Monitoring patients during their COVID-19 recovery

Information on strategies and tools to identify nutritional issues and improve patient-centred care

Consensus statements from the expert panels

  • To improve patient-centred care and follow up, self-monitoring tools should be accessible for patients to use at home.
  • Professionals should use a range of strategies to ensure nutritional issues which concern patients are identified and followed up.

 
What the guidelines say about monitoring

Think about remote rehabilitation and for home, ask about symptoms, specific diagnostic tests, using open questions. People who suffered more severely from COVID-19 (e.g. ICU patients) need regular review and monitoring (1–3).

The aims for monitoring nutritional status (1):

  • Meet all nutrient requirements, particularly protein and vitamin D (for those spending a lot of time indoors).
  • Ensure a varied and balanced diet.
  • Manage symptoms through eating adjustments.
  • Use ONS when necessary (complies with ACBS criteria), consulting a dietitian or SaLT where there are swallowing difficulties (3).

Value of support and communication

Dietitians’ role is highly relevant and referral for assessment and monitoring should be made where possible. A clear nutrition support plan should be designed to last up to two years post discharge from hospital and when patients have ongoing or long COVID (4). Nutritional screening should be used (2) to identify those at risk of nutritional problems.

Interdisciplinary communication is vital. Planning care entails considering local and clinical care pathways and shared decision making is needed to establish which healthcare professionals need to be involved (5) and patient centred goals are preferred (2). 

It is vital to ensure strong links between acute and community settings (2) so patients are not lost to follow when they move from hospital (or other setting) to home. It is suggested to give people a copy of their care plans, clinical records, rehabilitation plans, letters and prescriptions (5).

Use a holistic patient centred approach with multidisciplinary input (2, 6).

Strategies to ensure nutrition issues are identified and monitored

Professionals can:

  • assess patient’s abilities and patient’s expectations (e.g. how they can address their goals and what resources they have in place to achieve them) from health services
  • involve other professionals such as social prescribers, dietetic assistants, healthcare assistants, and volunteers to support monitoring
  • signpost to support groups in the community or other community organisations
  • encourage patients to join relevant social media support groups, use apps that provide prompts and incentives to increase adherence, and actively involve their family
  • assess the patient's ability to self-monitor and encourage them to do so. Explain that keeping a record, (a user friendly) app or diary to track symptom fluctuations helps reach a decision on how to manage the symptoms.


How self-monitoring can help

Active involvement of patients is empowering and their involvement with monitoring is necessary. Self-monitoring is particularly important where infection control measures prevent face to face meetings.

Self-monitoring by the patient can:

  • ensure symptoms are monitored regardless of care setting
  • test results are fed back to medical records
  • ensure an approach based on the patient's specific circumstances and symptoms can be used
  • track adherence with dietary changes or other symptom management techniques.

Tests that help monitor recovery

Listed below of different tools that have been recommended to assist in monitoring recovery. Some use recalled and subjective measurements, some are suitable for virtual consultations, and some are self-assessment tools.


Elderly

  • Video call to assess frailty, metabolic risk (6 weeks post discharge if applicable) (6).
Suggested test and/or monitoring goals
  • Emerging or new symptoms ruling out any other conditions that could have caused complications (7) MNA (8).

Those who are under hospital care or after

  • Look for allergies, lifestyle (physical activity, diet, alcohol consumption), past and present symptoms of COVID-19, treatment received for COVID-19 for instance oxygen, antibiotics or other immunomodulators (9).
  • GI: stool and urine analysis gastrointestinal symptoms irritable bowel syndrome symptoms severity score. 
  • Nutrition: anthropometric and biochemical evaluation. 
  • For patients admitted to hospital, schedule early and regular review starting approximately one month after discharge to assess ongoing symptoms (2, 10).
  • People who were in ICU should be offered multi-disciplinary assessment at discharge and 4–6 weeks later (6). 
  • For post discharge consider evaluation of impairments in physical, functional, cognitive, psychosocial, and occupational aspects (11).
Suggested test and/or monitoring goals
  • The Mini Nutritional Assessment from the Nestlé Nutrition Institute (12), which has shown to be a useful tool to monitor improvements in respiratory diseases and comorbidities (13).
  • Body mass index, body circumferences, bioelectric impedance analysis.

