a national reputation from her many presentations, published articles, and books on topics related to clinical nutrition. So, we’re very lucky to have her here. She’s authored online instructional software for healthcare science students and advanced level continuing education courses for nutrition professionals. She is currently on the board of directors for the National Pressure Ulcer Advisory Panel, and also serves as the vice president of the National Pressure Ulcer Advisory Panel. So, with that, I’d like to just thank Dr. Litchford for agreeing to be here and sharing her expertise with all of us. And I’m going to turn it over to you, Dr. Litchford. So, just going to pass the ball over to you and you can take it over. All right. Well, thank you so much. I certainly appreciate the invitation to be part of your webinar series. You know, as a clinician, I’ve worked with pressure ulcers and other types of trauma wounds in acute care, in long-term care, and in home care, but, you know, as a family member, I’ve dealt with a parent who developed a pressure ulcer in acute care and also in home care. So, I kind of see it from both sides of the coin. We asked the hospitals to submit questions that you had about nutrition in the preparation of this webinar. And, initially, we didn’t get but just a couple, but then we started getting lots more. And I wanted to thank you for these excellent and thought-provoking questions that you sent in. We got so many questions that I couldn’t cover them all in this hour webinar. So, that’s why we’re going to do a follow-up webinar. Also, I’m going to write out the answers to each of the questions, and I’ll probably have some references to support my answers as well for each of the questions. And so all of the hospitals will receive that as well. And you’ll get that before the second webinar. So, if I mention something in the webinar today that isn’t specifically in the PowerPoint, there are some references that I’ve added, then that will be on those answers to those questions that you submitted. Now, you’re welcome to ask questions during the webinar. We’re planning on doing most of the questions at the Q&A. Now, I’ve interspersed the questions you submitted throughout the webinar, but, again, all the questions are not included in today’s webinar because of insufficient time. I’ve got some polling questions and I want you to be honest in answering those polling questions because I’d like to get a sense of your perspective on nutrition and risk for pressure ulcers, risk for malnutrition in your particular care setting. So, as we get started, first off, we’ll do some — we’ll look at the objectives. All right. Now, of course, I can’t get this thing to move. There we go. All right. Here are our learning objectives. We’re going to look at the undernutrition-malnutrition continuum and the impact of inflammation on the risk for skin breakdown. I’m going to talk briefly about the current criteria for the diagnosis of malnutrition. I’ll spend more time on that in the second webinar. Today, I’m going to discuss the National Pressure Ulcer Advisory Panel Clinical Practice Guidelines specific to nutrition and wound healing, and also in prevention. The last set of clinical practice guidelines that came out in 2010, the prevention section was a separate document from the treatment section. In the 2014 CPG, it’s all together. And I’m going to talk a little bit about some innovative nutrition strategies that may be useful for you in the prevention of pressure ulcers. So, first poll question. If you were to guess, what percentage of your hospital patients were malnourished or maybe undernourished at the time of admission? Ten percent or less, up to 50 percent, between 50 and 75 percent, or more than 75 percent. And I’ll give you, you know, about 30 to 45 seconds to answer that question. Now, what percentage of your hospital patients were undernourished or malnourished at the time of admission? So, our choices were ten percent or less, up to 50 percent, between 50 to 75, or more than 75. Okay. Up to 50 percent has eight, it looks like. Three people said between 50 and 75. Nine people didn’t answer. Maybe you don’t know or maybe you don’t want to say. All right. So, do we see malnutrition in our hospital patients? When I was in school, which was back in the 20th Century, the feeling was that malnutrition was a problem in third-world countries and not so much in the U.S. But if you look at the data from the Nutrition Screening Initiative, which is a 20th Century document, about 40 to 60 percent of hospitalized older adults, so that would be 65 or older, are malnourished or at risk of malnutrition; 40 to 85 percent of nursing home residents are malnourished; and 20 to 60 percent of home care patients are malnourished. Now, if you look at some international data, that’s 21st Century data, the study by Lim was done at a hospital in Singapore, and it was done over a three-year period of time, with over 800 adults. And what Lim reported was that about a third of these patients had malnutrition, and that malnutrition led to longer lengths of stay, higher cost, and poorer outcomes during hospitalization; also, a much greater likelihood of being readmitted within 15 days. Mortality was higher in this group at one year, two years, and at three years. She did not look at, or he did not look at pressure ulcers in this particular study. Now, the Somanchi study was done in the U.S. at Johns Hopkins, and this was a study of 200 patients. And at Johns Hopkins they found that over 50 percent of the patients had malnutrition. And they compared two different medical wards. So, I think we’re seeing that we do see malnutrition in this country. Sometimes we don’t see it because we’re not looking for it. So, think about those patients that are readmitted. Here’s our second poll. If you were to guess, what percentage of your readmitted patients were undernourished or malnourished at the time that they were readmitted, ten percent or less, up to 50 percent, between 50 and 75 percent, or more than 75 percent? So, these are just the ones that come back, say, within 30 days. So, if you would answer that poll