19 May 2020

Summary

Good nutrition is absolutely central to any recovery or rehabilitation. Policy makers, healthcare leaders and dietetic leaders need to take action to ensure that everyone leaving hospital after suffering COVID-19, has access to suitable nutrition, with expert guidance from a dietitian.

As patients with COVID-19 are at high risk of malnutrition, all should be screened for malnutrition prior to discharge. Their nutritional risk should be included in discharge documentation, along with a handover of the nutritional care plan, suggested monitoring, and involvement of community dietetic colleagues and other relevant members of the multi-disciplinary team (MDT) in the community settling. Not having this in place will lead to prolonged rehabilitation which will stretch primary and secondary care services further.

The BDA believes the following action is required:

  • Every COVID-19 inpatient, regardless of Body Mass Index (BMI), should undergo nutritional screening taking into account weight loss, with particular attention to signs of muscle wasting. This should be recorded on discharge documentation, and a clear plan put in place to provide nutrition support where needed. It is essential that patients with overweight or obesity are screened for malnutrition. Unintentional weight loss and muscle wastage in all patients can lead to malnutrition. Dietetic teams should ensure clear communication between acute and community services as part of discharge processes, to include the nutritional needs and consideration of how nutritional care plans will work within the community setting.
  • Dietitians must be familiar with their local COVID-19 therapy pathways and have discussions with therapy leads and healthcare professionals involved to ensure nutrition and dietetics is embedded as part of a robust MDT pathway for rehab. Similarly, those leading therapy pathways should contact local dietetic services to ensure nutrition is embedded within them. Health services must ensure sufficient and if necessary additional resources and funding are directed to dietetic services in outreach care as well as services in the community.
  • Health services in the community must seek out and engage with their local dietetic services where required, ensuring those in their care have access to necessary dietary expertise.
  • The BDA, ESPEN and others have produced clinical guidance which should form the basis of all healthcare services rehab pathways, ensuring nutrition is considered at each stage of the patient’s recovery journey (see further information section below for links to these guidance documents).
  • Community dietetic teams must be provided with appropriate PPE to undertake their work (read BDA statement on PPE). Trusts and health boards should utilise digital technology to provide relevant nutritional information and support to patients in light of infection control risk (read BDA rapid implementation of digital tools).
  • Support for community nutritional rehabilitation needs to be in place for the long term, in particular as there is likely to be much greater demand from non-COVID patients in the near future due to the impact of shielding and reduced uptake of existing NHS services. Government must provide the resources necessary to achieve this.
  • All dietetic departments should collect consistent data on COVID-19 nutrition outcomes (see further information below).

Background

Research in Acute respiratory distress syndrome (ARDS) (1) found that mean weight loss at discharge in patients with ARDS was 18%. This is significant weight loss and can lead to malnutrition. This data also demonstrated that the associated functional impairments continue to be significant even a year later. Recent research (3) indicates 29% of 446 COVID-19 ICU patients had prolonged post-extubation swallowing dysfunction at discharge.

To assist recovery, rehabilitation and repletion of lost muscle mass, patients will need individualised dietetic advice to encouraged the consumption of adequate energy, protein and micronutrients, combined with exercise rehabilitation as advised by physiotherapy. They may also require support from other members of the MDT, including but not limited to: psychological support, occupational therapy and speech and language therapy as outlined in the British Society of Rehabilitation Medicine (2). Carefully planned holistic MDT support is required for these patients in the community.

As per NICE nutrition support guidelines (4) - people who are malnourished or at risk of malnutrition should have a management care plan that aims to meet their nutritional requirements. The guidance also states that all those who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable) documented and communicated in writing within and between settings. Research indicates that screening is rarely included on discharge documentation. Results from a study in 2011 (5), showed that nutritional screening was only consistently recorded in 18% of 171 hospitals studied. If this information is not being included on discharge documentation, there is a real concern that those discharged with COVID-19 at high risk of malnutrition, will not receive the nutritional support they require in the community. This includes the risk of malnutrition potentially being overlooked in those with higher BMI.

Community support

Nutrition support will have started in hospital and guidance on inpatient nutritional care should be followed to ensure patients leave hospital in the best possible condition. However, post-discharge there will be a requirement for ongoing nutrition support as part of nutritional rehabilitation. Guidance for nutritional care in the community should then be followed. See further information section below for inpatient ICU, inpatient non-ICU and community guidance documents.

Nutritional issues requiring dietetic input are likely to be multifactorial. In the initial weeks and few months post discharge, the nutritional requirement of these patients will be higher, this along with a reduced desire to eat from COVID-19 symptoms requires dietetic input to improve the patient’s nutritional status in order to progress with rehabilitation and regain strength and function.

Support may take a number of different forms. This may include the ongoing provision of home enteral feeding or oral nutrition support (with or without oral nutrition supplements). Community dietetic teams should be able to advise on the best approach for individual patients with a focus on nutrient dense nutrition and not just calories.

Given the large number of people returning to the community who may require nutritional support, and the predicted increased need for community dietetic support for other patients, other HCP may provide first-line advice for these patients. Dietitians should guide other HCPs to reliable first line advice and agree referral pathways to support patients with increased or more complex nutritional needs. Technology may offer opportunities for dietitians to provide support to patients and colleagues remotely. See further information section below for rapid implementation of digital tools document.

Further Information

  • An acute and community dietetic dataset for COVID-19 – will be published on this webpage soon

In development:

  • Patient facing webinars on:
    • Nutrition after being ill with COVID-19
    • Nutrition after having been in critical care
  • Both webinars will soon be available on the patient webinars website

References

  1. Herridge MS, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003;348(8):683‐693. doi:10.1056/NEJMoa022450. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/12594312/
  1. British Society of Rehabilitation Medicine. Rehabilitation in the wake of Covid-19 - A phoenix from the ashes. 2020. Last accessed May 2020. Available from: https://www.bsrm.org.uk/publications/latest-news/post/39-covid-19-bsrm-position-on-rehabilitation
  1. Barazzoni R, Bischoff SC, Breda J, et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection [published online ahead of print, 2020 Mar 31]. Clin Nutr. 2020;S0261-5614(20)30140-0. doi:10.1016/j.clnu.2020.03.022. Abstract available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138149/
  1. National Institute for health and Care Excellence. Nutrition Support in Adults. 2012. Last accessed April 2020. Available from: https://www.nice.org.uk/guidance/QS24
  1. The British Association for Parenteral and Enteral Nutrition. Nutrition Screening Surveys in Hospitals in the UK, 2007-2011. 2014. Last accessed April 2020. Available from: https://www.bapen.org.uk/resources-and-education/publications-and-reports/nsw-reports/nsw07-11-amalgamated-data