Nutrition: A Key Link in Clinical Decision Trees

In 2003, Novartis Medical Nutrition, Fremont, MI, commissioned a panel of experts to develop a comprehensive pressure ulcer program for long-term-care facilities. As a result, the panel of physicians, nurses, dietitians, and physical therapists designed a unique series of decision trees intended to help guide clinicians working with elderly residents at risk for or currently being treated for pressure ulcers. Pressure ulcers are used as a quality indicator by the Centers for Medicare & Medicaid Services.
Decision trees are a systematic approach that reminds staff of the essential steps in approaching a unique clinical problem. Each individual tree expands on its components and develops that particular discipline's contribution to the overall care.


Panel Objectives
The panel's goal was to address the serious consequences of pressure ulcers, including lifestyle limitations, reduced selfesteem, altered body image, pain, delay in rehabilitation, and increased morbidity and mortality.1,2 To that end, the panel established these objectives:
* encourage a team approach to the care of chronic wounds such as pressure ulcers
* bring a cohesiveness to current facility wound care programs already in use
* offer guidelines to facilities without formal wound care protocols.
The panel developed a medical decision tree for the prevention and treatment of pressure ulcers. The physician uses this tree to refer the resident's care to the appropriate interdisplinary team member, such as nursing, nutrition, and physical therapy. Each discipline has its own decision tree to utilize in determining care for the resident.
Decision Tree in Action
After appropriate staff training, 5 Autumn Care long-term-care facilities in Virginia and North Carolina implemented the decision tree program (Figure 1, page 476). The new program was evaluated after 3 months. Nineteen residents who had either documented wounds or were at high risk for pressure ulcer development had been assessed.
In Group 1,12 residents were identified as being at high risk for pressure ulcers. Six residents did develop pressure ulcers during the 3-month period, with the wounds healing for 5 of the 6 residents during this time.
In Group 2, 7 residents had documented wounds at the start of the program: 5 had pressure ulcers, 1 had a stasis ulcer, and 1 had a surgical wound. At the conclusion of the 3-month trial period, wounds had healed in 5 of the 7 residents.
Implementing the decision tree process promoted collaboration between departments, especially nursing and dietary, and led to identification of nutrition and hydration issues that may not have been considered.
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