key: cord-0815298-x2168e5i
authors: Latif, Jawairia; Elizabeth Weekes, C.; Julian, Anna; Frost, Gary; Murphy, Jane; Abigail Tronco-Hernandez, Yessica; Hickson, Mary
title: Strategies to ensure continuity of nutritional care in patients with COVID-19 infection on discharge from hospital: a rapid review
date: 2021-11-19
journal: Clin Nutr ESPEN
DOI: 10.1016/j.clnesp.2021.11.020
sha: 3d17ad85117a81f71fed664f7dfc1ad48650ace4
doc_id: 815298
cord_uid: x2168e5i

Background & Aims The risk of malnutrition in people with COVID-19 is high; prevalence is reported as 37% in general medical inpatients, 53% in elderly inpatients and 67% in ICU. Thus, nutrition is a crucial element of assessment and treatment. This rapid review aimed to evaluate what evidence is available to inform evidence-based decision making on the nutritional care of patients hospitalised with COVID-19 infection. Methods Cochrane Rapid Reviews guidance was followed; the protocol was registered (CRD42020208448). Studies were selected that included patients with COVID-19, pneumonia, respiratory distress syndrome and acute respiratory failure, in hospital or the community, and which examined nutritional support. All types of studies were eligible for inclusion except non-systematic reviews, commentaries, editorials and single case studies. Six electronic databases were searched: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PubMed, CINAHL and MedRxiv. Results Twenty-six articles on COVID-19 were retrieved, including 11 observational studies, five guidelines and 10 opinion articles. Seven further articles on pneumonia included three RCTs, one unblinded trial, three observational studies, and one systematic review on rehabilitation post-ICU admission for respiratory illness. The evidence from these articles is presented narratively and used to guide the nutritional and dietetic care process. Conclusions Older patients with COVID-19 infection are at risk of malnutrition and addressing this may be important in recovery. The use of nutritional management strategies applicable to other acute conditions are recommended. However, traditional screening and implementation techniques need to be modified to ensure infection control measures can be maintained. The most effective nutritional interventions require further research and more detailed guidance on nutritional management post-discharge to support long-term recovery is needed.

Observational studies Allard et al, 2020 (1) • Each patient monitored using electronic health record. After discharge, telephone contact made by a physical therapist to identify symptoms and disability, and provide early referral to telerehabilitation services.

• Data gathered using a structured form to identify self-reported disability and rehabilitation needs (physical and respiratory symptoms, mobility impairments, measures of independence and affect, nutritional, and swallowing symptoms) None • Dependence for basic and instrumental ADLs using Barthel's Index and Lawton's Scale.

• Comparison of outcomes between participants admitted to the ICU vs. those admitted to the ward.

Downgraded (GRADE) due to:

Risk of bias due to confounding

• Patients in ICU presented longer length of hospital stay (median [IQR] 16 [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] , vs. 6 [4] [5] [6] [7] [8] [9] days, p<0.0001) Registry data that were entered into the Japan Rehabilitation Nutrition Database were analysed.

Patients whose average energy intake for 1 week after hospitalization did not satisfy the basal energy expenditure were designated the lack of energy intake (intervention) group. • Randomized to receive oral supplementation and individualized nutritional guidance in addition to standard care.

• ONS: 1.5 g protein/kg/day as a whey-protein enriched milk product (Protino®, Arla Foods) + a multivitaminmineral tablet.

• After discharge, nutritional guidance continued by weekly phone-calls, and the ONS as a fixed dose of 28 g protein daily + multivitamin-Standard care in the department. No intervention but weekly contacts by phone after discharge.

Outpatient follow-up after 30 and 60 days. 

• 60 days re-admissionrate was significantly lower in the intervention compared to the control group (4.8 vs. 36.8%, p=0.01).

• Several outcomes improved in the intervention group: HGS (p<0.01), QOL after 30 and 60 days (p<0.01), loss of lean-body mass after 60 days (p = 0.02), and during the admission QOL (p<0.01).

•During admission, the control group experienced a larger weight loss compared to the intervention group (0.9 vs -0.1 kg) (p<0.01). mineral supplement for two months.

