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 (pointed below) to ensure nutritional issues that concern patients are identified and followed up.

 
How do I monitor patient’s nutritional status?

HCP should discuss goals with patients. It is advisable that goals are SMART. i.e. “specific, measurable, attainable, relevant and time based.”
Some examples that patients could report are:

  • being strong enough to flush the toilet on her own
  • have the strength to open the milk carton.

Guidance recommends that healthcare professionals think about remote rehabilitation care from hospital and conditions at 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 Oral Nutritional Supplements when necessary (complies with Advisory Committee on Borderline Substances criteria), consulting a dietitian or speech and language therapist where there are swallowing difficulties (3).

Value of support and communication

  • 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.
  • The Dietitians’ role is highly relevant and referral for assessment and monitoring should be made where required. The following is an example of a dietetic assessment [Word.doc], along with steps to establish a monitoring plan (which can be performed by non-dietitians). The grey boxes contain standard letter format to GP or other health professionals to support communication of assessment and plan. The Patient Association Nutrition Checklist included is adapted to virtual consultations. This format was designed by the Lambeth and Southwark Action on Malnutrition Project (LAMP) Nutrition and Dietetics Department.
  • A holistic, patient-centred approach with multi-disciplinary input is recommended (2, 6). If people are fatigued, due to long COVID and having difficulty preparing meals, then a referral to occupational therapy for coping strategies may enable them. The healthcare professional leading patient care should consider individual values, needs and preferences, and setting realistic goals. Physiotherapists, occupational therapists, social workers and GPs are most likely to signpost patients to sources of advice and support (support groups, social prescribing, online apps), explaining how to get support from social care, housing and employment, and advice about financial support (5, 6). Patients reporting symptoms of chronic fatigue should be fully assessed by a specialist clinician before advising graded increases in exercise/activity, as this may exacerbate symptoms.
  • It is suggested to give people a copy of their care plans, clinical records, rehabilitation plans, letters and prescriptions (5).
  • Interdisciplinary communication is vital. Planning care entails considering local and clinical care pathways and shared decision making to establish which healthcare professionals need to be involved (5); 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-up when they move from hospital (or other setting) to home. 


For more information see our Identifying who needs nutritional care during COVID-19 recovery

Strategies to ensure nutrition issues are identified and monitored

Professionals can:

  • assess the patient’s abilities and 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. 

There may be situations where the patient does not wish to engage, or is unable to do so until they receive some psychological support to put coping strategies in place. Signpost to available resources and services. Watching the Psychological wellbeing and communication with healthcare professionals video with Chandanee Kotecha, our psychologist, on our Nutrition and COVID-19 Recovery talks page may help.

Self-monitoring by the patient can:

  • ensure symptoms are monitored regardless of care setting
  • ensure 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.

Tools that assist in monitoring recovery

Interventions should be tailored to the individual where the dietitian will be responsible for leading on any nutritional components of the intervention. This may require for the dietitian to liaise with other members of the MDT as and when appropriate.

Listed below are 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.


People of any age

  • Video call to assess frailty, metabolic risk (6 weeks post discharge if applicable) (6).
  • Older adults may require a family member to help them setting up video or telephone consultations to ensure appropriate assessment and treatment.
Suggested test and/or monitoring goals
  • Emerging or new symptoms ruling out any other conditions that could have caused complications (7) Mini Nutritional Assessment (8).

Those who are under hospital care or have recently been discharged from hospital

  • Follow your local guidance to guide monitoring timescales, however patients who are severely malnourished will require more frequent monitoring.
  • For more information about what to monitor and when, follow the NICE guidelines.
  • 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 reviews to assess ongoing symptoms, starting approximately one month after discharge (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 tests and/or monitoring goals

Specific conditions and how these need a tailored approach 

  • 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).

Everybody

  • Use MUST with modifications for remote consultations and ask also about gastrointestinal symptoms. If malnutrition is evident, 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.

What sort of goals are useful to agree and prioritise?
Goals should be based on what matters to the person and what they see as their priorities. It is nonetheless important to prevent muscle mass loss and provide support for patient to improve stamina, resume normal hobbies, achieve functional independence and reach a desirable weight (3). This should be combined with gradual increase of physical activity. Discussion with a physiotherapist and/or GP should occur to ensure a suitable approach for patients.

It is recommended that general monitoring plans last to up to 2 years. For nutritional care, please refer to local guidance or service level agreements.

Following dietitian assessment, if the patient is undernourished or has a poor quality diet, it is important to determine if supplements of A, C, D, E, B6 and B12, Zinc and Selenium and high fibre should be included in the 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. See below useful links for physical activity and exercise.

Patient accessible digital resources to support COVID-19 recovery

Patients who are able to self-manage and access digital services can use the following freely available resources. We also include 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.

Dietary advice

  • The Eatwell Guide is an 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 British Lung Foundation provides advice on how to eat and drink more easily.
  • 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.
  • 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.


General for long COVID

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.

Physiotherapy


Post critical care recovery


Mental health


Fatigue


Loss of smell

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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.