In critically ill adult patients with COVID-19, lower energy and higher protein intake are associated with fewer mechanical ventilation and antibiotic days but not with ICU length of stay.

BACKGROUND: Coronavirus disease 2019 (COVID-19) nutrition management guidelines recommend hypocaloric, high-protein feeding in the acute phase of critical illness. This study aimed to determine, among critically ill adults with COVID-19, whether nutrition support affects outcomes in nonobese patients when providing a mean energy intake of ≥20 kcal/kg/day vs <20 kcal/kg/day and protein intake of ≥1.2 g/kg/day vs <1.2 g/kg/day, using actual body weight, and in patients with obesity when providing ≥20 kcal/kg/day vs <20 kcal/kg/day and a protein intake of ≥2 g/kg/day vs <2 g/kg/day using ideal body weight. METHODS: This retrospective study included adults with COVID-19 on mechanical ventilation (MV) admitted to the intensive care unit (ICU) from 2020 to 2021. Clinical and nutrition parameters were recorded the first 14 days of ICU stay. RESULTS: One hundred four patients were included: 79 (75.96%) were male and had a median age of 51 years and body mass index of 29.65 kg/m2 . ICU length of stay (LOS) was not affected by nutrition intake, but patients receiving <20 kcal/kg/day had fewer MV days (P = 0.029). In a subgroup analysis, MV days were lower in the nonobese group receiving <20 kcal/kg/day (P = 0.012). In the obese group, those receiving higher protein intake had fewer antibiotic days (P = 0.013). CONCLUSION: In critically ill patients with COVID-19, lower energy and higher protein intake were respectively associated with fewer MV days and, in patients with obesity, fewer antibiotic days, but they had no effect on ICU LOS.

Innovative strategy to improve enteral nutrition in prone positioning with patients with COVID-19.

BACKGROUND: Enteral nutrition is essential to improve outcomes in patients who are critically ill. Patients in the prone position, including those diagnosed with coronavirus disease 2019 (COVID-19) present additional challenges for enteral nutrition initiation. METHODS: A novel technique for placing feeding tubes while in the prone position was developed using an electromagnetic placement device and specialty trained clinical nurse specialists. Data were assessed retrospectively to determine effectiveness of this new practice. RESULTS: Sixty-eight patients had feeding tubes placed while in the prone position; 75% were able to be placed through the postpyloric route, 22% were placed through the gastric route, and 3% unable to be placed. Use of this technique facilitated earlier initiation of feedings by 2 days from time of admission and almost half a day from intubation to feeding. There was no additional radiation exposure from using this technique. CONCLUSION: Ability to place feeding tubes early while patients were prone reduced delays for starting enteral nutrition. Patients with COVID-19 in the prone position were able to receive effective nutrition support earlier with no additional complications.

Remote nutrition care during the first wave of COVID-19 pandemic: Did it impact nutrition therapy goals?

BACKGROUND AND AIMS: Nutrition societies recommended remote hospital nutrition care during the coronavirus disease 2019 (COVID-19) pandemic. However, the pandemic's impact on nutrition care quality is unknown. We aimed to evaluate the association between remote nutrition care during the first COVID-19 wave and the time to start and achieve the nutrition therapy (NT) goals of critically ill patients. METHODS: A cohort study was conducted in an intensive care unit (ICU) that assisted patients with COVID-19 between May 2020 and April 2021. The remote nutrition care lasted approximately 6 months, and dietitians prescribed the nutrition care based on medical records and daily telephone contact with nurses who were in direct contact with patients. Data were retrospectively collected, patients were grouped according to the nutrition care delivered (remote or in person), and we compared the time to start NT and achieve the nutrition goals. RESULTS: One hundred fifty-eight patients (61.5 ± 14.8 years, 57% male) were evaluated, and 54.4% received remote nutrition care. The median time to start NT was 1 (1-3) day and to achieve the nutrition goals was 4 (3-6) days for both groups. The percentage of energy and protein prescribed on day 7 of the ICU stay concerning the requirements did not differ between patients with remote and patients with in-person nutrition care [95.5% ± 20.4% × 92.1% ± 26.4% (energy) and 92.9% ± 21.9% × 86.9% ± 29.2% (protein); P > 0.05 for both analyses]. CONCLUSION: Remote nutrition care in patients critically ill with COVID-19 did not impact the time to start and achieve the NT goals.