for me. I’ll keep it open for a little bit longer. I see that the poll has ended, but I don’t see any results. Okay. Well, we had 12 people that didn’t answer this question, but five of them said up to 50 percent, and four said between 50 and 75 percent. All right. The next poll question, if you were to guess, what percentage of the physicians and other clinicians that work at your hospital believe that nutrition plays a role in pressure ulcer prevention, ten percent or less, up to 50 percent, between 50 and 75 percent, and more than 75 percent? What percentage of the physicians and other clinicians believe that nutrition plays a role in the pressure ulcer prevention? And we should have some numbers here in just a minute — or just a few seconds. Deidre, are you able to show the results? I’m showing — I hit “Apply” already. Let me try again. Because I’m not seeing any results on this one. Okay. Here we go. Five said ten percent or less; one, up to 50 percent; two, 50 to 75; four, more than 75 — that’s good — and 14, no answer. All right. The reason why I bring this topic up is that in the mid-20th Century, it was in medical textbooks that — or at least some medical textbooks that nutrition played a very minimal role in the maintenance of skin and the healing of wounds, whether they were surgical wounds, trauma wounds, or pressure ulcers. And there’s still clinicians that believe that nutrition really doesn’t play that big of a role. And I think part of the confusion is that we define malnutrition a little differently in the 21st Century than we used to 50 years ago. We used to think that all types of malnutrition were the same, kind of a one-size-fits-all, but, in reality, what has been proposed is that there is starvation-related malnutrition and there is inflammation-related malnutrition, and they respond differently based on the type of malnutrition that you have. So, we’ll talk a little bit more about that. Well, this is what the data shows about malnutrition and pressure ulcers. There have been a number of studies identifying risk factors that are related to malnutrition, unintended weight loss, underweight, malnutrition, dehydration are just some of the ones that — risk factors associated with pressure ulcer development. And this is the Lyder study that was in a hospital setting. Lyder also reported that Medicare patients, adults over 65, who were at risk for pressure ulcers, of that group, 76 percent were malnourished. Low BMI, reduced food intake, impaired ability to eat independently, either they can’t open the packages, they’re too weak to feed themselves, they can’t chew or can’t swallow were also risk factors for pressure ulcers. Now, Fry did an interesting study that was published in 2010. Fry looked at patient characteristics and the occurrence of never events. And what he reported was that preexisting malnutrition or weight loss correlated with a fourfold higher risk for development of pressure ulcers. So, I think there’s a good bit in the literature to show that malnutrition is related to the increased risk for pressure ulcers. So, let’s turn the clock back further than the 20th Century and ask the question does nutrition really make a difference, and ask Hippocrates. What would he say about it? Well, he’s not here, so we can’t ask him, but he had two observations, at least these statements were credited to him. One is that “Healing is a matter of time, but sometimes also a matter of opportunity.” And he was also credited with saying “Let food be thy medicine and medicine be thy food.” And so my question to you is when we think about wound care clinicians, are we missing pivotal opportunities in the area of preventing skin breakdown as well as healing pressure ulcers? How do we spend our money? Certainly in Western healthcare we are investing millions and billions of dollars in medications, in special products to promote healing and to prevent skin breakdown. Yet, just to be honest, many of these interventions generate sub-optimal results, and there are lots of reasons why that might happen, but what about nutrition opportunities? What kinds of things might we have been missing? The patient who’s losing weight, the patient who won’t eat or can’t eat, the patient who’s too tired to eat, or the patient who has a pressure ulcer that isn’t healing, maybe the ulcer is stalling out. This is from a paper that I wrote, it was about frailty and sarcopenia, but this is going to be a population that’s going to be at high risk for skin issues, whether they’re trauma injuries or pressure ulcers, looking at what happens to adults? Now, some adults come into the hospital for a procedure and they’re in good health. They eat well, their weight is normal, but because of the things that happen during their course of care, they are not able to eat, the inflammation is quite high, and so we see them becoming undernourished and malnourished during the course of their hospitalization. Then there’s that other group of people who have been declining over time, and maybe nobody has noticed. With aging, they’ve gotten too tired to shop and too tired to cook and too tired to eat. And so what they do is they will consume one of those oral nutritional supplements that are advertised on television thinking that it’s a meal replacement or maybe a couple of meals. So, if they drink one of those products a day, the thought is, well, you know, this makes up the difference in the fact that I’m not eating and I’m not cooking. We also see poor dietary intake because of limited food budget. So, we start off with poor dietary intake, and that — none of this even addresses poor dietary choices people have been making up to this point. You add illness, injury, and surgery, you have increased nutrient needs, a loss of reserves, we see impaired nutrient transportation — transport, and utilization. Some of this is a decline in organ systems, sometimes it’s food medication issues. And so that’s what develops into this cycle of under nutrition and malnutrition. Where we see a decrease in foot intake, an unplanned weight loss, loss of fat stores, loss of muscle, and loss of physical strength. I mentioned inflammation, that