• Outpatient follow-up after 30 

Identify malnutrition:  Focus on immunocompromised, older adults, poly-morbid, malnourished individuals, people with underlying long term conditions (diabetes), ICU patients, patients who are unable to eat  Identify dysphagia -particular attention to patients discharged from ICU (post-extubation dysphagia)  Identify refeeding syndrome (9, 10, 14, 16, 17, 19, 20) 

Use protocols, algorithms, existing local policies or pathways to direct nutritional support once nutrition risk status is established. (10, 16, 17, 19, 21) Link with existing pathways e.g. NICE rehabilitation pathway or community malnutrition pathway (16, 17, 19)  1-2g/kg body weight (9, 12, 20, 21) Adjust according to nutritional status, physical activity level, disease status, comorbidities, and tolerance (9, 20) J o u r n a l P r e -p r o o f 

Body weight, BMI, food intake, compliance to dietary advice and ONS, blood tests, clinical condition, and functional tests (such as sit to stand), self-reported activity, progress towards agreed goals and ability to undertake activities of daily living. (15, 19, 20) Monitor prescription compared to delivery of EN and PN; avoid under and overfeeding.

(17) Prescription of ONS for at least one month (post discharge) and regular monitoring if compliance is in question (9) Frequency: During hospitalisation:

 weekly for low to moderate nutrition risk  every 2-7 days for high risk The prevalence of malnutrition (as undernutrition) in people infected with COVID-19 is reported to be 37% in general medical inpatients (8), 52.7% in older inpatients (9) and 66.7% in patients admitted from ICU (10). The average length of hospital stay varies from less than a week to nearly two months and stay in ICU from one to three weeks (11) . Length of hospital stay for malnourished patients with COVID-19 has been shown to be significantly higher (almost double) than that of nonmalnourished patients (12) . This supports recommendations that nutrition support should be initiated as soon as possible for hospitalised patients (13) .

Nutrition support, including oral nutritional supplements (ONS), enteral and parenteral nutrition, plays an important role in meeting nutritional requirements and aiding recovery (14) . Nutritional inadequacy during hospitalisation exacerbates the risk of malnutrition, increasing the likelihood that any deficiency may persist beyond discharge with potentially long-term effects on functionality and health (14) . Continuity of nutritional care has a vital role in ameliorating these effects. 

This review was conducted in accordance with the Cochrane Rapid Reviews guidance (19) , and the protocol was registered on PROSPERO (registration number CRD42020208448).

Studies were selected using defined eligibility criteria (Table 1) 

consensus it was agreed that guidelines scoring >60% for all six domains were considered high quality, those scoring >60% for three to five domains were moderate quality, >60% in only two domains were low quality and only one domain were very low quality.

Data on population, intervention, duration and follow-up, comparator, outcomes and results were extracted wherever possible and displayed in a table (Table 2) . A second author (CEW) checked the data for accuracy and completeness. All data were synthesised narratively by one author (JL) and Statistical pooling of data was not possible due to the heterogeneous nature of the articles identified. Variations in interventions, subjects and outcomes, as well as risk of bias, prevented meta-analysis. Therefore, the results are described qualitatively.

For this review, guidelines were defined as systematically developed recommendations produced to direct the management of patients (28) . All other papers (excluding systematic reviews, RCTs and observational studies) were referred to as opinion articles. The seven articles on pneumonia included three RCTs (55-57), one trial abstract (58) and three observational studies (59) (60) (61) . The rapid systematic review (62) presented evidence on rehabilitation in patients post-ICU admission for respiratory illness. The evidence from these papers will be presented together and used to produce guidance on the nutritional and dietetics care process.

GRADE quality appraisal was applied to the systematic review, RCTs, and observational studies. The systematic review and the three RCTs were judged to be of low quality mainly due to indirectness of evidence. Of the observational studies, four were judged to be low quality while the remaining six J o u r n a l P r e -p r o o f were very low quality (see Table 2 for reasons). There was insufficient information to allow quality assessment of the six abstracts.