How do guideline recommended energy targets compare with measured energy expenditure in critically ill adults with obesity: A systematic literature review.

BACKGROUND: Critically ill patients with obesity have unique and complex nutritional needs, with clinical practice guidelines conflicting regarding recommended energy targets. The aim of this systematic review was to 1) describe measured resting energy expenditure (mREE) reported in the literature and; 2) compare mREE to predicted energy targets using the European (ESPEN) and American (ASPEN) guideline recommendations when indirect calorimetry is not available in critically ill patients with obesity. METHODS: The protocol was registered apriori and literature was searched until 17th March, 2022. Original studies were included if they reported mREE using indirect calorimetry in critically ill patients with obesity (BMI≥30 kg/m2). Group-level mREE data was reported as per the primary publication using mean ± standard deviation or median [interquartile range]. Where individual patient data was available, Bland-Altman analysis was used to assess mean bias (95% limits of agreement) between guideline recommendations and mREE targets (i.e. ASPEN for BMI 30-50, 11-14 kcal/kg actual weight compared to 70% mREE and ESPEN 20-25 kcal/kg adjusted weight compared to 100% mREE). Accuracy was assessed by the percentage (%) of estimates within ±10% of mREE targets. RESULTS: After searching 8019 articles, 24 studies were included. mREE ranged from 1607 ± 385 to 2919 [2318-3362]kcal and 12-32kcal/actual body weight. For the ASPEN recommendations of 11-14 kcal/kg, a mean bias of -18% (-50% to +13%) and 4% (-36% to +44%) was observed, respectively (n = 104). For the ESPEN recommendations 20-25 kcal/kg, a bias of -22% (-51% to +7%) and -4% (-43% to +34%), was observed, respectively (n = 114). The guideline recommendations were able to accurately predict mREE targets on 30%-39% occasions (11-14 kcal/kg actual) and 15%-45% occasions (20-25 kcal/kg adjusted), for ASPEN and ESPEN recommendations, respectively. CONCLUSIONS: Measured energy expenditure in critically ill patients with obesity is variable. Energy targets generated using predictive equations recommended in both the ASPEN and ESPEN clinical guidelines have poor agreement with mREE and are frequently not able to accurately predict within ±10% of mREE, most commonly underestimating energy needs.

Medical Nutrition Therapy in Critically Ill Patients with COVID-19-A Single-Center Observational Study.

Medical nutrition should be tailored to cover a patient's needs, taking into account medical and organizational possibilities and obstacles. This observational study aimed to assess calories and protein delivery in critically ill patients with COVID-19. The study group comprised 72 subjects hospitalized in the intensive care unit (ICU) during the second and third SARS-CoV-2 waves in Poland. The caloric demand was calculated using the Harris-Benedict equation (HB), the Mifflin-St Jeor equation (MsJ), and the formula recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN). Protein demand was calculated using ESPEN guidelines. Total daily calorie and protein intakes were collected during the first week of the ICU stay. The median coverages of the basal metabolic rate (BMR) during day 4 and day 7 of the ICU stay reached: 72% and 69% (HB), 74% and 76% (MsJ), and 73% and 71% (ESPEN), respectively. The median fulfillment of recommended protein intake was 40% on day 4 and 43% on day 7. The type of respiratory support influenced nutrition delivery. A need for ventilation in the prone position was the main difficulty to guarantee proper nutritional support. Systemic organizational improvement is needed to fulfill nutritional recommendations in this clinical scenario.

[Nutrition Plays a Vital Role in the Prevention and Treatment of COVID-19].

