Bonnie Caulfield

Continuous Quality Improvement (CQI)

Manchester Memorial Hospital, Manchester, CT

Identification of Problem and Study Rationale

Wounds are a large burden on the healthcare system. In a 2014 analysis of Medicare cost
estimations, it was projected that all wounds cost a range of $28.1 billion to $96.8 billion. Out of
all wounds, surgical and diabetic ulcers were the most expensive1. Chronic wounds and their
long-term tole on both the individual patient and the healthcare system are an especially taxing
phenomenon. An estimate of about 2% of the entire US population is affected by chronic wounds
and 3% of the elderly population over the age of 65 have open wounds1. Nonhealing wounds
account for more the $3 billion in cost per year, affecting 3-6 million people in the US2. Proper
wound care has the potential to decrease these figures and improve the timely healing of wounds.
Nutritional supplementation to promote wound healing is especially important to achieve
the best patient outcomes in hospital settings. The current protocol for patients presenting with
wounds at Manchester Memorial Hospital is to provide a 10-day wound healing regimen of 220
mg zinc sulfate, 500 g vitamin C and 25,000 IU vitamin A. In terms of energy and protein
requirements, there is not a set protocol in place. Research has suggested that on top of these
micronutrients, additional supplementation of amino acids may be beneficial to improve the rate
of wound healing as well as prevent complications. A product of increasing interest is Juven, a
therapeutic nutrition powder with key ingredients of HMB, Arginine, Glutamine, Collagen
protein, zinc, and vitamins C, E and B12 to help support wound healing3. Juven comes in the
form of packets with available flavors of Orange, Fruit Punch or Unflavored. These packets can
be easily added to 8-10 ounces of water or juice as well as mixed into food products much like
Beneprotein packets are currently used at Manchester Memorial. Juven is also safe to add to
enteral feeding formulas. The recommended dosage for Juven is two packets daily. Since this is
an Abbott product, and Manchester Memorial already stocks Abbott products, I hope to
determine if there is scientific evidence to support its use and whether it would benefit the patient
population at Manchester Memorial. I will explore the key ingredient and whether they have
scientifically significant benefits. I will also determine if standard recommended energy and
protein requirements should be implemented.

Measurable Indicators
It is not plausible to compare the use of evidence-based supplementation for promoting
wound healing prior to and post the implementation of Juven due to the duration of patient
hospital stays being too short to determine long term effects. Instead, I will conduct research to
determine if the implementation of Juven is scientifically supported. I will also determine if,
based on the current protocol at Manchester Memorial Hospital, patients’ energy requirements
are sufficient based on standards. The data was collected by:
1. Gathering the initial nutrition assessment notes from patients with active wounds from
my time at Manchester Memorial.
2. Each of the patients will be assessed to determine whether the energy and protein
calculations are meeting the recommended needs of the patients based on their wound
status.
3. A theoretical comparison of current wound healing protocol and standard
recommendations will be used to determine if patients’ needs are being met.
Data Collection
The data on whether the key ingredients of Juven are effective and beneficial for
supporting wound healing was collected through searches on Pubmed for published scientific
research. I attempted to uncover information on the key ingredients in Juven of Arginine,
Glutamine, HMB and collagen protein which differ from the current protocol at Manchester
Memorial. A challenge I ran into while doing research was that many articles on studies that
examined these ingredients and their effects had to be purchased in order to view. For my
research I used free texts that I was able to access, but more evidence exists. Patients I assessed
during my time at Manchester Memorial were used as theoretical subjects for me to compare the
current protocol with recommended energy needs and theoretical supplementation with Juven to
determine, based on my research, if the supplementation with Juven would be beneficial.

Data Analysis

Energy and Protein needs:

The Nutrition Care Manual recommends following the American Society for Parenteral
and Enteral Nutrition and the Wound Healing Society’s standard energy levels of 30-35
kcal/kg/day to support optimal wound healing. For protein, the recommended range is 1.25-1.5
g/kg/day for individuals with chronic wounds2. It is important to keep in mind patient specific
conditions and disease states when making these recommendations.