The five guidelines were assessed using the AGREE II tool, which requires users to produce an overall assessment and recommendation for use. Table 3 shows the final scaled domain scores for the three reviewers (JL, MH and AJ) and details of how each item within the domains scored. The scope and purpose, editorial independence and clarity of presentation scored highly in most guidelines, however stakeholder involvement was limited, partly due to a lack of information provision, but also because many of the wider healthcare team were not consulted. No patients were consulted in any guideline. This latter limitation was recognised by some guideline authors and perhaps understandable given the nature of the pandemic. The lowest scoring domains were rigour of development and applicability. Limits to the rigour of development reflect the urgency with which these guidelines were produced, and the lack of published data on the management of COVID-19.

The applicability domain refers to advice on how the recommendations should be applied in practice, and low scores here also reflect the limited experience of COVID-19 and the rapid production of the guidelines. We do not recommend the guideline by Chen et al (2020) because of shortcomings in most domains, however we do recommend the use of the other guidelines.

Six studies (30-32, 34, 37, 38) including two abstracts ( criteria (34, 38) , and low BMI with or without weight loss (31) , as indicators of risk. Risk of malnutrition or undernutrition ranged from 74% to 92% (30-32, 34, 38) . Weight loss was variable;

J o u r n a l P r e -p r o o f 61% patients in one study (32) , 24-53% patients with ≥5-10% weight loss in others (32, 34) .

Prevalence of low BMI ranged from 9-15% (32, 34) and patients with severe COVID-19 were more prone to have low BMI, higher weight loss and greater nutritional risk (31) . Only one study (30) reported weight loss was seen in 'only a few patients' and only 4% had a BMI ≤18.5kg/m 2 , thus other factors were driving malnutrition risk.

Two studies reported patients with COVID-19 have reduced oral intake: consuming <50% nutritional requirements in 39-56% patients (31, 34) . The risk of weight loss and sarcopenia post ICU discharge was also reported (37) . One study (30) reported nutritional risk linked to mortality; higher NRS scores had significantly higher mortality and a longer stay in hospital. The importance of the acute disease effect (defined as no, or unlikely to have, adequate nutritional intake for more than five days) in assessing nutritional risk in patients with COVID-19 infection was emphasised (30) .

Shirado et al (60) compared patients with low energy intakes to those with adequate intakes, finding lower energy intake was associated with higher mortality, higher pneumonia recurrence rate during hospitalization, and lower discharge home rate suggesting assessment of energy intake is relevant.

Eekholm et al (59) 

All guidelines agreed that screening using a validated tool was an important initial step in the process and a variety of tools were recommended ( Table 4 ).

The practical difficulties in obtaining measurements for a nutrition risk assessment e.g. body weight, were widely acknowledged and alternatives suggested. Limitations of these alternative measures due to access restrictions or infection control policies were acknowledged (45, 49) .

Lawrence et al (39) carried out a survey of nutritional care pathways on COVID-19 in the UK and reported that the majority of the pathways included MUST for screening ( Table 2 ). For assessment, the focus was on COVID-specific symptoms (hunger or skipping meals, poor appetite and taste changes) and physical symptoms (weight loss, energy levels, weakness, shortness of breath and muscle loss) while emotional or psychological symptoms were included in only 32-63% of pathways.

The outcomes most frequently monitored routinely were weight and food intake while patient 

Evidence for the efficacy of rehabilitation interventions in patients with severe respiratory illness post-ICU was assessed (62) . Only two of the included studies tested nutritional interventions; one tested an individualised expert programme (lectures, counselling, fortified foods, oral nutritional supplements or parenteral or enteral nutrition plus physical rehabilitation), and one simply reported as 'nutritional care'. The meta-analysis showed significant improvements in ADLs. This could be generalizable to COVID-19.

The combined evidence from two RCTs (55, 57) on pneumonia suggests long-term benefits of dietitian led individualised nutrition support during admission and 6 months post discharge in older adults, including significant improvement in daily energy and protein intakes. This intervention combined with patient and caregiver education (55) resulted in further benefits to malnutrition risk through significant improvement in MNA-SF scores, and lower readmission rate in the intervention group.