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused an ongoing global pandemic of coronavirus disease 2019 (COVID-19). Proper nutritional support helps boost the immunity of the human body, strengthen the high-risk populations' defense against SARS-CoV-2, reduce the prevalence of COVID-19, prevent mild cases from developing into severe cases, and reduce the occurrence of adverse symptoms during recovery. Nutritional support is an important guarantee to provide protection against virus infection, promote patient recovery, and improve patient prognosis. Whole nutritional food formulas designed according to the characteristic clinical symptoms of COVID-19 provide patients with comprehensive nutritional support of appropriate nutritional content, which effectively improves the nutritional status of patients and provides strong technical support to improve their quality of survival. During the critical period of COVID-19 prevention and control, more emphasis should be placed on the essential role of nutritional support and the clinical efficacy of nutritional support should be given full play.

Managing nutrition support product shortages: What have we learned?

Product shortages related to the components of parenteral nutrition (PN) therapy have been well described over the past decade. The situation has more recently worsened and expanded globally because of the impact the COVID-19 pandemic has placed on supply chain issues and workforce demand. The impact of enteral nutrition (EN) product shortages is less well documented when compared with PN, and development of management strategies is often left up to the discretion of individual providers. The recent crisis in infant formula supply has heightened the national awareness of how a nutrition support product shortage can significantly impact patient safety. This review provides a historical perspective of PN and EN product shortages to gain insight into the lessons learned and applies this to strategies for managing current and future product shortages. Strategies for managing PN and EN shortages can best succeed if they are tailored to address aspects that are unique to the inpatient and outpatient care setting. In addition, patients who transition between care settings are vulnerable to harm related to product shortages if measures are not in place to communicate and address these shortages. Teamwork and communication within an organization and among key stakeholders are necessary to develop processes that aim to minimize patient harm related to product shortages.

Prone position, time to reach nutrition target, and energy/protein achievement rate on the seventh day of intensive care unit stay in patients with COVID-19: A cohort study.

BACKGROUND: We aimed to evaluate the mean time to reach the energy (EAR) and protein (PAR) achievement rate among patients with coronavirus disease 2019 (COVID-19) who did or did not undergo prone position (PP) therapy in the first week of their stay in the intensive care unit (ICU), and the interaction of these nutrition therapy indicators on the association between PP and clinical outcomes. METHODS: This cohort study used retrospective data collected from medical records of patients with COVID-19 admitted to the ICU (≥18 years). We collected nutrition data, clinical information, prescription of PP, and its frequency during the first week, and clinical outcomes. RESULTS: PP therapy was administered to 75.2% of 153 patients (61.5 ± 14.8 years, 57.6% males) during the first week of their ICU stay. Patients who underwent PP reached nutrition therapy goals later (4 [3-6] vs 3 [2-4] days; P = 0.030) and had lower EAR (91.9 ± 25.7 vs 101.6 ± 84.0; P = 0.002) and PAR (88.0 ± 27.7 vs 98.1 ± 13.5; P = 0.009) in comparison to those who did not receive PP. Grouping patients who underwent PP according to the EAR (≥70% or <70%) did not show any differences in the incidence of ICU death, duration of mechanical ventilation, or ICU stay (P > 0.05). CONCLUSIONS: In this exploratory study, PP was associated with a delayed time to reach the nutrition target and the lowest EAR and estimated protein requirement on the seventh day of ICU stay in patients with COVID-19. Permissive enteral nutrition prescription in patients who underwent PP was not associated with worse clinical outcomes.

The emerging roles of next-generation metabolomics in critical care nutrition.

Critical illness leads to millions of deaths worldwide each year, with a significant surge due to the COVID-19 pandemic. Patients with critical illness are frequently associated with systemic metabolic disorders and malnutrition. The idea of intervention for critically ill patients through enteral and parenteral nutrition has been paid more and more attention gradually. However, current nutritional therapies focus on evidence-based practice, and there have been lacking holistic approaches for nutritional support assessment. Metabolomics is a well-established omics technique in system biology that enables comprehensive profiling of metabolites in a biological system and thus provides the underlying information expressed and modulated by all other omics layers. In recent years, with the development of high-resolution and accurate mass spectrometry, metabolomics entered a new "generation", promoting its broader applications in critical care nutrition. In this review, we first described the technological development and milestones of next-generation metabolomics in the past 20 years. We then discussed the emerging roles of next-generation metabolomics in advancing our understanding of critical care nutrition, such as nutritional deficiency risk evaluation, metabolic mechanisms of nutritional therapies, and novel nutrition target identification.

