Pressure ulcers and nutritional deficits in elderly long-term care patients: Effects of a comprehensive nutritional program on pressure ulcer healing, length of hospital stay and charges to patients

The elderly are at the highest risk of developing pressure ulcers that result in prolonged hospitalization, high health care costs, increased mortality, and decreased quality of life. The burden of pressure ulcers will intensify because of a rapidly increasing elderly population in the United States (US). Poor nutrition is a major predictor of pressure ulcer formation. The purpose of this study was to examine the effects of a comprehensive, interdisciplinary nutritional protocol on: (1) pressure ulcer wound healing (2) length of hospital stays, and (3) charges for pressure ulcer management. Using a pre-intervention/post intervention quasi-experimental design the study sample was composed of 100 patients 60 years or older, admitted with or acquiring a pressure ulcer. A pre-intervention group (n= 50) received routine pressure ulcer care (standard diet, dressing changes, and equipment). A post-intervention group received routine care plus an interdisciplinary nutrition intervention (physical therapy, speech therapy, occupational therapy, added protein and calories to the diet). Research questions were analyzed using descriptive statistics, frequencies, Chi-Square Tests, and T-tests. Findings indicated that the comprehensive, interdisciplinary nutritional protocol had a significant effect on the rate of wound healing in Week3 and Week4, total hospital length of stay (pre-intervention M= 43.2 days, SD=31.70 versus M=31.77, SID-12.02 post-intervention), and pressure ulcer length of stay (pre-intervention 25.28 days, SD5.60 versus 18.40 days, SD 5.27 post-intervention). Although there was no significant difference in total charges for the pre-intervention group ($727,245.00) compared to the post-intervention group ($702,065.00), charges for speech (m=$5885.12, SD=$332.55), pre albumin (m=$808.52,SD= $332.55), and albumin($278 .88, SD=55.00) were higher in the pre-intervention group and charges for PT ($5721.26, SD$3655.24) and OT($2544 .64, SD=1712.863) were higher in the post-intervention group. Study findings indicate that this comprehensive nutritional intervention was effective in improving pressure ulcer wound healing, decreasing both hospital length of stay for treatment of pressure ulcer and total hospital length of stay while showing no significant additional charges for treatment of pressure ulcers.

Children with special health care needs: Comparison of the effects of home care setting, prescribed pediatric extended care setting, and long-term care setting on child and family health outcomes and health care service use

Technological advances during the past 30 years have dramatically improved survival rates for children with life-threatening conditions (preterm births, congenital anomalies, disease, or injury) resulting in children with special health care needs (CSHCN), children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who require health and related services beyond that required by children generally. There are approximately 10.2 million of these children in the United States or one in five households with a child with special health care needs. Care for these children is limited to home care, medical day care (Prescribed Pediatric Extended Care; P-PEC) or a long term care (LTC) facility. There is very limited research examining health outcomes of CSHCN and their families. The purpose of this research was to compare the effects of home care settings, P-PEC settings, and LTC settings on child health and functioning, family health and function, and health care service use of families with CSHCN. Eighty four CSHCN ages 2 to 21 years having a medically fragile or complex medical condition that required continual monitoring were enrolled with their parents/guardians. Interviews were conducted monthly for five months using the PedsQL™ Generic Core Module for child health and functioning, PedsQL™ Family Impact Module for family health and functioning, and Access to Care from the NS-CSHCN survey for health care services. Descriptive statistics, chi square, and ANCOVA were conducted to determine differences across care settings. Children in the P-PEC settings had a highest health care quality of life (HRQL) overall including physical and psychosocial functioning. Parents/guardians with CSHCN in LTC had the highest HRQL including having time and energy for a social life and employment. Parents/guardians with CSHCN in home care settings had the poorest HRQL including physical and psychosocial functioning with cognitive difficulties, difficulties with worry, communication, and daily activities. They had the fewest hours of employment and the most hours providing direct care for their children. Overall health care service use was the same across the care settings.