the inflammation — the malnutrition that we see associated with inflammation is different than malnutrition that’s associated with starvation. During the inflammatory process, whether it is due to disease or injury, or infection, there are a series of reactions. Some of these are included on this slide. This slide’s very busy, but the slide also just addresses the nutrition issues. We have a genomic response where we have this turn on of genes, a gene transcriptor, or NF-kB. We also have an immune response. And both of these, both the genomic response and the immune response ultimately trigger the synthesis of cytokines. And there are three that have been associated with the decline in nutritional status, interleukin-16 — interleukin 1b, interleukin 6, and tumor necrosis factor. Now, in order to synthesize these components, the body needs energy and it needs protein. In order to make more immune cells, whether they’re T cells or macrophages or mast cells, you’ve got to mobilize nutrients. The cytokines do a couple of things, the cytokines impact appetite. The person isn’t hungry. The person is listless. The person isn’t very clear-minded. And the cytokines trigger the release of oxidants that promote lean body mass loss. One thing the cytokines also do is slow down gut motility. So, everything moves at a slower pace and that contributes to that anorexia as well. Now, the cytokines trigger the liver to redirect its synthesis of acute phase proteins or acute phase reactants. And so you start making more CRP, C-reactive proteins, fibrinogen and ferritin, and there are just a couple of those positive acute phase proteins or reactants. All of these take nutrients, protein, and energy. And so if you’re not consuming enough, you have a high inflammatory response, the body is going to start breaking down protein stores to meet these nutrient needs. And so this is Jensen’s proposal about malnutrition, that if a person has inflammatory processes that are prominent, typically we’re looking at an acute illness or an acute injury. And so you have a very high inflammatory response. So, you’re breaking down lean body mass at a very rapid pace. And even our obese patients may have sarcopenic obesity, so they don’t have a lot of lean body mass stores, body mass stores, but they’ve got a lot of fat stores. Our chronic conditions have a lower level of inflammation, but still that ongoing chipping away of the muscle tissue. What we know with sarcopenia is that, starting at age 40, adults start losing lean body mass and strength. We all know that we’re more sedentary than our ancestors were, and so we see a lot of sarcopenia. And as people get older, they lose more and more lean body mass. Now, with starvation, our gentleman here on the end, starvation is not associated with inflammatory stress. Now, our gentleman in the picture may have some conditions that are inflammatory-related, but let’s just assume that this is just starvation because this is a homeless person or this is a person who may have some eating disorders or some issue that impacts food intake. Now, if you were to look at interventions, when you look at that person who’s starving, who doesn’t have inflammatory processes going on, the person’s going to be losing weight as long as their energy and protein requirements aren’t being met, but once you start meeting those, this person will improve, gain weight, and the skin will respond in kind if you have a problem with skin breakdown. However, if the person has a marked inflammatory response, you’re going to see that rapid weight loss, but just by giving nutrition intervention is not going to reign in the inflammation. We’ve done a lot of studies looking at using vitamin supplements to try and reign in inflammation, and none of them had been particularly successful. So, the goal with an acute illness or injury is to provide that nutrition to provide supportive care while — or to provide nutrients while supportive care addresses the acute medical issues. And so it is a supportive care in terms of providing nutrition. Now, with chronic disease, we’re going to have a slower loss of lean body mass and loss of weight possibly. Again, as long as the inflammatory processes are present, we’re always going to be providing nutrients, but that additional supportive care is going to make a difference in terms of controlling whatever the chronic condition is. So, how do you decide that someone’s malnourished? Here’s our next poll question. What is the primary measure to — measure or biomarker that you or your colleagues use to diagnose malnutrition? Is it weight loss or body mass index, serum albumin or prealbumin, physical appearance or functional status — and functional status, or using the characteristics of malnutrition that are from the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition? And please be honest, what’s the primary measure or biomarker? We’ll give you a few seconds to answer that poll. Okay. We have 24 people that didn’t answer. Three people did say the characteristics of malnutrition. Only two people said albumin and prealbumin; that’s the right answer. Albumin and prealbumin have been used as markers of malnutrition, but that’s 20th Century thinking. So, what do we know about albumin? Well, it’s primarily — the primary serum protein that’s synthesized by the liver, and it’s involved in colloidal osmotic pressure, but it’s not a sensitive measure of nutritional status. Whenever I talk about pressure ulcers, I always have physicians that come up to me, if they’re in the audience, and they’ll say, “Well, we’ve used albumin or prealbumin for years as our marker, and that’s what determines whether they receive a protein supplement or not.” Well, what we know about albumin is that it’s not very sensitive, it has a long half-life, and you also have large extravascular reserves. And so what happens is that when serum levels fall, albumin just moves from the extravascular space into the serum, and when synthesis improves it moves back to the extravascular reserves. And that’s why albumin will stay within normal ranges, or maybe just slightly low with uncomplicated starvation, because it’s just a