Impact of malnutrition on clinical outcomes in patients diagnosed with COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is now the third leading cause of death in the United States. Malnutrition in hospitalized patients increases risk of complications. However, the effect of malnutrition on outcomes in patients infected is unclear. This study aims to identify the impact of malnutrition on mortality and adverse hospital events in patients hospitalized with COVID-19. METHODS: This study used data from the National COVID Cohort Collaborative (N3C), a COVID-19 repository containing harmonized, longitudinal electronic health record data from US health systems. Malnutrition was categorized into three groups based on condition diagnosis: (1) none documented, (2) history of malnutrition, and (3) hospital-acquired malnutrition. Multivariable logistic regression was performed to determine whether malnutrition was associated with mortality and adverse events, including mechanical ventilation, acute respiratory distress syndrome, extracorporeal membrane oxygenation, and hospital-acquired pressure injury, in hospitalized patients with COVID-19. RESULTS: Of 343,188 patients hospitalized with COVID-19, 11,206 had a history of malnutrition and 15,711 had hospital-acquired malnutrition. After adjustment for potential confounders, odds of mortality were significantly higher in patients with a history of malnutrition (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.63-1.79; P < 0.001) and hospital-acquired malnutrition (OR, 2.5; 95% CI, 2.4-2.6; P < 0.001). Adjusted odds of adverse hospital events were also significantly elevated in both malnutrition groups. CONCLUSIONS: Results indicate the risk of mortality and adverse inpatient events in adults with COVID-19 is significantly higher in patients with malnutrition. Prevention, diagnosis, and treatment of malnutrition could be a key component in improving outcomes in these patients.

Protein requirements and provision in hospitalised COVID-19 ward and ICU patients: Agreement between calculations based on body weight and height, and measured bioimpedance lean body mass.

BACKGROUND: A large proportion of hospitalised COVID-19 patients are overweight. There is no consensus in the literature on how lean body mass (LBM) can best be estimated to adequately guide nutritional protein recommendations in hospitalised patients who are not at an ideal weight. We aim to explore which method best agrees with lean body mass as measured by bioelectric impedance (LBMBIA) in this population. METHODS: LBM was calculated by five commonly used methods for 150 hospitalised COVID-19 patients previously included in the BIAC-19 study; total body weight, regression to a BMI of 22.5, regression to BMI 27.5 when BMI>30, and the equations described by Gallagher and the ESPEN ICU guideline. Error-standard plots were used to assess agreement and bias compared to LBMBIA. The actual protein provided to ICU patients during their stay was compared to targets set using LBMBIA and LBM calculated by other methods. RESULTS: All methods to calculate LBM suffered from overestimation, underestimation, fixed- and proportional bias and wide limits of agreement compared to LBMBIA. Bias was inconsistent across sex and BMI subgroups. Twenty-eight ICU patients received a mean of 51.19 (95%-BCa CI 37.1;64.1) grams of protein daily, accumulating to a mean of 61.6% (95%-BCa CI 43.2;80.8) of TargetBIA during their ICU stay. The percentage received of the target as calculated by the LBMGallagher method for males was the only one to not differ significantly from the percentage received of TargetBIA (mean difference 1.4% (95%-BCa CI -1.3;4.6) p = 1.0). CONCLUSIONS: We could not identify a mathematical method for calculating LBM that had an acceptable agreement with LBM as derived from BIA for males and females across all BMI subgroups in our hospitalised COVID-19 population. Consequently, discrepancies when assessing the adequacy of protein provision in ICU patients were found. We strongly advise using baseline LBMBIA to guide protein dosing if possible. In the absence of BIA, using a method that overestimates LBM in all categories may be the only way to minimise underdosing of nutritional protein. TRIAL REGISTRATION: The protocol of the BIAC-19 study, of which this is a post-hoc sub-analysis, is registered in the Netherlands Trial Register (number NL8562).