People with other conditions

  • People with chronic respiratory diseases (e.g. COPD).
Suggested test and/or monitoring goals
  • Monitored by dietitians to monitor quality and quantity of diet, especially energy (kcal) and vitamin D (14).

  • People with diabetes.
Suggested test and/or monitoring goals
  • A lower caloric intake but higher protein may be beneficial (15).

  • People being tube fed at home.
Suggested test and/or monitoring goals
  • Should be monitored by a dietitian and difficulties with swallowing pathology should be monitored by a Speech and Language Therapist and dietitians and if necessary, specific diagnostic tests (16).
  • For more information on diagnostic tests please see our Identifying who needs nutritional care during COVID-19 recovery

Everybody

  • Use MUST with modifications for remote consultations and ask also about gastrointestinal symptoms. If malnutrition, use this advice (1). ABCDE (anthropometric, biochemical, clinical, dietary, environmental) – more information can be found on the Bapen website. It is also important to analyse energy and protein and micronutrient intake to provide nutritional recommendations to support the functional recovery of post acute COVID-19 (9).
Suggested test and/or monitoring goals
  • Prediction equations or weight-based formulae or indirect calorimetry if necessary.

Tailoring to patient preferences or culture

Patients with post COVID syndrome should receive support from HCP taking into full consideration individual values, needs and preferences; setting realistic goals, telling them who to contact, sources of advice and support (support groups, social prescribing, online apps), how to get support from social care, housing and employment, and advice about financial support (5, 6).

What sort of goals are useful to agree and prioritise?

Elderly and malnourished patients

The aims are gain muscle mass, patient feeling stronger, resume normal hobbies, improve stamina, achieve functional independence and desirable weight (3). This should be combined with gradual increase of physical activity. Discuss with physiotherapist and GP a suitable approach for patients.

After assessment with dietitian, determine if supplements of A, C, D, E, B6 and B12, Zinc and Selenium and high fibre should be included in diet (16). A dietitian can also explain the importance of a varied and nutritionally adequate diet and discuss frequency to assess vitamin levels how to monitor this.

For a prolonged home stay due to quarantine (for those at risk or who have COVID-19), maintenance of indoor physical activity is crucial: greater than 30 min daily or greater than one hour every other (second) day. This is important alongside nutritional care (11).

Food and symptom diaries resources

  • Watch a public talk on this topic, Is there a link between food and my symptoms? by Hannah Hunter, Allergy Dietitian, found on our Nutrition and COVID-19 Recovery page.
  • Download a food diary [Word.doc]
  • Some lessons can be learned from the guidance Pacing for people with ME [PDF] to pace activities and physical activity on Chronic Fatigue patients. They provide an idea to keep a diary too.

Useful links for dietary tips and general recovery

  • Patients are able to self-manage and access digital services. The NHS Your COVID Recovery website provides advice on symptoms of post-COVID syndrome or long COVID, such as eating well, taste and smell changes, swallowing, etc.
  • Post-COVID Hub website provides high quality information from the British Lung Foundation for people who cannot eat or drink properly.
  • LongCovidSOS includes a list of post COVID clinics as well as list of online support resources in different languages that some UK or international organisations have provided, mainly about respiratory health and rehabilitation but with useful links to support groups across the world.
  • Support your recovery from Lancashire Teaching Hospitals NHS Foundation Trust. Their COVID-19: Supporting your recovery website provides an online course developed for patients that contains general advice for COVID recovery and long COVID, as well as a section on eating well with infographics, images and tips for various dietary concerns. This webpage, also contains videos with different exercises to keep patients mobile.
  • The Eatwell Guide is a NHS sponsored website to learn tips, recommendations and recipes for a healthy diet.
  • The Nutrition and diet resources website is a Scottish charity and contains various resources for swallowing difficulties and gastrointestinal issues at a cost.
  • The Malnutrition Pathway website provides resources for healthcare practitioners, which they can share with patients.

