Nutrition care practice patterns for patients with COVID-19-A preliminary report.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 is a respiratory virus that poses risks to the nutrition status and survival of infected patients, yet there is paucity of data to inform evidence-based quality care.
METHODS: We collected data on the nutrition care provided to patients with coronavirus disease 2019 (COVID-19) by registered dietitian nutritionists (RDNs).
RESULTS: Hospitalized COVID-19 patients (N = 101) in this cohort were older adults and had elevated body mass index. The most frequent nutrition problems were inadequate oral intake (46.7%), inadequate energy intake (18.9%), and malnutrition (18.4%). These problems were managed predominantly with enteral nutrition, food supplements, and multivitamin-multimineral supplement therapy. Over 90% of documented problems required a follow-up.
CONCLUSION: This data set is the first of its kind to report on the types of nutrition diagnoses and interventions for COVID-19 cases used by RDNs and highlights the need for increased and continued nutrition care.

CLINICAL RELEVANCY STATEMENT

We describe for the first time that the most frequent nutrition problems in hospitalized patients with coronavirus disease 2019 (COVID‐19) are inadequate oral and energy intake and malnutrition. Registered dietitian nutritionists manage these problems with interventions such as enteral nutrition, food supplements, and multivitamin‐multimineral supplement therapy. Most documented problems required follow‐up, which underscores the need for continued nutrition care in COVID‐19 patients.

INTRODUCTION

Coronavirus disease 2019 (COVID‐19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), poses great risks to the nutrition status and survival of infected patients. The Nutrition Care Process (NCP) is a systematic method for providing nutrition care and includes the 4 steps of assessment, diagnosis, intervention, and monitoring and evaluation. Each step has corresponding terminology that is used to standardize nutrition care documentation in electronic healthcare records and for data collection in research. The NCP has been altered during the global pandemic, with many hospitals and clinics installing policies that prevent registered dietitian nutritionists (RDNs) from performing key assessments. , This has led to great variation in nutrition care practices used to treat patients with COVID‐19 and a paucity of data to inform evidence‐based quality care. The data analysis described here uses a registry design, whereby, the RDNs document care into a web‐based platform as they provide it without restriction or input from the research team. The assessments, nutrition diagnoses, and interventions the RDNs chose to enter into the repository reflected their individual nutrition care practice patterns.

METHODS

To support outcome measurement of nutrition care delivery, the Academy of Nutrition and Dietetics has developed the Academy Health Informatics Infrastructure (ANDHII). ANDHII is a Health Insurance Portability and Accountability Act (HIPAA)–compliant web‐based platform intended to collect aggregated data entered directly by RDNs. The data are collected in structured and free text forms. The structured data are based on the NCP and its corresponding terminology. Because of the nature of this study design, the researchers did not dictate to the RDNs how to assess or diagnose malnutrition nor what interventions to recommend. The RDNs used their usual care practices and then documented them into ANDHII. Each patient entry was labelled with “COVID‐19” within the patients’ clinical history. One hundred and one patient entries were recorded between May 19 and July 2, 2020, utilizing a recently described methodology. ,

This data collection is ongoing and will continue as the pandemic progresses. The American Academy of Family Physicians institutional review board determined that this study did not need to be submitted for either an exempt determination or for review and approval as it does not involve human subjects, intervention, or interaction with patients, and no identifiable information was sent to researchers. This manuscript describes the initial findings, which were used to inform a larger prospective study titled “RESTORE: Nutritional Care Practices and Status of SARS‐CoV‐2 Patients.” The RESTORE Study aims to identify standard nutrition care practices used by RDNs that may influence the burden of disease in patients with COVID‐19 who are admitted to the intensive care unit.

RESULTS AND DISCUSSION

Comprehensive nutrition assessments, proper identification of diagnoses, and evidence‐based interventions are the foundation of quality care. With high patient census, patients who are in quarantined, enteral nutrition feeds, and equipment shortages, RDNs may face multiple challenges in providing quality care during the current pandemic. The virus impacts nutrition status in individuals. Reduced appetite and fevers may lead to malnutrition, weight loss, muscle wasting, and reduced immune resilience. Preexisting conditions such as overweight and obesity, hypertension, and diabetes increase patients’ risk for manifesting moderate or severe symptoms. Patients who are hospitalized with COVID‐19 have a higher prevalence of malnutrition than their hospitalized counterparts without COVID‐19. This study is the first of its kind to report on the types of nutrition diagnoses and interventions for COVID‐19 cases. Patients who were hospitalized COVID‐19 in this cohort were older adults and, on average, had an elevated body mass index (BMI) (Table 1). Described below are cross‐sectional relationships of how RDNs documented their assessment, diagnosis, intervention, and monitoring and evaluation of patients with COVID‐19.