The combined evidence from one RCT (56) and one retrospective cohort study (61) suggests benefits of enteral nutrition (nasogastric feeding) during hospital admission in older adults including to nutritional status through improved arm muscle circumference, shorter length of stay (LOS) and J o u r n a l P r e -p r o o f fewer adverse events. Compared to parenteral nutrition (PN), patients who received nasogastric feeding had lower hospital mortality and complication, and more discharges home (61) .

Overall these studies suggest nutrition support combined with rehabilitation may improve performance of ADLs in older adults.

Six observational studies (including three abstracts) (30, 31, (34) (35) (36) 38) (n=724) reported data on nutritional support requirements. The number of patients requiring ONS ranged from 6-74% (30, (34) (35) (36) 38) , and patients at nutritional risk received more frequent ONS than patients without (31) . The number of patients requiring EN ranged from 6-15% (30, 34, 35) , PN ranged from 5-12% (30, 34) and patients requiring both EN and PN 8% (30). Zhao et al (30) reported that critically ill (please refer to Table 2 for definition) patients were more likely to receive nutritional support than severely ill (please refer to Table 2 for definition) patients and had higher mortality and longer hospital stays.

The presence of dysphagia was high at 52% (38) and the number of patients requiring texture modified diets ranged from 55-89% (35, 38) , the majority because of post-extubation dysphagia, 45% (37).

All recommendations were based on opinion and no data were presented to support these strategies, which are reproduced in Table 4 (43, 46, 48, 49) . Food fortification was advised by four papers, as a general strategy (41) , in the community (47, 51) or at home (43) .

Recommendations for ward-based strategies are listed in Table 4 . In underlying conditions e.g.

diabetes, relaxation of previous dietary restrictions may be temporarily necessary in the presence of a poor appetite or unintentional weight loss (51) .

Four guidelines (41) (42) (43) (44) and seven opinion articles (46) (47) (48) (49) (50) (51) (52) provided guidance on oral nutritional supplements although the criteria for their use varied. Nutritional treatment should continue with ONS (41, 46, 51) in cases where required. Guidance for initiation of ONS in the community was also provided by four papers (46) (47) (48) 51) . ONS should be stopped when goals have been met and malnutrition risk is resolved (51) . Three guidelines (41, 42, 44) and three opinion articles (49, 50, 52) provide guidance on artificial nutrition. The criteria for escalation to EN varied (41, 42, 50, 52) but all articles advised consideration of PN if EN is not tolerated. Two opinion articles (50, 52) stated a preference for PN in patients with expected respiratory complications.

Three guidelines (41, 42, 44) and three opinion articles (46, 50, 52) provided advice on nutritional requirements, of which five (41, 44, 46, 50, 52) advised broadly similar energy targets ranging from 25-30Kcal/Kg/day with adjustment according to nutritional status, physical activity level, disease status, tolerance and refeeding risk, and one (42) focused on ICU.

Optimisation of protein intake was emphasised by two guidelines (41, 44) and six opinion articles patient-centred goals should be discussed and agreed. In hospital appropriate goals include improved intake, weight maintenance, preservation of muscle mass and function (46) . During acute illness goals may be to minimise weight loss, muscle mass and strength (51) . During recovery, goals may be to gain muscle strength, return to a desirable weight, resume hobbies or to improve stamina (51) .

The only evidence on implementation comes from two guidelines (41, 42) and five opinion articles (47-49, 51, 52) . Collaboration between healthcare professionals, catering and family was recommended by all articles to provide integrated care and minimise face-to-face contact (Table 4) .

The following evidence comes from two observational studies (29, 33) , three guidelines (40, 42, 44) and six opinion articles (46-49, 51, 52) all on COVID-19.

Two studies (29, 33) (n=1976) reported on rehabilitation needs of patients post COVID-19 infection in predominantly older people. Li et al (29) used a self-designed questionnaire and reported ongoing physical and psychological dysfunction during recovery including sleep disorders (64%), anxiety (62%), decreased activity endurance (61%), respiratory dysfunction (58%) and loss of appetite (55%).