redistribution of reserves. So, where did we get the idea that albumin was a good marker? Well, for those of you that are nutrition professionals in our audience, you remember studying about kwashiorkor and marasmus when you took that first nutrition class. We used to think that, based on the data of these two different disorders, that albumin really was a good marker of nutritional status. In kwashiorkor, the more classic view is the little boy on the left with the large distended belly, the ascites, the fatty liver, skinny arms and legs, low albumin. His diet is adequate in calories but has almost no protein, or very low quality protein. Now, if you look at the child on the right, this is a little girl. Now, she doesn’t have quite the distended belly that the little boy does, and she does have some pretty skinny arms and legs, but notice that her hair is white, and that is another distinguishing characteristic of kwashiorkor, and that is a pediatric diagnosis. Now, compare that to marasmus, that is what we’ll see with disordered eating, where there is a severe loss of lean body mass, and the person has a skeletal appearance. Would you think that person would have a low albumin? Well, actually, this person has a normal albumin, because we don’t have the inflammatory processes going on. The diet is very low in both calories and protein. Now, the first study that I’ve seen in the literature dates back to 1944, and that’s Ancel Keys’ study on the Minnesota Starvation Study. And Keys had some conscientious objectors from World War II, these were college students, all men, volunteer to participate in a semi-starvation diet. They were on the diet for six months. You look at the baseline data, these men were very physically fit and on the slim side, a BMI of 21.7 on average, and a serum albumin of 4.3. Less than 10 percent fat on their bodies. After six months on a semi-starvation diet, the average BMI was 16.4, so very underweight, but the albumin didn’t change significantly, 3.9. And so this data, in and of itself, shows that albumin and prealbumin — or albumin specifically doesn’t really tell us much. One of your questions was what types of labs should be done to ensure that proper nutrition of patients with wounds and how often should it be done. Well, I think I’ve made the case that albumin doesn’t really tell us very much, but what about prealbumin, because that’s the other one that is ordered? A dentist did a study looking at changes in prealbumin and nutrient intake and systemic inflammation in a little over 100 older men in recuperative care. These men were at a VA hospital. And he tracked prealbumin, CRP, tumor necrosis factor, and interleukin 6. And what he found was that in these men, they had a high protein, high calorie intake to address the fact that they were undernourished, but the protein intake only accounted for six-percent variance in the prealbumin, but the CRP and the interleukin 6 accounted for about 56 percent. So, tracking albumin or prealbumin really isn’t going to tell us anything, and there are really not any labs that we do consistently in an acute care setting that tell us much about changes in overall nutritional status, especially protein status. Now, you can look at some labs to look at micronutrient deficiencies, iron, B12, zinc possibly, but, again, these aren’t the predictors of protein status. And so, unfortunately, there aren’t any labs that will address this. A primary thing to do that the dietician should be doing is nutrition-focused physical assessment, looking for changes in muscle wasting as well as fat wasting, and changes in functional status. So, we’re going to shift gears a little bit and talk about resources or recommendations to help elevate the importance of nutrition in patients, and especially patients at risk for pressure ulcers. Well, the National Pressure Ulcer Advisory Panel is kind of a think tank in the U.S. for making recommendations for prevention and treatment of pressure ulcers; so, nutrition is one of the components of that. During the World Wide Pressure Ulcer Awareness Day, which is the third Thursday in November, they’ve only done this for a couple of years now, but NPUAP has started sponsoring free webinars on those days, as well as last year there was a video done for families about turning and repositioning loved ones, whether they were in home care or in the hospital setting, being sure that they didn’t stay on those bony prominences so long. There’s also some materials available at the NPUAP website that were developed for World Wide Pressure Ulcer Awareness Day that are directed towards patients. And I think we’ll see more of those things in the future. Now, I want to spend the bulk of the rest of our time talking about the guidelines in the clinical practice guidelines. There’s a quick reference guide, and that is free. You can download that for free. If you want a hard copy, you do have to pay for that. And then the clinical practice guideline is a much longer document, and that provides you with a detailed analysis and the description of the methodology for the development of the guidelines. Now, these guidelines were developed using standard procedures where the quality of the research was rated, but they also looked at recommendations as well. Now, there are lots of recommendations. I’m only going to talk about the nutrition ones, nutrition screening, nutrition assessment, care planning, energy intake, protein intake, hydration, and vitamins and minerals. So, let’s look at what’s in the guidelines. Number one is to screen nutrition status for each individual at risk of or with a pressure ulcer, and this would be done at admission, and this would also be done if the patient had a significant clinical change, or if they do have a pressure ulcer, when progress towards the pressure ulcer is not observed. The strength of evidence is related A through D, and then the strength of recommendations is based on how many thumbs up or thumbs down the recommendation received, and that’s on each of these slides. Now, the Nutrition Screening Tool needs to be a valid tool, and it needs to be a reliable tool to determine nutritional