Application and evaluation of an Institute of Medicine approach to dietary assessment and planning in long -term care

The primary purpose of these studies was to determine the effect of planning menus using the Institute of Medicine's (IOMs) Simple Nutrient Density Approach on nutrient intakes of long-term care (LTC) residents. In the first study, nutrient intakes of 72 subjects were assessed using Dietary Reference Intakes (DRIs) and IOM methodology. The intake distributions were used to set intake and menu planning goals. In the second study, the facility's regular menus were modified to meet the intake goals for vitamin E, magnesium, zinc, vitamin D and calcium. An experiment was used to test whether the modified menu resulted in intakes of micronutrients sufficient to achieve a low prevalence (<3%) of nutrient inadequacies. Three-day weighed food intakes for 35 females were adjusted for day-to-day variations in order to obtain an estimate of long-term average intake and to estimate the proportion of residents with inadequate nutrient intakes. ^ In the first study, the prevalence of inadequate intakes was determined to be between 65-99% for magnesium, vitamin E, and zinc. Mean usual intakes of Vitamin D and calcium were far below the Adequate Intakes (AIs). In the experimental study, the prevalence of inadequacies was reduced to <3% for zinc and vitamin E but not magnesium. The groups' mean usual intake from the modified menu met or exceeded the AI for calcium but fell short for vitamin D. Alternatively, it was determined that addition of a multivitamin and mineral (MVM) supplement to intakes of the regular menu could be used to achieve goals for vitamin E, zinc and vitamin D but not calcium and magnesium. ^ A combination of menu modification and MVM supplementation may be necessary to achieve a low prevalence of micronutrient inadequacies among LTC residents. Menus should be planned to optimize intakes of those nutrients that are low in an MVM, such as calcium, magnesium, and potassium. A MVM supplement should be provided to fill the gap for nutrients not provided in sufficient amounts by the diet, such as vitamin E and vitamin D. ^

Pressure ulcers and nutritional deficits in elderly long-term care patients : effects of a comprehensive nutritional program on pressure ulcer healing, length of hospital stay and charges to patients

The elderly are at the highest risk of developing pressure ulcers that result in prolonged hospitalization, high health care costs, increased mortality, and decreased quality of life. The burden of pressure ulcers will intensify because of a rapidly increasing elderly population in the United States (US). Poor nutrition is a major predictor of pressure ulcer formation. The purpose of this study was to examine the effects of a comprehensive, interdisciplinary nutritional protocol on: 1) pressure ulcer wound healing 2) length of hospital stays, and 3) charges for pressure ulcer management. Using a pre-intervention/post intervention quasi-experimental design the study sample was composed of 100 patients 60 years or older, admitted with or acquiring a pressure ulcer. A pre-intervention group (n= 50) received routine pressure ulcer care (standard diet, dressing changes, and equipment). A post-intervention group received routine care plus an interdisciplinary nutrition intervention (physical therapy, speech therapy, occupational therapy, added protein and calories to the diet). Research questions were analyzed using descriptive statistics, frequencies, Chi-Square Tests, and T-tests. Findings indicated that the comprehensive, interdisciplinary nutritional protocol had a significant effect on the rate of wound healing in Week3 and Week4, total hospital length of stay (pre-intervention M= 43.2 days, SD=31.70 versus M=31.77, SD=12.02 post-intervention), and pressure ulcer length of stay (pre-intervention 25.28 days, SD5.60 versus 18.40 days, SD 5.27 post-intervention). Although there was no significant difference in total charges for the pre-intervention group ($727,245.00) compared to the post-intervention group ($702,065.00), charges for speech (m=$5885.12, SD=$332.55), pre albumin (m=$808.52,SD= $332.55), and albumin($278 .88, SD=55.00) were higher in the pre-intervention group and charges for PT ($5721.26, SD$3655.24) and OT($2544 .64, SD=1712.863) were higher in the post-intervention group. Study findings indicate that this comprehensive nutritional intervention was effective in improving pressure ulcer wound healing, decreasing both hospital length of stay for treatment of pressure ulcer and total hospital length of stay while showing no significant additional charges for treatment of pressure ulcers.