Up to 40% patients indicated the need for dietary instructions.

Leite et al (33) used data from a post-discharge tele-rehabilitation programme following COVID-19

infection to identify self-reported disability and rehabilitation needs of mainly ICU patients. Patients in ICU presented longer hospital stay, lower independence for activities of daily living, greater prevalence of weight loss with lack of appetite, more oxygen therapy, more shortness of breath during routine and non-routine activities and greater difficulty standing up for 10 minutes.

Together these data indicate patients hospitalized due to COVID-19 present high levels of physical and psychological disability which is exacerbated in those admitted to the ICU.

Three opinion articles (47, 51, 52) suggested monitoring of anthropometric, nutritional, clinical and functional measures (Table 4) .

One guideline (42) recommended frequency of monitoring during hospitalisation based on the degree of nutritional risk and another (51) advised regular monitoring built into clinical reviews by community healthcare professionals following hospital discharge.

Two guidelines (40, 44) and three opinion articles (46, 48, 49) recommended remote working and virtual monitoring of patients during hospitalisation and as part of rehabilitation teams post discharge (44) . The BDA advised further discussion to support individuals unable to access or interact with technology or telephone consultation (48) .

This rapid review aimed to answer the following question: in patients hospitalised with COVID-19 infection, what is the best way of ensuring continuity of nutritional care post-hospital discharge to minimise the nutritional consequences of infection and optimise recovery? We did not identify any RCTs or intervention studies relating to COVID-19, but eleven observational studies provided new information. The remaining papers were guidelines and opinion articles produced rapidly at the start of the pandemic (around February -June 2020). We also found four intervention studies, three observational studies and a systematic review examining nutrition and pneumonia or respiratory illness recovery, which provided useful data to support nutritional interventions for COVID-19.

The observational studies involving patients with COVID-19 infection were of low quality and were predominantly hospital based. Two examined patient-reported nutritional needs post COVID-19

infection (29, 33) , and the others evaluated the nutritional characteristics of patients with COVID-19 J o u r n a l P r e -p r o o f infection and the relationship between these factors and clinical outcomes (30) (31) (32) (34) (35) (36) (37) (38) . They reported wide-ranging symptoms, a need for dietary information, high prevalence of risk of malnutrition, substantial use of artificial feeding and nutritional support, and higher mortality and longer hospital stay in those at higher risk of malnutrition. This reinforces what we already know about the influence of malnutrition on clinical outcomes; it is well established that those at higher nutritional risk have longer hospital stays leading to higher healthcare costs and higher mortality (63) . These data show that older patients with COVID-19 infection are potentially a high-risk population for malnutrition, particularly those with ICU admission, with a requirement for dietetic input and nutrition support.

The data on pneumonia included three RCTs (55-57) (low quality), the unblinded trial (58) , and the retrospective cohort study (61) (low quality) which suggested that individualised dietetic-led care during and after hospitalisation, and enteral nutrition during hospitalisation could improve both nutritional and clinical outcomes. This provides some evidence to support the effectiveness of wardbased strategies to meet nutritional requirements in patients with acute lung infections. Previous research highlights the effectiveness of nutrition support in improving clinically important outcomes (64) (65) (66) and this can lead to net savings in healthcare costs (63) . The cross-sectional study in hospitalised older patients with pneumonia (59), although very low quality, suggests that older adults with lung infections are at risk of readmission and nutritional care does not appear to be prioritised.

The five guidelines referenced the increased risk of malnutrition in patients with COVID-19 infection.

Nutrition screening was consistently recommended, and all provided guidance on dietary interventions according to stage of disease, care setting or nutritional status of the patient. Only two guidelines (41, 44) recommended specific energy and protein targets for ward-based care, and only one (41) addressed the issue of dysphagia. Two guidelines (41, 42) considered goals and monitoring, and three (40, 41, 44) looked at continued and community-based care. Only one guideline (42) J o u r n a l P r e -p r o o f detailed the difficulties in obtaining access to patients with COVID-19 infection and proposed strategies to minimise contact whilst striving for optimum nutrition. Although nutritional management based on other clinical conditions can be applied to COVID-19, implementation must be given careful consideration for them to be effective. The quality of four guidelines (40) (41) (42) 44) was moderate based on consensus judgement and the reviewers were able to recommend the use of three with modifications (40) (41) (42) and one as it stands (44) . These are useful sources of advice for practicing dietitians. However, given their production at beginning of pandemic practitioners should be aware of the limitations of the guidance and the need for them to be reviewed and updated once further evidence has been generated.