Table 1

Patient descriptive characteristics

Variable	N	Mean ± SD (minimum, maximum)	Median
Age, y	77	63.48 ± 14.98 (24.00, 88.00)	65.00
Glycosylated hemoglobin measurement, %	19	9.35 ± 3.40 (5.80, 17.00)	8.80
Triglycerides, serum, mg/dl	80	280.36 ± 156.81 (73.00, 817.00)	239.50
Weight, kg	39	82.27 ± 21.22 (28.46, 147.5)	79.64
BMI, kg/m2	127	29.57 ± 6.80 (16.50, 56.40)	28.40
BMI categories		Percent distribution, % a	Test percent b
Underweight and normal	26	20.47	28.40
Overweight	42	33.07	29.20
Obese	59	46.46	42.40

Abbreviations: BMI, body mass index, SD, standard deviation.

P‐value by χ2 test = 0.1384 (using estimates from US population for BMI groups.

Estimated US population proportions for BMI groups that were used for comparison in chi‐square analysis.

Nutrition assessment

The most prevalent nutrition assessments documented by RDNs, aside from client history, were total energy estimated intake from oral nutrition in 24 hours, BMI, medical treatment/therapy, and triglycerides (Table 2).

Table 2

Distribution of top 5 nutrition care process terminology (NCPT) (n = 2690) used in each nutrition care process (NCP) step in the national quality improvement—COVID‐19 data set (N = 101 patients)

NCPT used in NCP steps		Frequency of NCPT	%
Total	NCPT domains	2690
Nutrition assessment (n = 1217)
Patient, client, family other history	Client history	197	16.2
Total energy estimated intake from ON in 24 h	Food/nutrition‐related history	151	12.4
Body mass index	Anthropometric measurements	125	10.3
Medical treatment/therapy	Client history	117	9.6
Triglycerides, serum	Biomedical data	80	6.6
Nutrition diagnosis (n = 652)
Problem (n = 212)
Inadequate oral intake	Intake	99	46.7
Inadequate energy intake	Intake	40	18.9
Malnutrition (undernutrition)	Clinical	39	18.4
Increased nutrient needs	Intake	16	7.5
Inadequate protein intake	Intake	9	4.2
Etiology (n = 212)
Custom etiologies	–	137	64.6
Inadequate energy intake	Intake	24	11.3
Altered gastrointestinal function	Clinical	22	10.4
Increased nutrient needs	Intake	16	7.5
Inadequate EN infusion	Intake	4	1.9
Signs and symptoms (n = 228)
Total energy estimated intake from ON in 24 h	Food/nutrition‐related history	148	64.9
Total energy estimated intake from EN in 24 h	Food/nutrition‐related history	28	12.3
EN formula/solution	Food/nutrition‐related history	19	8.3
Weight loss	Anthropometric measurements	11	4.8
Total energy estimated intake in 24 h	Food/nutrition‐related history	8	3.5
Nutrition intervention (n = 394)
Nutrition prescription	Nutrition prescription a	118	29.9
Modify composition of EN	Food and/or nutrient delivery	102	25.9
Insert enteral feeding tube	Food and/or nutrient delivery	34	8.6
Commercial beverage medical food supplement therapy	Food and/or nutrient delivery	33	8.4
Multivitamin, multimineral supplement therapy	Food and/or nutrient delivery	18	4.6
Monitoring and evaluation (n = 427)
Total energy estimated intake from EN in 24 h	Food/nutrition‐related history	111	26.0
Total energy estimated intake from ON in 24 h	Food/nutrition‐related history	75	17.6
Finding of abdominal distension	Nutrition‐focused physical findings	60	14.1
Gastric residual volume	Biochemical data, medical tests, and procedures	39	9.1
EN formula/solution	Food/nutrition‐related history	23	5.4

Abbreviations: EN, enteral nutrition; NCP, nutrition care process; NCPT, nutrition care process terminology; ON, oral nutrition.

Parent term not a domain.

Nutrition diagnosis

A nutrition diagnosis is composed of 3 parts: problem (diagnostic term), etiology (free text entry on cause), and signs and symptoms (derived from the assessment terms). Inadequate oral intake, inadequate energy intake, and malnutrition (undernutrition) were the most frequently documented problem terms reported in this cohort. Custom etiologies, inadequate energy intake, and altered gastrointestinal function were the most common etiologies reported. The etiology portion is less structured; thus, many practitioners use terms unique to their practice and preferences. “Intubation” and “Poor PO [intake by mouth] due to intubation” were the most common custom etiologies. Total energy estimated from oral nutrition in 24 hours, total energy estimated intake from enteral nutrition, and enteral nutrition formula/solution were the most commonly documented signs/symptoms (Table 2).