risk. And then those that are identified as at risk of malnutrition or individuals with existing pressure ulcers would be referred to the registered dietician. Now, the last part of that recommendation says the “interprofessional nutrition team.” Because these are international guidelines, the terminology includes a broader scope, and that’s how it’s termed in other countries. And they don’t all have access to an RD or an RDN. Now, these are the four balanced screening tools that are recognized in the guidelines and the links that you can use to access them. The first one, the Mini Nutrition Assessment, is a U.S. tool. The other tools were developed in other countries, but they still may be helpful to you. It’s ideal if these are done through your electronic medical record and the score, as well as the interpretation of the score is populated somewhere in your medical record so that the providers and the clinicians have a sense of what the person’s risk score was and what that means. The next recommendation deals with nutrition assessment, and these are basic things that all your RDNs are going to be doing, looking at weight status, looking at ability to eat independently, looking at total adequacy of intake. And so what else can we do other than that? Are there other validated malnutrition screening tools other than just height and weight and BMI on admission that you would find useful? Well, this is where these new guidelines from the Academy of Nutrition and Dietetics and the A.S.P.E.N. group on characteristics of malnutrition come in. These were published in 2012. And I’m going to discuss these in more detail in the second webinar, but there are characteristics and benchmarks. Some of the benchmarks have time parameters also for describing malnutrition as a nutrition diagnosis. The characteristics, there’s six of them, evidence of reduced dietary intake, unintended weight loss, changes in body composition, loss of subcutaneous fat, muscle loss, and fluid accumulation. Now, not all fluid accumulation is related to decline in protein status, so we’re only looking at that if it is. And then hand-grip strength. Now, the patient must meet two of the characteristics. And I didn’t provide this for you in the handout, but I will include that on our next webinar. We’ll talk a little bit more about defining malnutrition using these new guidelines. So, if you’re not using them, I hope that you will investigate that as your criteria. So, what about the care plan? Well, the recommendations are that you need a care plan, and it needs to be based on evidence-based guidelines on nutrition and hydration. And that’s for individuals who exhibit nutritional risk, so they’re at risk for malnutrition, and at risk for a pressure ulcer or have an existing pressure ulcer. What about energy intake? Well, we certainly want to be sure that we are addressing their individualized needs. And the guidelines recommend 30 to 35 calories per kilogram of actual body weight for adults at risk of a pressure ulcer and at risk of malnutrition. Now, you could have somebody who’s at risk for a pressure ulcer, but their nutritional status is very good, and they aren’t going to score high enough on one of those risk evaluation tools to be at risk for malnutrition. And then that requires clinical judgment to decide do they really need this level of energy intake per day. Certainly, if they have a pressure ulcer and they’re also at risk for malnutrition, you’d want to add 30 to 35 calories per kilo. If they’re underweight, they may need more. If they’re obese, they may need less, as noted on the fourth recommendation there. What about special diets? Well, the recommendation is, if at all possible, liberalize those therapeutic restrictions. Now, sometimes that’s not always the best choice, and the goal is we don’t — we want them to eat more food, and so we don’t want to decrease their food and fluid intake because of their dietary restrictions. Sometimes that can’t be avoided. Also recommend fortified foods or high calorie, high protein, oral nutritional supplements, either with meals or between meals. Now, this recommendation is between meals. I’m going to talk a little bit about protein requirements in just a few minutes, but that’s what this guideline recommends. And you see the strength of evidence and the strength of the recommendations. All the nutrition recommendations have at least one thumb up, no thumbs down; that means the panel decided it was something they would certainly recommend doing. And then if you’re not able to meet nutrient requirements for energy orally, then enteral or parenteral nutrition should be considered if it’s consistent with the individual’s goals. What about protein? Well, it follows the same pattern about people that are assessed at risk for pressure ulcers, we want to be sure they get adequate protein and high quality protein. And the level is 1.25 to 1.5 grams of protein per kilo of body weight for adults at risk of a pressure ulcer and at risk for malnutrition when compatible with goals of care and reassessed as the condition continues. So, there are going to be some individuals that will not tolerate that level of protein. Certainly, if they have a pressure ulcer, we want to be sure they’re getting adequate protein. The recommendation is the same, 1.25 to 1.5 grams of protein per kilo of actual body weight for people with an existing pressure ulcer and who are assessed to be at risk for malnutrition. The recommendation is to use high calorie, high protein nutritional supplements in addition to the diet if they cannot consume enough energy and protein from the diet, and certainly always consider the renal function, because a high level of protein may not be well-tolerated. And then if you do use a supplement of a high protein supplement that contains the conditionally indispensable amino acid arginine and other micronutrients, this is recommended in individuals with a stage three or four pressure ulcer, or multiple pressure ulcers when nutritional requirements can’t be met in a traditional way or with lower calorie supplements that don’t have the additional conditionally essential amino acids such as