Collagen Protein and Wound Healing:

Collagen is essential in building healthy skin, so it seems that supplementation would
improve wound healing. A randomized, controlled, multicenter trial took place at 23 long-term-
care facilities across four states and included 89 patients with Stage II, III or IV pressure ulcers.
Participants were randomized to receive standard wound care with daily placebo or standard care
with a daily concentrated, fortified, collagen protein hydrolysate supplement. The Pressure Ulcer
Scale for Healing, or PUSH, was used to assess wounds weekly. The tool measures pressure
ulcer healing based on surface area, exudate, as well as the type of wound tissue to score sounds
between 0 and 17, 0 meaning that the wound is healed. The study concluded that after the 8 week
treatment, the patients who received the experimental supplement had an average PUSH score of
3.55 while those in the control group had a PUSH score of 4.114. Based on these results, collagen
hydrolysate was beneficial in promoting improved pressure ulcer healing compared to standard
wound care.

Arginine, Glutamine, and HMB in Wound Healing:

Arginine is considered conditionally essential in times of illness and stress. The majority
of dietary arginine is absorbed in the jejunum and is metabolized into ornithine and urea.
Orthinine, a substrate of polyamines, promotes regeneration, the healing of damaged tissues, and
can be metabolized to glutamate-semialdehyde, a precursor for pyrroline-5-carboxylate (P5C).
Through the metabolism of arginine, a P5C reductase is created which catalyzes P5C reduction
to synthesize proline which is known to promote wound healing, skin remodeling and collagen
synthesis5. A multicenter, 2-group, randomized, controlled, blinded clinical trial that included
200 malnourished adults in long-term care and home care services with stage II, III, and IV
pressure ulcers compared supplementation with an energy-dense, protein rich oral formula with
arginine zinc and antioxidants to an equivalent volume of isocaloric and isonitrogenous formula.
This took place over the course of 8 weeks and used percent change in pressure ulcer area as the
primary end point as well as secondary end points of complete healing, prevalence of infection,
total number of dressing at 8 weeks and percent change in area in 4. There was not any
significant change in secondary endpoints, but it was determined that supplementation with the
enriched formula was effective at reducing the pressure ulcer area compared to the control
formula. The enriched formula had an average reduction of 60.9% while the control formula
reduced the pressure ulcer area by only 45.2%. Limitations of the study include that participants
needed to be malnourished, had to be capable of consuming oral supplements, and be living in
long-term care institutions or home care services to be part of the study. The overall conclusion
of this study was that malnourished patients who had pressure ulcers benefited from 8 weeks of
supplementation with a nutrition formula that was enriched with arginine, zinc, and antioxidants
and had improved wound healing6.
The amino acid of Glutamine is also considered conditionally essential in critically ill
patients. Despite this increased need for Glutamine, many critically ill patients have glutamine
deficiencies and it is unclear why. Glutamine provides a primary fuel for cells in the immune
system and is a nontoxic carbon and nitrogen donor for nucleotide precursor synthesis.
Monocyte, lymphocyte and neutrophil function is influenced by adequate glutamine levels7. This
is especially important as a major complication of wound healing is infection.
A study focusing on Diabetic wound healing tested the effect of supplementation with
arginine, glutamine, and HMB on the hydroxyproline levels of wound tissue. Hydroxyproline is
a marker used to determine collagen concentrations in tissue which is an indicator of wound
healing. This pilot study followed 9 patients that underwent wound debridement. They were
randomized and assigned to either a placebo control group or an experimental group that
received supplementation 2 times daily for a total of 2 weeks. It was determined that the
experimental group had a mean percent change in hydroxyproline concentration of +67.8% while
the control/placebo group had a mean percent change of 78.4% at the end of the 4 weeks8. Based
on these results, it is supported that an amino acid supplement with arginine, glutamine, and
HMB can improve diabetic wound healing through an increase in collagen production.

Patien Age & Weight MMH Kcals % MMH Protein (g) %

t
Gender kcals recommended standard protein recommended standard
(30-35kcal/kg) met for (g) (1.25-1.5g/kg) met for
kcals protein
1 60 yo F 59.6 kg 1490-1788 1788-2086 ~85% 60 74-89 ~73%
(25-30kcal/kg) (1g/kg)

2 60 yo 104 kg 2600-3120 3120-3640 ~85% 104-125 130-156 ~80%

M (25-30kcal/kg) (1-1.2g/kg)

3 80 yo F 55 kg 1375-1650 1650-1925 ~85% 55-66 69-83 ~80%

(25-30kcal/kg) (1-1.2g/kg)
4 58 yo 89 kg 2225-2670 2670-3115 ~85% 89-107 111-134 ~80%
M (25-30kcal/kg) (1-1.2g/kg)