The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The optimal protein dose in critical illness is unknown. We aim to conduct a systematic review of randomized controlled trials (RCTs) to compare the effect of higher versus lower protein delivery (with similar energy delivery between groups) on clinical and patient-centered outcomes in critically ill patients. METHODS: We searched MEDLINE, EMBASE, CENTRAL and CINAHL from database inception through April 1, 2021.We included RCTs of (1) adult (age ≥ 18) critically ill patients that (2) compared higher vs lower protein with (3) similar energy intake between groups, and (4) reported clinical and/or patient-centered outcomes. We excluded studies on immunonutrition. Two authors screened and conducted quality assessment independently and in duplicate. Random-effect meta-analyses were conducted to estimate the pooled risk ratio (dichotomized outcomes) or mean difference (continuous outcomes). RESULTS: Nineteen RCTs were included (n = 1731). Sixteen studies used primarily the enteral route to deliver protein. Intervention was started within 72 h of ICU admission in sixteen studies. The intervention lasted between 3 and 28 days. In 11 studies that reported weight-based nutrition delivery, the pooled mean protein and energy received in higher and lower protein groups were 1.31 ± 0.48 vs 0.90 ± 0.30 g/kg and 19.9 ± 6.9 versus 20.1 ± 7.1 kcal/kg, respectively. Higher vs lower protein did not significantly affect overall mortality [risk ratio 0.91, 95% confidence interval (CI) 0.75-1.10, p = 0.34] or other clinical or patient-centered outcomes. In 5 small studies, higher protein significantly attenuated muscle loss (MD -3.44% per week, 95% CI -4.99 to -1.90; p < 0.0001). CONCLUSION: In critically ill patients, a higher daily protein delivery was not associated with any improvement in clinical or patient-centered outcomes. Larger, and more definitive RCTs are needed to confirm the effect of muscle loss attenuation associated with higher protein delivery. PROSPERO registration number: CRD42021237530.

Case presentation and panel discussion: Critical illness.

Despite a mounting evidentiary base, controversies surrounding critical care nutrition support persist. Anchored by a case of a 60-year-old male with esophageal cancer who develops acute hypoxemic respiratory failure and septic shock, five panelists from the American Society of Parenteral and Enteral Nutrition (ASPEN) 2021 Pre-Conference discuss key clinical dilemmas in critical care nutrition, including hierarchy of evidence, bedside evaluation of malnutrition, optimal protein dose, use of fiber, and therapies targeting gut function and gut microbiota .

Energy requirements for critically ill patients with COVID-19.

Early reports suggested that predictive equations significantly underestimate the energy requirements of critically ill patients with coronavirus disease 2019 (COVID-19) based on the results of indirect calorimetry (IC) measurements. IC is the gold standard for measuring energy expenditure in critically ill patients. However, IC is not available in many institutions. If predictive equations significantly underestimate energy requirements in severe COVID-19, this increases the risk of underfeeding and malnutrition, which is associated with poorer clinical outcomes. As such, the purpose of this narrative review is to summarize and synthesize evidence comparing measured resting energy expenditure via IC with predicted resting energy expenditure determined via commonly used predictive equations in adult critically ill patients with COVID-19. Five articles met the inclusion criteria for this review. Their results suggest that many critically ill patients with COVID-19 are in a hypermetabolic state, which is underestimated by commonly used predictive equations in the intensive care unit (ICU) setting. In nonobese patients, energy expenditure appears to progressively increase over the course of ICU admission, peaking at week 3. The metabolic response pattern in patients with obesity is unclear because of conflicting findings. Based on limited evidence published thus far, the most accurate predictive equations appear to be the Penn State equations; however, they still had poor individual accuracy overall, which increases the risk of underfeeding or overfeeding and, as such, renders the equations an unsuitable alternative to IC.