arginine. So, let’s talk about protein. It’s one thing to say, well, they need this level, but how do you make that happen? Number one, all protein is not equal. There are low quality sources of protein that have a lot of fillers in them, like our luncheon meats. Certainly pork skins aren’t even a complete source of protein. And your ground meats are also not complete sources of proteins so that if the person is consuming an incomplete form of protein, it’s not going to be equivalent to a high quality source of protein. Now, my picture here has a picture of some whole muscle meats and fish. We also have nuts and legumes. Now, these have got to be added with different combinations of food so you’re getting a complete force of protein. But remember that not all sources of protein are nutritionally equivalent. Now, the whole role of adding protein is to trigger tissue synthesis. And what we found out in the study is that you’ve got to have a certain level of one of the indispensable amino acids, which is leucine, to trigger what’s called the mTOR pathway, that’s what starts tissue synthesis to heal skin and to maintain skin. And so if you look at all of your different products on the market for protein supplements, whey protein has more than twice or about twice the amount of leucine as in many other even complete sources of protein. So, most of your soy products are complete sources of protein, your collagen, collagen whey products may be fortified to be complete sources, but naturally they don’t contain as much leucine as whey does. And the studies that looked at providing enough leucine for tissue synthesis got the best results in the products that were naturally high in leucine. And there have been some studies suggesting that perhaps we ought to add leucine as a separate dietary supplement. Leucine is an indispensable amino acid, and the body cannot synthesize it. It has to come from food. So, you can see that even if the products are all the same in terms of meeting minimum amino acid requirements, if you really want to synthesize tissue, which is what we want to do to not only prevent skin breakdown as well as heal it, having one with a higher level of leucine is going to be your best value. We do not know exactly how high leucine needs to be to be — exactly when it triggers tissue synthesis. What about the timing of the meal, does that make a difference, or the timing of the protein? Which menu promotes tissue synthesis? Menu one, now, this is a person who skips breakfast, has a light lunch, and a heavy supper in terms of protein distribution. So, no protein at breakfast, a little bit at lunch, maybe ten to 15 grams, and maybe 50 grams of protein at the evening meal; versus menu two, equal at each meal; or menu three, a little bit of protein at breakfast, a little bit of protein at lunch, whole lot of protein at supper; or no difference in outcomes. So, if you would answer that poll. So, which menu promotes tissue synthesis? Having a lot of protein at the evening meal and not much at breakfast, maybe a little bit at lunch; having equal amounts at each meal; or having a little bit for lunch — breakfast and lunch, and a whole lot for supper; or maybe it doesn’t make any difference at all, you had all your protein at once during the day, at one meal. And do we have some results of that? Our time is quickly getting away from us. Deidre, do you have some results for that one? Hold on. We added a few seconds to the poll. All right. Also, think about which pattern best describes you. How do you eat? All right. Well, we’ve got to have some dieticians in the audience because menu two is the correct answer, and that’s equal amounts at each meal. Very good. But how realistic is that in the hospital setting? How realistic is it in your own personal life to have equal amounts of protein at each meal? But what the studies have shown, the Mamerow study, Layman, there have been several studies, Simmons, have shown that the equal distribution of protein at each meal provides that level of leucine that you need to trigger the mTOR pathway to promote tissue synthesis. And so it may be that in the breakfast meal you might have to use a protein supplement added to a beverage or added to a product that the person consumes. I think adding it at the last two meals of the day is a little bit easier than at breakfast, but that’s going to promote tissue synthesis. Having three times that at one meal gives you no more tissue synthesis because the body gets to a saturation point. We get to a certain level of amino acids and then we saturate the sites. And so the studies are showing 28 to 32 grams of protein per meal. For athletes, the numbers are a little bit higher. What about hydration? Well, water is going to be very important in meeting needs of our patients. We know that skin is more fragile in our dehydrated patients, and so it’s going to be very important that they are assessed for hydration and that hydration is provided for them. What we see with dehydration, again, as the skin is much more fragile, and it is via water that nutrients move from the digestive tract to the leucite, as well as removal of waste products. So, that is going to be very, very important, that hydration be assessed using labs as well as nutrition-focused physical assessment. The recommendation is for people with increased needs to add increased fluids. Remember that we don’t have real strong science on really determining what fluid or water requirement are for individuals. The RDA is for water; it’s not for fluids. And so the data that we have has been collected by the military for soldiers in very hot climates, how much water do they need, and by elite athletes. And so our recommendations of one milliliter per calorie or 30 mills per kilo of body weight are based on clinical judgment. And so you’ve got to look at that overall picture and realize where that all comes from, but we do see a lot of disorders of water balance in our acute care populations. What about vitamins and minerals? Well, individuals certainly who are assessed to be at risk for pressure ulcers need to consume a balanced diet, and if they’re at risk for a pressure