AVG ~85% ~78%

Table 1. Comparison of current protocol vs standard recommendations for energy and protein requirements for
wound healing for 4 patients
Discussion
Table 1 shows the comparison of 4 patients that I did an initial nutrition assessment on
who had active wounds during my time at Manchester Memorial Hospital. There is not currently
a set protocol for protein and energy requirements for patients with wounds despite the Nutrition
Care Manuals recommendations of 30-35kcal/kg and 1.25-1.5g protein/kg. I determined what
percentage of the patients’ energy and protein needs were being met based on my calculations by
comparing them to what those requirements would be if the NCM recommendations were used. I
determined that only about 85% of the energy needs of patients were being met and about 78%
of protein needs were being met.
The Nutrition Care Manual also notes that micronutrients should be provided to
counteract any deficiencies that the patient is experiencing. Currently at Manchester Memorial,
patients are supplemented with 220 mg zinc sulfate, 500 g vitamin C and 25,000 IU vitamin A as
well as a multivitamin if they have a Braden score below 17. I concluded that currently the
energy and protein requirements of patients with wounds are likely not being met at Manchester
Memorial due to the fact there are not set standards in place.

Suggested Remedies
Based on the evidence I gathered through research as well as the comparison of current
energy and protein requirement at MMH, I think that in order to promote better wound healing in
patients, Juven supplementation as well as standard recommendations of 30-35kcal/kg and 1.25-
1.5g protein/kg should be implemented. The key ingredients in Juven of HMB, Arginine,
Glutamine and Collagen protein have scientific evidence to support that they promote wound
healing. Since the majority of scientific trials of amino acid supplementation took place over 2
and more weeks, I think that Juven should be provided for patients at MMH for the duration of
their hospital stay or until their wound has healed if their stay is of long duration.
Implementation of guidelines should also consider other health conditions or illnesses that may
require protein restriction.

I have determined my recommendation for updated standard wound healing

supplementation to be as follows:

Energy Protein requirements Supplementation

requirements

Wound Healing 30-35 kcal/kg/day 1.25-1.5 g/kg/day 2 packets of Juven daily

Regimen for length of admit or
until wound is healed

Table 2. Recommendation for new Wound Healing guidelines at MMH

References

1. Sen CK. Human Wounds and Its Burden: An Updated Compendium of Estimates. Adv
Wound Care (New Rochelle). 2019;8(2):39-48. doi:10.1089/wound.2019.0946
2. “Surgical and Chronic Wounds.” - Nutrition Care Manual,
https://www.nutritioncaremanual.org/topic.cfm?
ncm_category_id=1&lv1=255665&lv2=273002&ncm_toc_id=273002&ncm_heading=N
utrition+Care&showtbar=1. 
3. “Juven®: Healthcare Professionals.” Juven®, https://juven.com/hcp. 
4. Lee SK, Posthauer ME, Dorner B, Redovian V, Maloney MJ. .  Pressure Ulcer Healing
with a Concentrated, Fortified, Collagen Protein Hydrolysate Supplement.  Advances in
Skin & Wound Care.   2006; 19 (2): 92-96.
5. Chu AS, Delmore B. Arginine: What You Need to Know for Pressure Injury
Healing. Adv Skin Wound Care. 2021;34(12):630-636.
doi:10.1097/01.ASW.0000795900.25030.5e
6. Cereda E, Klersy C, Serioli M, Crespi A, D'Andrea F; OligoElement Sore Trial Study
Group. A nutritional formula enriched with arginine, zinc, and antioxidants for the
healing of pressure ulcers: a randomized trial [published correction appears in Ann Intern
Med. 2015 Dec 15;163(12):964]. Ann Intern Med. 2015;162(3):167-174.
doi:10.7326/M14-0696
7. Andrews FJ, Griffiths RD. Glutamine: essential for immune nutrition in the critically
ill. Br J Nutr. 2002;87 Suppl 1:S3-S8. doi:10.1079/bjn2001451
8. Jones MS, Rivera M, Puccinelli CL, Wang MY, Williams SJ, Barber AE. Targeted amino
acid supplementation in diabetic foot wounds: pilot data and a review of the
literature. Surg Infect (Larchmt). 2014;15(6):708-712. doi:10.1089/sur.2013.158