The remaining papers were opinion articles, which offer further advice based on experience, most extrapolating from knowledge of lung disease and/or malnutrition. These address many of the same areas as the guidelines, with an emphasis on identification of nutritional risk and general advice on treatment. They also covered post-discharge procedures and ongoing community care in much more detail. Like the guidelines, advice on monitoring was limited.

The systematic review (62) suggested a benefit of multidisciplinary rehabilitation in combination with nutrition support, on functional outcomes in older adults. Multi-disciplinary working, in both community and hospital settings, was a recurring theme in most of the guidelines and opinion papers. This is especially relevant as evidence (67) Tables and figures (for the main manuscript) 1. Some concern on randomisation process, and measurement bias 2. Indirectness of evidence from pneumonia • Energy and protein goals met in 79% and 76% in the intervention group, respectively • Energy and protein intake in the intervention group was significantly higher compared to control (mean difference in daily energy intake of 286 kcal (95% CI 226 to 541) and in mean daily protein intake of 13g (95%CI 6 to 20) 

Nutritional status assessment in patients with Covid-19 after discharge from the intensive care unit

A UK survey of nutritional care pathways for patients with Covid-19 prior to and post hospital stay

Persistent symptoms and disability after COVID-19 hospitalization: data from a comprehensive telerehabilitation program

Rehabilitation needs of the first cohort of post-acute COVID-19 patients in Hubei, China

Evaluation of Nutrition Risk and Its Association With Mortality Risk in Severely and Critically Ill

Malnutrition and nutritional therapy in patients with SARS-CoV-2 disease

Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): A guideline for the acute and subacute rehabilitation

ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand

Recommendations for the prevention and treatment of the novel coronavirus pneumonia in the elderly in China

A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version)

ASPEN Report on Nutrition Support Practice Processes With COVID-19: The First Response

COVID-19 -Recommendations for community action by dietitians for older and vulnerable people living in their own home 2020

Nutritional considerations for primary care teams managing patients with or recovering from Covid-19 2020

Practical considerations for nutritional management of non-ICU COVID-19 patients in hospital 2020

Guidance on management of nutrition and dietetic services during the COVID-19 pandemic 2020

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Evaluation of Nutrition Risk and Its Association With Mortality Risk in Severely and Critically Ill COVID-19 Patients

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Gastrointestinal Complications in Critically Ill Patients With COVID-19

*severely ill criteria: 1) respiratory distress and respiratory rate 30 times/min, 2) oxygen saturation in a resting state 93%, 3) arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) 300 mm Hg

**critically ill criteria: 1) respiratory failure and need for mechanical ventilation, 2) shock, and 3) other organ failure requiring ICU monitoring

x albumin (g/L) + 0.417 × (measured weight/usual weight) × 100; IQR: interquartile range ; BMI: Body Mass Index; AMC: Arm Muscle Circumference; TSF: Triceps Skin Fold thickness

PN: Parenteral Nutrition; PEG: percutaneous endoscopic gastrostomy; ICU: Intensive Care Unit; MNA-SF: Mini-Nutritional Assessment-Short Form; MUST: Malnutrition Universal Screening Tool; NRS-2002: Nutrition Risk Score 2002; ONS: Oral Nutritional Supplements; RCT: Randomised controlled Trials; GRADE: GRADE Working Group criteria; AGREE II: Appraisal of Guidelines for Research & Evaluation tool; COPD: chronic obstructive pulmonary disease; ADLs: activities of daily living; PTSD: post-traumatic stress disorder; HCPC: Health and Care Professions Council; BDA: British Dietetic Association; GI: gastrointestinal; QoL: Quality of life

