COVID-19 impacted dietary care for patients on dialysis, raising malnutrition concerns
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The COVID-19 pandemic led to a variety of changes in the nutritional care provided to patients receiving hemodialysis across the United States, according to results of a survey administered to 191 dialysis dieticians.
These changes included bans on eating or drinking during dialysis treatments throughout the pandemic and less time dedicated to nutritional care for patients who tested positive for COVID-19, both of which researchers cited as concerning given the high risk for malnutrition in this patient population.
“Despite the intensive nutrition needs of the dialysis population (with or without COVID-19 infection) and the fact that [CMS] requires a dietitian in every dialysis unit, previous research demonstrates that a significant portion of the dialysis dietitian’s time is spent in indirect care and that many patient encounters are short,” Rachael May, MS, RDN, LD, clinical dietitian at Banner Health, and colleagues, wrote. “As much of health care has shifted to telehealth in response to the pandemic, and regulations have eased to allow telehealth under more circumstances during the pandemic, it is unclear whether dialysis dietitians are also providing virtual care to in-center patients, or whether they are still seeing patients in person, given that patients still must attend dialysis. Whatever the modality of the encounter, it is important to investigate whether dietitians are able to spend additional time with their patients given the increased nutrition burden they may be facing during the pandemic.”
Contending that potential burnout experienced by dialysis dietitians is also an important consideration, researchers from Case Western Reserve University developed a survey to assess how job responsibilities may have shifted and to capture observations regarding patient nutritional behaviors approximately 10 months into the pandemic (the survey was open for 2 weeks in December 2020).
“The survey asked individuals to think about what was happening currently compared to a pre-pandemic period, rather than trying to differentiate between how the pandemic had waxed and waned in different states at different times,” the researchers wrote.
Less time spent with patients, behavior shifts
While most respondents indicated no change in the amount of time they were spending with patients, 52% reported that patients who tested positive for COVID-19 were transferred to another designated facility and 36% reported spending less time with these patients. In addition, 39% reported spending less time with all patients (positive or negative for COVID-19), with stated reasons including wanting to limit exposure, extra time taken to put on personal protective equipment and being asked to take on responsibilities, such as screening patients and employees for COVID-19.
Although respondents reported “relatively few changes in patient health behaviors and nutrition-related biomarkers,” results showed the most common changes were cooking at home more often, engaging in physical activity less often, increases in serum phosphorous and increases in interdialytic weight gain. No significant changes in medication compliance were observed by dietitians, though 88% of respondents did report noticing an increase in patient stress levels.
Regarding food access, 69% of respondents reported that patients had a family or friend shop for them while 60% reported patients were going to the store less often. Further, 31% of respondents noted that patients were using foodbanks/pantries and/or SNAP more frequently and 28% reported that patients shared having less money for food.
Eating, drinking bans
Eating/drinking bans were common, with more than 60% of respondents noting such bans (Fresenius facilities were more likely to institute eating/drinking bans than DaVita and nonprofit facilities).
“Prior to the pandemic, eating during dialysis was becoming a more accepted practice in the U.S., supported by the publication of the 2018 International Society of Renal Nutrition and Metabolism (ISRNM) consensus statement supporting intradialytic meals and/or [oral nutrition supplements] ONS to improve nutritional status and data demonstrating reductions in mortality and hospitalizations with an intradialytic ONS protocol,” the researchers wrote. “However, our data suggest that the pandemic may be causing a reversal in the progress made toward intradialytic nutrition: 62% of respondents stated that their center adopted a no eating/drinking policy during dialysis due to COVID-19 and masking policies, with wide variation in how ONS protocols were handled.
Clinicians must be vigilant in not allowing an eating/drinking prohibition during treatment to become permanent, especially as respondents cited concerns for the impact of this ban on patients who have diabetes and/or dementia. The benefits of providing meals and/or ONS during treatment may outweigh the risk of COVID-19 transmission when precautions are taken.”
Mental health impact, future research
The survey also revealed additional stressors placed upon dialysis dietitians, with 20% stating they considered leaving their position or employer during the pandemic.
“Dialysis dietitians are not immune from the mental health effects of working as a health care professional during the COVID-19 pandemic. Workplace solutions for stress management in health providers may include providing opportunities to speak with team members about how stress during the pandemic is affecting work, setting clear expectations, and making mental health resources more accessible,” May and colleagues concluded.
“Future research should monitor whether trends observed in this survey become permanent. Beyond the concerns about permanent eating/drinking prohibitions discussed above, other trends to monitor include increased patient loads for dietitians, increased responsibilities such as screening, and other external factors (PPE, fear of infection) influencing the already limited time for direct patient care.”
Perspective
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ESKD patients are a vulnerable group of individuals with a higher risk of COVID. Understanding the impact to nutrition is important to patient care. The study cites some interesting findings regarding the role of the dietitian in nutrition management of COVID patients. However, the surveys were conducted prior to the release of the vaccine. We do not know how the vaccine roll-out would have impacted the findings of the survey.
The study suggests that dietitians’ workflow and standards of care for COVID patients are unique to this group of patients. DaVita has provided guidance in alignment with CDC and OSHA on several key areas of management of COVID-positive patients. This includes cohorting practices, prioritizing care for COVID patients and guidance on eating at treatment. As reflected in the surveys, it appears some facilities are not allowing eating at treatment. What is not discussed are whether or not eating during treatment was permitted prior to COVID and potential challenges with patient mask adherence during treatment.
Eliminating eating at treatment could have a negative impact on the nutrition care of some ESKD patients, which remains to be seen. It appears COVID has had some potential impact on eroding recent progress in allowing eating at treatment of high protein, quality foods. With patients at risk of malnutrition and in some patients complicated by diabetes, the renal community would benefit from further investigation on the COVID exposure risk of a small snack during treatment and brief removal of [a patient’s] mask.
While COVID is certainly providing challenges, renal dietitians are experts in nutrition and have done an amazing job caring for their patients. Their focus will remain on prioritizing their patients at risk, coordinating care with cohort facilities, performing assessments, and partnering with their IDT and patient caregivers to provide interventions/resources in the ongoing nutrition management of this unique population. Going forward, together, I believe our teams will grow from this adversity and be stronger as we continue our goal of improving quality of life to hundreds of thousands of patients on a daily basis.
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