ulcer and the dietary intake is poor, then a vitamin/mineral supplement is recommended when intake is poor or deficiencies are confirmed or suspected. And same with a person with a pressure ulcer. Now, didn’t we used to recommend zinc and vitamin C back in the day? Well, back in the 20th Century, yes, we did. The vitamin C studies in animals showed that, at least in pigs, the skin does peel faster when they have vitamin C supplements, but that data did not transfer to the human model. And so in the studies looking at humans, adding extra vitamin C every day for wound healing doesn’t seem to make any difference with pressure ulcers. So, just a regular multi vitamin in which the RDA is met is more than sufficient. And same with zinc, we used to recommend zinc. Zinc, copper, and iron compete for receptor sites, and so if you give large doses of zinc, more than 50 milligrams a day, for example, you can deplete the body of copper, and copper is involved in making cross-linkages. And so the skin may heal, but it doesn’t have any elasticity, and so the skin breaks open. So, even though we used to recommend that back in the day, we do not recommend zinc and vitamin C now for everyone at risk for pressure ulcers or with pressure ulcers. Now, if you have a large draining wound, you may be losing considerable amounts of zinc, and that is a different situation that is not addressed in the NPUAP guidelines. We’re down to the last few minutes of our webinar today, and I’ve got a couple more questions that you had submitted. One is about what if the nutritionist doesn’t have order-writing privileges, what are the best practices recommended to ensure that diet orders are seen and acted upon? Well, the best practice is for your RDNs to have order-writing privileges. And if they don’t, there is a procedure that your organization can go through to grant them this privilege, but it is organization-specific. Now, CMS has come out and said the registered dietician/nutritionist is the most qualified person to write orders for diet, and so I’ve not see any best practices. Certainly, we see a lot of dietary communications sent, either electronically or a new form that’s put in a paper medical record, but I’ve not seen any that are clearly best practices. Is there any research or recommendations that show the benefits of ordering protein supplements based on patient needs under protocol versus physician order? Not specifically that, but there are a number of studies that show that by incorporating oral nutritional supplements early on, you can — they’re very helpful in preventing pressure ulcers, but not specifically answering that question. And a lot of these studies were done in Europe, and that’s part of why the importance of those oral supplements as a way to meet protein and energy requirements. And then our last question deals with how long does it take before nutrition is starting to show a difference? Well, unlike medications that may block a reaction and show a dramatic change, or a wound that maybe is draining and you use a dressing that will wick up a lot of that moisture, you can see a dramatic reaction or a response. With nutrition, it takes longer because the energy and the protein has to be assimilated. If inflammatory stress is quite high, then it becomes part of that supportive care as well as it works in conjunction with those acute care interventions that are being used. We’ve seen in the studies where they’ve used even trophic enteral formulas, where they give a low dose. There was a study that came out looking at vent patients, that they had fewer GI problems when they started nutrition earlier versus later. But nutrition isn’t going to give you quite as fast a response as some other things. In your slide, I’ve got a list of references, I have several slides of those. And I want to end our discussion by challenging you to take action, to look at missed opportunities, and to remember this Chinese proverb that “He who takes medicine and neglects diet, wastes the skills of his doctors.” Michelle, it looks like our time, we are slightly over. I don’t — it looks like — No, thank you so much, Mary. Before — I know we’ve gone a little over. We started a little bit late, though, too. I wanted to just see if anybody had any burning questions that they would like to ask while we have Dr. Litchford here with us. And I know some people may have to go because of other, you know, commitments, but please feel free to take advantage of this time. If you have a question, submit it through the chat, raise your hand, let us know. We’re welcome to take some questions right now. And I don’t see any hands up at this point. The — I know — let’s see, are there any questions from anyone? Nothing in the chat and no hands raised. Okay. Let me ask just a couple of questions on my own. So, would you recommend protein supplements when the albumin or prealbumin fall below a normal reference range? Well, as we discussed, albumin and prealbumin are not markers of protein status. They’re markers of inflammation. What do we know about inflammation? We know that with inflammation we have a physiological response that results in a decrease in appetite and an increased nutrient requirement for protein and energy to make all of these cytokines and other immune cells in the body. And so even though back in the 20th Century we used to say when the albumin got to this level or the prealbumin got to this level, this is when we add a protein supplement, I think you have to look at that lab as an inflammatory marker and recognize that the presence of inflammation really increases that person’s risk for malnutrition. They may be undernourished before they got to the hospital, but the presence of the higher inflammatory stress as a result of the surgery or whatever is going on in the course of care that is increasing that inflammatory rate is being reflected by that lower level of albumin and prealbumin. And so even though there’s not a “if A, then B,” you must use your clinical judgment to really determine whether those protein requirements are being met. Okay. So, what if you have a patient that’s at risk for a pressure ulcer but they have