Critical care dietetic outcomes during the first wave of the COVID-19 pandemic

ABSTRACT

The COVID-19 pandemic led to a surge in patients being admitted to the Intensive Care Unit (ICU) and increased dietetic input was required for their daily nutritional management. Non-ICU dietitians were upskilled to meet this increased demand – resulting in an increase to 5 band 6 dietitians and 1 band 7 dietitian overseen by the band 8a clinical lead. The service also changed from a 5-day to a 7-day service. The aim of this service evaluation was to analyse changes in nutritional outcomes during the COVID-19 pandemic, and how changes to the dietetic service impacted upon dietetic outcomes. Outcomes included energy and protein provision, feed type used and prokinetic use. Data was collected for all ICU patients under dietetic care with a confirmed COVID-19 diagnosis for the period of 22/03/2020 to 04/06/2020 (75 days). Total patient cohort equalled 66. Patients were reviewed daily until the patient was discharged from ICU or the patient passed away. All data was then retrospectively analysed using descriptive statistics, and an independent t-test was used to compare COVID-19 feed delivery to previous feed deliverydata. Ethical approval was not required for this service evaluation. Of the 66 patients, 62 required enteral nutrition (EN). Feeding was commenced within 48 hours of ICU admission in 92% of patients. Average percentage feed delivery was 82.4% for energy and protein. This total does not include additional protein supplementation;therefore, the overall protein delivery was higher, with 36% of patients being prescribed 1 to 2 20g protein supplements per day. A total of 60% of patients were initially started on a fluid restricted feed for fluid balance or due to being proned. A total of 50% of patients continued with a fluid restricted feed, with 44% of patients receiving a standard protocol feed (1kcal/ml high-protein feed) and 6% receiving a peptide or renal feed. Prokinetics were required in 35% of patients. A total of 3% of patients (n=2) required parenteral nutrition due to persistent high gastric residual volumes despite prokinetics. Of the 66 patients, 46 (70%) were discharged alive from ICU. Of these, 70% were receiving total or supplementary EN at the time of discharge from the ICU. A number of barriers to maintaining high standards of patient outcomes arose at the onset of the COVID-19 pandemic. These included disruptions to normal MDT working, challenges in undertaking face-to-face assessments and reviews, and an increased caseload and footfall - thereby increasing the demand for ICU trained dietitians. Despite these barriers, this service evaluation demonstrates that percentage feed delivery remained relatively stable when compared to the pre-COVID 2020 audit (n = 35) - 82.4% vs. 85% respectively. An independent-samples t-test was conducted to compare feed delivery in pre-COVID and COVID-19 samples. There was no significant difference in the scores for pre-COVID (M = 85%, SD = 13.4) and COVID (M = 82.4%, SD = 16.8) samples;t(180) = -0.81, p =.42. This is despite 36% of patients requiring proning during COVID vs. 0% pre-COVID, and increased gastrointestinal intolerance evidenced by 35% of patients requiring prokinetics vs. 29% pre-COVID. These factors eliminated the ability to utilise ‘catch-up’ feeding, which significantly improves feed delivery in normal circumstances. This suggests that changes in dietetic provision of service, including delivering a 7-day service, thereby allowing more prompt management of nutritional issues and improved access to dietetic expertise, facilitated the maintenance of the pre-existing high standards of nutritional care. Achieving this degree of feed delivery necessitated the use of a variety of different feeds – to manage tolerance, fluid volume, electrolyte imbalances and ensure nutritional adequacy. Adapting feeding regimens to best meet the patients need is a key role of the dietitian, and in the absence of dietetic input it is unlikely these feeding strategies would have been utilised. The COVID-19 pandemic presented new challenges and obstacles to eve y aspect of the healthcare sector;necessitating fast adaptations, novel methods of working and reinforcing the importance of multidisciplinary teams to guide patient care in the absence of evidence-based guidelines. This service evaluation demonstrates that forward-planning and the expansion of services in alignment with demand can assure that patient care need not be compromised, despite the unprecedented challenges and barriers presented by the COVID-19 pandemic.