Nutritional status assessment in patients with Covid-19 after discharge from the intensive care unit

A UK survey of nutritional care pathways for patients with Covid-19 prior to and post hospital stay

Persistent symptoms and disability after COVID-19 hospitalization: data from a comprehensive telerehabilitation program

Rehabilitation needs of the first cohort of post-acute COVID-19 patients in Hubei, China

Evaluation of Nutrition Risk and Its Association With Mortality Risk in Severely and Critically Ill

Malnutrition and nutritional therapy in patients with SARS-CoV-2 disease

Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): A guideline for the acute and subacute rehabilitation

ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand

Recommendations for the prevention and treatment of the novel coronavirus pneumonia in the elderly in China

A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version)

ASPEN Report on Nutrition Support Practice Processes With COVID-19: The First Response

COVID-19 -Recommendations for community action by dietitians for older and vulnerable people living in their own home 2020

Nutritional considerations for primary care teams managing patients with or recovering from Covid-19 2020

Practical considerations for nutritional management of non-ICU COVID-19 patients in hospital 2020

Guidance on management of nutrition and dietetic services during the COVID-19 pandemic 2020

Practical guidance for using 'MUST' to identify malnutrition during the COVID-19 pandemic Malnutrition Action Group (MAG) update, 2020

Managing Adult Malnutrition. A Community Healthcare Professional Guide to the Nutritional Management of Patients During and After COVID-19 Illness 2020

Nutritional management of COVID-19 patients in a rehabilitation unit

Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): Rationale and feasibility of a shared pragmatic protocol

Effect of nutritional support in patients with lower respiratory tract infection: secondary analysis of a randomized clinical trial

Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial

Effect of Nutritional Intervention Programs on Nutritional Status and Readmission Rate in Malnourished Older Adults with Pneumonia: A Randomized Control Trial

Clinical effects of enteral nutrition support on nutritional status of elderly patients with severe pneumonia

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

Nasogastric Tube Feeding Versus Total Parenteral Nutrition in Older Dysphagic Patients with Pneumonia: Retrospective Cohort Study

Impact of Energy intake at One Week after Hospitalization on Prognosis for Older Adults with Pneumonia

Rehabilitation to enable recovery from COVID-19: a rapid systematic review

Early nutrition protocol during Covid-19 pandemic

Nutritional inpatient care in geriatric population during covid-19 outbrake: some basics forgotten in the rush?

Nutritional evaluation and management in patients with Covid-19 following hospitalization in intensive care units

The effect of protein-based nutritional supplementation during and after hospital stay in patients with community acquired pneumonia

Nutritional management of non-critically ill hospitalized patients affected by Covid-19: The experience of dietitians in an Italian single center

Oropharyngeal dysphagia and malnutrition in patients with Covid-19 at the Consorci Sanitari Del Maresme, Catalonia, Spain: Prevalence and needs of compensatory treatment

Identifying older people at risk of malnutrition and treatment in the community: prevalence and concurrent validation of the Patients Association Nutrition Checklist with 'MUST'

Downgraded twice (GRADE) due to: 1. Some concern due to insufficient information on randomisation, and no protocol therefore risk of reporting bias and lack of information on intended adherence to intervention 2. Indirectness of evidence from pneumonia• TSF, AMC (0.01cm SD=0.91 vs -0.51cm SD=0.98, p=0.02) of EN group were significantly increased compared with that of the same group before treatment.• AMC in the control group were significantly lower than in the same group before treatment (p<0.05).• Nitrogen balance in EN group was better than in control group (p=0.045).• Mortality rate in EN group (9.1%) was lower than in control group (16%).• Incidence of adverse reactions in EN group was significantly lower than in control group (2 vs 9 events; p=0.03).• • Randomized to receive oral supplementation and individualized nutritional guidance in addition to standard care.• ONS: 1.5 g protein/kg/day as a whey-protein enriched milk product (Protino®, Arla Foods) + a multivitaminmineral tablet.• After discharge, nutritional guidance continued by weekly phone-calls, and the ONS as a fixed dose of 28 g protein daily + multivitamin-Standard care in the department. No intervention but weekly contacts by phone after discharge.Outpatient follow-up after 30 and 60 days. 