Nutrition intervention

Given the above nutrition diagnoses, it is reasonable that the most common nutrition interventions were nutrition prescription, modification of enteral nutrition composition, and insertion of a feeding tube. RDNs frequently reported use of multivitamin‐multimineral supplement therapy and use of commercial beverages and medical food therapy as interventions (Table 2).

Monitoring and evaluation

The terms selected for future monitoring and evaluation aligned with the most frequent diagnostic statements. Total energy estimated intake from enteral and oral nutrition and finding of abdominal distension were among the most frequently documented (Table 2).

Longitudinal data collected at follow‐up

When documenting follow‐up visits into ANDHII, monitoring and evaluation terms selected during the initial visit automatically populate into the assessment fields. This triggers the practitioner to reassess these parameters, enabling them to demonstrate change (or lack thereof) in key parameters. Practitioners can also record whether the initially documented diagnoses(is) are (is) resolved, continued, new, or removed. If practitioners failed to select monitoring and evaluation terms that relate to their diagnosis or chose not to assess the terms prospectively, it is impossible to determine whether the initially documented diagnostic terms resolved or improved. Given the short duration of data collection during this pilot stage, a preponderance of “continued” diagnoses is reasonable. However, it is concerning that a large number of indicators are not documented in follow‐up visits.

The time frame of this study was during a period in which COVID‐19 was peaking. It is possible that because institutions were inundated with COVID‐19 cases, documentation norms were altered. A limitation in this study, as is inherent with registry studies, is that clinicians record the data points they deem appropriate. Thus, we do not have complete information on various characteristics such as disease acuity, comprehensive drug treatment, or intubation status. It is also of interest that RDNs did not document diarrhea or other gastrointestinal problems as a symptom to be monitored given a high prevalence of gastrointestinal symptoms in patients with COVID. In addition, inadequate protein intake is a nutrition problem that was not frequently documented in this data, although it may be of interest in this population and could be more closely monitored. To ensure optimal documentation and data collection, RDNs must diligently monitor and evaluate the indicators that require monitoring, as nutrition problems are prevalent in the patients with COVID‐19 (Table 3). ANDHII has potential for showing the effectiveness of RDNs and the NCP, if documentation patterns are consistent.

Table 3

Nutrition care outcomes evaluation for top 5 monitored indicators, and nutrition diagnosis status

Indicator	Improved, %	Not improved, %	Stable, %	Absence of monitoring upon follow‐up, %
Total energy estimated intake from enteral nutrition in 24 h	3	27.3	25.8	43.9
Total energy estimated intake from oral nutrition in 24 h	9.1	18.2	38.6	34.1
Abdominal distention	0	0	0	100
Gastric residual volume	0	0	25.8	74.2
Diarrhea	0	0	0	100

CONCLUSIONS

The data described in this research show that, through ANDHII, we can document important nutrition care patterns, determine the current, most frequently documented assessments, diagnoses, and interventions related to nutrition support, and demonstrate that RDNs’ care has the potential to resolve important nutrition challenges faced by patients with COVID‐19. However, to demonstrate the effectiveness of interventions, RDNs must diligently monitor and evaluate the indicators during follow‐up visits. These data provide the basis for the design of the forthcoming RESTORE Study.

FUNDING INFORMATION

Financial and material support for the development of ANDHII has been provided by the Academy of Nutrition and Dietetics and the Commission on Dietetic Registration. Funding for “The RESTORE Study: Nutritional Care Practices and Status of SARS‐CoV‐2 Patients” is being provided by Nestlé Health Sciences and the Clyde F. Wallace, Jr. Memorial Fund within the Academy of Nutrition and Dietetics Foundation.

AUTHOR CONTRIBUTIONS

Alison Steiber, Constantina Papoutsakis, Lindsay Woodcock, and Taylor C. Wallace equally contributed to the conception and design of the research; Velarie Ansu, Lisa A. Spence, Lindsay Woodcock, Kathryn Kelley, and Nana Gletsu‐Miller contributed to the acquisition and analysis of the data; Alison Steiber, Constantina Papoutsakis, Taylor C. Wallace, Velarie Ansu, Lisa A. Spence, Lindsay Woodcock, Kathryn Kelley, and Nana Gletsu‐Miller contributed to the interpretation of the data; and Alison Steiber drafted the manuscript. All authors critically revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.

CONFLICT OF INTEREST

Constantina Papoutsakis, Lindsay Woodcock, Kathryn Kelley, and Alison Steiber are employees of the Academy of Nutrition and Dietetics, which has a financial interest in the ANDHII platform and the NCP terminology.