Children with Special Health Care Needs: Comparison of the Effects of Home Care Setting, Prescribed Pediatric Extended Care Setting, and Long-Term Care Setting on Child and Family Health Outcomes and Health Care Service Use

Technological advances during the past 30 years have dramatically improved survival rates for children with life-threatening conditions (preterm births, congenital anomalies, disease, or injury) resulting in children with special health care needs (CSHCN), children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who require health and related services beyond that required by children generally. There are approximately 10.2 million of these children in the United States or one in five households with a child with special health care needs. Care for these children is limited to home care, medical day care (Prescribed Pediatric Extended Care; P-PEC) or a long term care (LTC) facility. There is very limited research examining health outcomes of CSHCN and their families. The purpose of this research was to compare the effects of home care settings, P-PEC settings, and LTC settings on child health and functioning, family health and function, and health care service use of families with CSHCN. Eighty four CSHCN ages 2 to 21 years having a medically fragile or complex medical condition that required continual monitoring were enrolled with their parents/guardians. Interviews were conducted monthly for five months using the PedsQL TM Generic Core Module for child health and functioning, PedsQL TM Family Impact Module for family health and functioning, and Access to Care from the NS-CSHCN survey for health care services. Descriptive statistics, chi square, and ANCOVA were conducted to determine differences across care settings. Children in the P-PEC settings had a highest health care quality of life (HRQL) overall including physical and psychosocial functioning. Parents/guardians with CSHCN in LTC had the highest HRQL including having time and energy for a social life and employment. Parents/guardians with CSHCN in home care settings had the poorest HRQL including physical and psychosocial functioning with cognitive difficulties, difficulties with worry, communication, and daily activities. They had the fewest hours of employment and the most hours providing direct care for their children. Overall health care service use was the same across the care settings.

A synthesis of long-term research by the Florida Coastal Everglades LTER Program

This paper synthesizes research conducted during the first 5–6 years of the Florida Coastal Everglades Long-Term Ecological Research Program (FCE LTER). My objectives are to review our research to date, and to present a new central theme and conceptual approach for future research. Our research has focused on understanding how dissolved organic matter (DOM) from upstream oligotrophic marshes interacted with a marine source of the limiting nutrient, phosphorus (P), to control productivity in the oligohaline estuarine ecotone. We have been working along freshwater to marine transects in two drainage basins located in Everglades National Park (ENP). The Shark River Slough transect (SRS) has a direct connection to the Gulf of Mexico, providing this estuarine ecotone with a source of marine P. The oligohaline ecotone along our southern Everglades transect (TS/Ph), however, is separated from this marine P source by the Florida Bay estuary. We originally hypothesized an ecosystem productivity peak in the SRS ecotone, driven by the interaction of marine P and Everglades DOM, but no such productivity peak in the TS/Ph ecotone because of this lack of marine P. Our research to date has tended to show the opposite pattern, however, with many ecosystem components showing enhanced productivity in the TS/Ph ecotone, but not in the SRS ecotone. Water column P concentrations followed a similar pattern, with unexpectedly high P in the TS/Ph ecotone during the dry season. Our organic geochemical research has shown that Everglades DOM is more refractory than originally hypothesized. We have also begun to understand the importance of detrital organic matter production and transport to ecotone dynamics and as the base of aquatic food webs. Our future research will build on this substantial body of knowledge about these oligotrophic estuaries. We will direct our efforts more strongly on biophysical dynamics in the oligohaline ecotone regions. Specifically, we will be focusing on inputs to these regions from four primary water sources: freshwater Everglades runoff, net precipitation, marine inputs, and groundwater. We are hypothesizing that dry season groundwater inputs of P will be particularly important to TS/Ph ecotone dynamics because of longer water residence times in this area. Our organic geochemical, biogeochemical, and ecosystem energetics work will focus more strongly on the importance of detrital organics and will take advantage of a key Everglades Restoration project, scheduled for 2008 or 2009, that will increase freshwater inputs to our SRS transect only. Finally, we will also begin to investigate the human dimensions of restoration, and of a growing population in south Florida that will become increasingly dependent on the Everglades for critical ecosystem services (including fresh water) even as its growth presents challenges to Everglades sustainability.