Dudrick Research Symposium: Expanding the boundaries of cancer care through nutrition support.

The 2020 Dudrick Research Symposium, entitled "Expanding the Boundaries of Cancer Care Through Nutritional Support," was held on March 30, at the American Society for Parenteral and Enteral Nutrition (ASPEN), Nutrition Science & Practice Conference. It was scheduled to take place in Tampa, Florida, but had to be held virtually. The Dudrick Symposium honors the many pivotal and innovative contributions made by the late Dr Stanley J. Dudrick, physician scientist, academic leader, and a founding member of ASPEN. This year, in addition to honoring his legacy, we honored his life. As the 2019 recipient of the Dudrick Research Scholar Award, Dr Pimiento chaired the symposium. The presentations focused on discussing the history, the present and future frontiers in the overlapping fields of nutrition support and cancer care. The late Dr John Daly opened the presentation with a moving tribute to Dr Dudrick's life and then spoke about the impact of nutrition support on surgical care and outcomes for cancer patients. Dr Pimiento discussed the role of nutraceuticals for cancer chemoprevention, and the level 1 clinical evidence surrounding this topic. Dr Kraemer explored the role of exercise physiology for optimal nutrient utilization and the overlap between targeted physical activity and nutrition support to obtain better outcomes on the cancer population. The symposium was closed by Dr Stephen Hursting, who discussed the impact of obesity in the soaring cancer rates and its relationship with clinical outcomes. In this article, we cover the presentations by Drs Pimiento and Kraemer.

Exploring sports nutritionists' and players' perspectives of nutrition practice within English professional football during the COVID-19 pandemic.

The outbreak of the COVID-19 pandemic, and the subsequent suspension of all football-related activity, caused significant disruption to the daily habits of professional football players and support staff. Even when the most severe restrictions were lifted, strict control measures remained in place which likely continued to impact upon nutrition support and intake of players. Thus, this study aimed to understand how restrictions impacted upon nutrition support within professional football, as well as identify how these experiences could inform future practice. Interviews were conducted with twelve sports nutritionists and twelve male professional football players to explore their perspectives of nutrition provision during the COVID-19 pandemic. Thematic analysis indicated three common outcomes: (a) Sub-optimal Nutrition Provision; (b) Reduction in Time with or Access to Players, and; (c) Adaption of Nutrition Practice and/or Dietary Habits. In sum, football clubs should consider the immediate and short-term impact of COVID-19 restrictive measures as players' transition back to normality. Specifically, clubs should provide sports nutritionists with greater capacity to control the nutrition provision, including portion size and food quality. Looking ahead, sports nutritionists are encouraged to reflect upon the novel opportunities that have emerged and consider how these may enhance long-term practice.

Protein requirements for critically ill ventilator-dependent patients with COVID-19.

BACKGROUND: Recent studies indicate critically ill patients with coronavirus disease 2019 (COVID-19) are hypermetabolic; however, protein requirements in critically ill COVID-19 patients are unknown. Our intent was to evaluate the nitrogen accretion response to varying protein intakes for critically ill ventilator-dependent patients with COVID-19. METHODS: Adult patients (age ≥ 18 years) with COVID-19, admitted to the intensive care unit (ICU) and who required mechanical ventilation were retrospectively evaluated. Patients received continuous enteral nutrition (EN), including supplemental protein boluses, and had a 24-h urine collection for determination of nitrogen balance (NBAL). Data are expressed as mean ± SD with a P-value < .05 as significant. RESULTS: Twenty-two patients provided 29 NBAL determinations. Protein intake from EN and protein supplements was 0.9 ± 0.7 g/kg/day at the time of the NBAL with an NBAL of -12.1 ± 10.9 g/day at 7 ± 4 days in the ICU. Combined caloric intake from EN and propofol at the time of the NBAL was 12 ± 8 kcal/kg/day. Nitrogen equilibrium (NBAL of -4 g/day or better) occurred in five patients. Patients achieving nitrogen equilibrium received more protein than those with a negative NBAL (1.2 ± 0.4 g/kg/day vs 0.8 ± 0.8 g/kg/day, P = .046). The linear regression for NBAL in response to graded increases in protein intake was as follows: NBAL = 8.5 × protein intake (g/kg/day) - 18.8 (r = 0.450, P < .001). CONCLUSION: Critically ill ventilator-dependent patients with COVID-19 exhibit significant variability in nitrogen accretion response to increases in protein intake and often have a markedly negative NBAL.