no signs of malnutrition, would it be appropriate in that case to increase energy and protein intake? That’s a very good question. We have patients that come to the hospital that are in excellent nutritional status. They eat very well and they really don’t show any evidence of malnutrition. They score not at risk. Then, according to the guidelines, they would not meet the criteria to add increased protein and increased energy, but, again, that becomes clinical judgment. However, if during the course of their care, within a few days, their nutritional status may change, especially if there’s been a rapid loss of weight, rapid loss of strength, and the dieticians might be called in to do some nutrition-focused physical assessment and some functional status assessment to look at what has really changed with this person. So, again, it gets back to our clinical judgment. The guidelines indicate that they must be at risk for a pressure ulcer as well as at risk for malnutrition for these guidelines, but, again, always an individualized assessment and the goal is to prevent the skin breakdown. And so that’s something that we always have to keep in mind to be compatible with our goals of care and our patient preferences. Okay. Thanks for answering that. I do have one last question I wanted to ask. When you went to the question about the menus and which menu — you know, what proportion — how heavy, I guess, in the protein content that you’d want to have at each meal, and the answer I guess was equal at each meal, but what about the other nutrient elements, carbs and fat, et cetera, what proportion of that should be in the meal, relative to the protein? Well, that’s an interesting question. The relationship of the carb and the fat probably have less to do with the tissue synthesis if basic requirement for energy are being met. So, you’ve got a normal distribution of fat and carb in the diet, and so, you know, we’ve always talked about 30 percent of calories from fats, the new dietary guidelines don’t even — aren’t that specific. They don’t even give a total percentage of fat in the diet as we’ve had in past year’s guidelines. You want to look at your total amount of carbs. You’ve also got to look at your insulin response. If you have a person with diabetes and you have got elevated blood sugar, that’s going to affect your ability to utilize nutrients. And I don’t have my slide in this set. I can put it in the next set. If you have too much carb and you’re getting too much of an insulin response, the cells can become rigid and the utilization of nutrients can become impaired. And so that’s going to contribute to greater fragility of the skin, it’s going to be more fragile, and you’re going to have poor healing because you don’t have good utilization of nutrients as a result of that response. And so that is something that you would want to consider for someone who has either pre-diabetes or diabetes, or hyperglycemia as related to increased stress of what has brought them to the hospital. Right. Right. All right. Well, last chance for any additional questions that anyone might have at this point. And just to remind everyone, we will be doing a summary. Dr. Litchford is actually going to be responding to all of the questions, and we plan to be sending that out to you as soon as it’s completed. So, look for that, and also information on the next webinar. So, at this time, Mary, would you mind just moving the slide — advancing the slide through to the last one? I just want to remind everyone that our next webinar is on February 18th, and that’s when we will have two of our hospitals presenting, sharing updates on their implementation efforts. So, thank you, again, Dr. Litchford, for the wonderful presentation. I found it very educational, even for my own diet. And thank you everyone for joining. So, please remember to complete the webinar evaluation survey as you exit the webinar. Michelle. So, thank you very much. Michelle. Yes. We do have one question. Oh, we do. Okay. I don’t see it. Here it comes. Is that in the chat window? Yes. All right. Let me just see that. So, do you have any recommendations for vitamin A supplement with patients receiving steroids who have a pressure ulcer? The studies with vitamin A have looked at — some of them have looked at 10,000 international units a day for about two weeks, ten days to two weeks. Some of them have looked at 15,000 to 30,000, I guess that’s for the shorter period of time. If you gave 10,000, then you can do it a little bit longer than two weeks. What the high levels of vitamin A do is counteract the effect of the steroid, and it can jump start your stalled wound if the wound is stalled because of the steroid. But it also impacts the effectiveness of the steroid. So, you’ve got to decide how beneficial that is. And I will look up that study and put it in the — my questions, because I don’t have that in front of me. And I — vitamin A was not mentioned in the NPUAP guidelines. One thing that I will mention about vitamin A is that we are seeing vitamin A deficiencies in individuals that have had gastric bypass surgery. And so these are individuals three and four years from surgery, so we may start seeing some of that where we’ll need to supplement with vitamin A, and especially if they’re on steroids, if they’ve got a subclinical deficiency that hasn’t been identified prior to their hospitalization, they have surgery, they’re on steroids, we’re going to start seeing a need to add more vitamin A to meet nutrient requirements as well as dealing with those stalled wounds. So, those recommendations are going to be much higher, but that’s just what I see coming down in the future, but I will look that study up and put it in the question and answers. Great question. Thank you very much. Okay. Well, great. Well, thank you for that question. And thank you, again, Dr. Litchford. It was a very informative webinar. And I think that all of our participants really enjoyed it. So, that concludes this webinar everyone. And we look forward to meeting up again next month, and also, Dr. Litchford, to your second webinar. Well, thank you very much. All right. Thank you everyone.