• 60 days re-admissionrate was significantly lower in the intervention compared to the control group (4.8 vs. 36.8%, p=0.01).• Several outcomes improved in the intervention group: HGS (p<0.01), QOL after 30 and 60 days (p<0.01), loss of lean-body mass after 60 days (p = 0.02), and during the admission QOL (p<0.01).•During admission, the control group experienced a larger weight loss compared to the intervention group (0.9 vs -0.1 kg) (p<0.01). 

Nutrition screening and assessment should be undertaken using validated tools e.g. MUST, NRS-2002, Subjective Global Assessment, Mini Nutritional Assessment for geriatric patients, NUTRIC score for ICU patients, GLIM criteria, MNA-SF, or a local validated tool (9, 10, 12, (14) (15) (16) (18) (19) (20) Estimation of risk by assessing oral intake and potentially impacting symptoms (17) Consider at nutritional risk if BMI <22Kg/m 2 and/or weight loss in the last three months and/or reduced food intake (21) Alternative measures (in the absence of measurements of weight and/or height): patient or family reported values of height, previous weight and weight loss  measurement of ulna length and mid arm circumference  subjective criteria e.g. loose clothing, history of decreased food intake, reduced appetite, reported dysphagia or underlying psycho-social or physical disabilities  Patients Association Nutrition Checklist (based on self-report) (15, (17) (18) (19) (36) Discharge: Reassess nutritional risk on discharge and handover to community  Ongoing dietary counselling and individualised nutrition plans in nutritionally high risk, frail, sarcopenic, post ICU or critical care recovery patients  Ongoing assessment of muscle mass (15) (16) (17) (18) 

Identify malnutrition:  Focus on immunocompromised, older adults, poly-morbid, malnourished individuals, people with underlying long term conditions (diabetes), ICU patients, patients who are unable to eat  Identify dysphagia -particular attention to patients discharged from ICU (post-extubation dysphagia)  Identify refeeding syndrome (9, 10, 14, 16, 17, 19, 20) 

Use protocols, algorithms, existing local policies or pathways to direct nutritional support once nutrition risk status is established. (10, 16, 17, 19, 21) Link with existing pathways e.g. NICE rehabilitation pathway or community malnutrition pathway (16, 17, 19)  1-2g/kg body weight (9, 12, 20, 21) Adjust according to nutritional status, physical activity level, disease status, comorbidities, and tolerance (9, 20) J o u r n a l P r e -p r o o f Caution for refeeding syndrome (9, 10, 16) On discharge: Provide resources e.g. BDA Older Adults Factsheets and Guide to Nutrition and Hydration in Older Age (14)  Continue ONS if intake severely impacted, ongoing breathlessness, fatigue or if using a mask or nebulisers, or medium/high risk of malnutrition (9, 16, 19)  Review by a dietitian to establish need for ongoing ONS and to ensure prescriptions meet the UK ACBS indications (16)  Arrange community dietitian or GP review and communicated in writing (15)  Artificial nutrition if patient has ongoing severe swallowing dysfunction, neurological dysfunction, or gastrointestinal dysfunction (17) ImplementationMDT working:  Team could include clinical psychologists, speech and language therapists, physiotherapists, occupational therapists, and dietitians  Nurses for patients at risk of pressure ulcers  Podiatrists for diabetic foot injuries  Falls prevention  Mental health services (9, 10, 14, 15, 17, 19, 20) (9, 14, 15, 17, 19, 20) 

Body weight, BMI, food intake, compliance to dietary advice and ONS, blood tests, clinical condition, and functional tests (such as sit to stand), self-reported activity, progress towards agreed goals and ability to undertake activities of daily living. (15, 19, 20) Monitor prescription compared to delivery of EN and PN; avoid under and overfeeding.(17) Prescription of ONS for at least one month (post discharge) and regular monitoring if compliance is in question (9) Frequency: During hospitalisation: weekly for low to moderate nutrition risk  every 2-7 days for high risk (10) Community:  1 week to 3 months intervals