Use of telehealth in home nutrition support: Challenges and advantages.

Coronavirus disease 2019 (COVID-19), after initially being detected in Wuhan, China in late 2019, quickly spread to most regions of the world, meeting World Health Organization criteria for a pandemic. Social distancing along with other measures implemented to control spread had a drastic impact on the provision of healthcare including deferred elective procedures and surgeries as well as delayed care and evaluation for emergent diagnoses such as heart attacks and strokes. In the home nutrition practice, patients began to delay routine laboratory tests and were canceling or deferring annual visits. Our group soon began to rapidly deploy telehealth to meet the needs of the home nutrition patients. Telehealth is not a new concept with descriptions of healthcare being provided at a distance with the use of telephone in the 1870s. However, widespread adoption has been limited because of regulation (licensure, prescriptions, credentialing, and privileges), lack of reimbursement, as well as adoption and availability of technology needed to carry out telehealth visits. As regulations and limits on reimbursements were waived during COVID-19 pandemic, our home nutrition practice began to evaluate core components of the care we provide for our patients and assess which could be successfully transitioned to telehealth. In addition to the history and regulation of telehealth, the current manuscript provides details regarding successful implementation of telehealth visits such as change management, selection of telehealth platform, scheduling and logistics, as well as carrying out the virtual visit including history and physical exam.

Regulatory and legislative issues on telehealth.

The use of telehealth to deliver health care services in the United States experienced rapid expansion with the advent of the COVID-19 public health emergency (PHE) and associated waivers. Prior to the pandemic, adoption of telehealth by health care providers was hampered by outdated legislative and regulatory barriers at the federal and state levels. This paper provides a review of the legislative and regulatory landscape for telehealth in the United States and how it has changed during the COVID-10 PHE. It remains to be seen whether the temporary flexibilities surrounding delivery and payment of telehealth services will remain in place; some require Congressional action to make permanent while others can be made permanent through rulemaking. Other actions are dependent on state legislatures and commercial payers. Issues under debate by stakeholders include long-term audio-only coverage; broadband connectivity; disparities in access to telehealth; appropriate payment for telehealth versus in-person care; concerns about fraud, quality, and safety; and the need for additional data to inform future policymaking. Insights are provided into these key issues that are expected to shape future legislative and regulatory action at the federal and state levels. Health care providers and patients need to engage in advocacy work at the federal and state level, and with commercial payers, to affect meaningful long-term change.

Nutrition risk prevalence and nutrition care recommendations for hospitalized and critically-ill patients with COVID-19.

BACKGROUND: Nutritional status is an often-overlooked component in infectious disease severity. Hospitalized or critically ill patients are at higher risk of malnutrition, and rapid assessment and treatment of poor nutritional status can impact clinical outcomes. As it relates to the COVID-19 pandemic, an estimated 5% of these patients require admission to an ICU. Per clinical practice guidelines, nutrition therapy should be a core component of treatment regimens. On account of the urgent need for information relating to the nutritional support of these patients, clinical practice guidance was published based on current critical care guidelines. However, a growing body of literature is now available that may provide further direction for the nutritional status and support in COVID-19 patients. This review, intended for the health care community, provides a heretofore lacking in-depth discussion and summary of the current data on nutrition risk and assessment and clinical practice guidelines for medical nutrition therapy for hospitalized and critically ill patients with COVID-19.