Useful links for mental health, physiotherapy and post-COVID symptoms

This is a list of resources that are not specifically related to nutrition but to other symptoms or post COVID syndrome and may affect nutrition and/or may be worsen or improved through diet.

Physiotherapy


Post critical care recovery


Mental health


Fatigue

References

(1) Barazzoni R, Bischoff SC, Breda J, Wickramasinghe K, Krznaric Z, Nitzan D, et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clinical Nutrition. 2020 Jun;39(6):1631–8.

(2) Cawood AL, Walters ER, Smith TR, Sipaul RH, Stratton RJ. A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community. Nutrients. 2020 Oct 22;12(11):3230.

(3) A Community Healthcare Professional Guide to the Nutritional Management of Patients During and After COVID-19 Illness. :9.

(4) NIHR Evidence - Living with Covid19 - webinars - Informative and accessible health and care research [Internet]. [cited 2021 Apr 26]. Available from: https://evidence.nihr.ac.uk/themedreview/living-with-covid19-webinars/?source=chainmail

(5) COVID-19 rapid guideline: managing the long-term effects of COVID-19. :35.

(6) National guidance for post-COVID syndrome assessment clinics (6 November 2020) [Internet]. Patient Safety Learning - the hub. [cited 2021 Jan 9]. Available from: https://www.pslhub.org/learn/coronavirus-covid19/guidance/national-guidance-for-post-covid-syndrome-assessment-clinics-6-november-2020-r3465/

(7) Eekholm S, Ahlström G, Kristensson J, Lindhardt T. Gaps between current clinical practice and evidence-based guidelines for treatment and care of older patients with Community Acquired Pneumonia: a descriptive cross-sectional study. BMC Infect Dis. 2020 Dec;20(1):73.

(8) Bauer JM, Morley JE. Editorial: COVID-19 in older persons: the role of nutrition. Curr Opin Clin Nutr Metab Care. 2021 Jan;24(1):1–3.

(9) Gem COVID. Post-COVID-19 global health strategies: the need for an interdisciplinary approach. Aging Clin Exp Res. 2020 Jun 11;1–8.

(10) Lawrence V, HIckson M, Weekes E, Julian A, Frost G, Murphy J. A UK survey of nutritional care pathways for Covid-19 patients post hospital stay. Journal of Human Nutrition and Dietetics. submitted.

(11) Aytür YK, Köseoğlu BF, Taşkıran ÖÖ, Ordu-Gökkaya NK, Delialioğlu SÜ, Tur BS, et al. Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): A guideline for the acute and subacute rehabilitation. :17.

(12) Haraj NE, El Aziz S, Chadli A, Dafir A, Mjabber A, Aissaoui O, et al. Nutritional status assessment in patients with Covid-19 after discharge from the intensive care unit. Clinical Nutrition ESPEN. 2020 Oct;S2405457720304010.

(13) Yang P-H, Lin M-C, Liu Y-Y, Lee C-L, Chang N-J. Effect of Nutritional Intervention Programs on Nutritional Status and Readmission Rate in Malnourished Older Adults with Pneumonia: A Randomized Control Trial. IJERPH. 2019 Nov 27;16(23):4758.

(14) Weekes CE, Emery PW, Elia M. Dietary counselling and food fortification in stable COPD: a randomised trial. Thorax. 2009 Jan 8;64(4):326–31.

(15) Ochoa JB, Cárdenas D, Goiburu ME, Bermúdez C, Carrasco F, Correia MITD. Lessons Learned in Nutrition Therapy in Patients With Severe COVID‐19. Journal of Parenteral and Enteral Nutrition. 2020 Sep 24;jpen.2005.

(16) Chen Q, Wang L, Yu W, Xi H, Zhang Q, Chen X, et al. Recommendations for the prevention and treatment of the novel coronavirus pneumonia in the elderly in China. Aging Med. 2020 Jun;3(2):66–73.

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