Support for operational challenges during patients COVID-19 recovery

Information for professionals to help with operational challenges

Impact of social distancing

Recommendations for best practice

Health systems (e.g. GP, pharmacy, nursing) should strive to share information and follow clear guidance to address recovery needs for COVID-19 patients. 

Messages from healthcare staff and operational staff should be provided in a consistent way.

Professionals should have access to:

  • online resources, webinars, updated and emerging evidence (Lawrence et al., 2021)
  • clinical networks and hubs (NHS, 2020) to increase effectivity of operations and systems.

Department links

Departments should have a good link between them, clear documentation, record-keeping and communication. Communication between professionals needs to be improved and care should focus on holistic and comprehensive approaches.

To ensure strong links between acute and community settings (Cawood et al., 2020) some solutions are:

  • Healthcare workers should be trained, and resources allocated (Cawood et al., 2020).
  • Multidisciplinary follow up should be prescribed at least for six weeks post discharge (Eekholm et al., 2020).
  • Redeployment of staff and upskilling (Lawrence et al., 2021).
  • Have access to helpful information from CCGs (Clinical Commissioning Groups).
  • Ensure effective information sharing including clinical records (for baseline measures) and use MDT virtual or in-person meetings (NICE, 2020).
  • Work closely with physiotherapists or other healthcare professionals.

Virtual consultations

Remote rehabilitation tailored to patient (Africa CDC, no date) is currently used and encouraged (Cawood et al., 2020; Iannaccone et al., 2020). Bear in mind that people may not have access to the COVID-19 app (those who have a phone may have been excluded due to the need for a positive PCR test), may not have a phone and may not engage with digital technologies (NHS, 2020). Access to post-COVID syndrome assessment clinics and virtual support is still limited so it is vital to provide access to this. Many health services have implemented a triage process before providing telephone or in person appointments. Another way of making decisions to provide face to face treatment is to use a flowchart recently published in a UK context (Lee, Koo and Panter, 2021).

Nutritional support is essential to improve outcomes during the recovery phase. Essential nutritional advice for people living at home should be given through consistent written or online information (Barazzoni et al., 2020; Brugliera et al., 2020). Although benefits have been documented, there are challenges and some of them are related with patients’ cues that are lost when remotely consulting and although this can reduce travel time and costs for patients, virtual consultations are often not viable when the best care can be provided face to face. In this sense, remote consultations are not a one-size-fits-all solution to deliver care for COVID-19 recovery (Lee, Koo and Panter, 2021).

Use of telehealth should consider:

  • Throughout the period of home care, healthcare personnel should perform regular (e.g. daily) follow-up (face-to-face visits or phone interviews for symptoms).
  • Patients treated in the community can be directed to various websites that give advice on general health and symptoms – see our Understanding symptoms during your COVID-19 recovery patients page.
  • Identifying nutritional needs early can help to support healthcare staff. Multidisciplinary teams should therefore, be asking subjective questions to patients using systematic and consistent approaches.
  • For inpatients, nursing staff should be alerted when dietitians are not allowed to enter wards, in addition to relevant nutritional information being disseminated at multidisciplinary team meetings in order to reinforce the importance of screening and addressing nutritional needs (Lawrence et al., 2021).
  • There is a list of procedures utilised in multidisciplinary dysphagia that have been categorised according to their risk of COVID-19 transmission in Miles et al. (Miles et al., 2020). Other considerations for the use of telehealth when assessing and monitoring dysphagia have been proposed. Authors have also suggested screening procedures for dysphagia in the context of the COVID-19 pandemic.

For those without COVID-19 but indirectly affected, consider nutrition-related risks such as: 

  • poor food availability and accessibility for those who struggle to go to the shops 
  • interruption in nutrition support services
  • lack of visits from family or friends to provide food, company and feeding assistance
  • cancellation of social lunch clubs 
  • increased unemployment with limited financial resources 
  • sedentary lifestyles and higher consumption of unhealthy foods
  • deconditioning in older adults (Public Health England, 2021). See underlying mechanisms for further information.
  • a major review of the impact of lockdowns in African countries on nutrition and food security has been completed to highlight learning for future use of lockdown procedures. The results highlight both the need and scope to design nutrition-sensitive lockdown strategies, which are effective from an epidemiological perspective but minimize trade-offs with food and nutrition security. There may be some learning from this for Western countries too (Daum et al., 2020). To read more see the full article https://490c.uni-hohenheim.de/fileadmin/einrichtungen/490c/Publikationen/WP_006-2020_Nutrition-sensitive_Lockdowns.pdf.

Recommendations for improving food and nutrition security (Carducci et al., 2021):

  • Trigger effective government investments in small and medium sizes enterprises (as well as gender-sensitive and gender-transformative), including support to workers through social innovations and employee health programmes.
  • Invest on nutrition literacy approaches and policies to increase demand for nutritious foods.
  • Strengthen social protection programmes (promote cash or vouchers for nutritious food markets) and enable safe trade corridors for nutritious foods.
  • It is key to activate local and governmental actors, as well as creating partnerships and bring international partners to translate these recommendations.

How to reach out to patients who do not access telehealth

  • Patients living at home who have COVID-19 or post-COVID syndrome can access nutritional support via their GP surgery website or contacting them by telephone.
  • Ensure GPs and A&E staff are fully informed of whether patients are recovering from COVID-19, as well as anyone interacting with them. Where appropriate, include patient discharge letters from hospital if they have been hospitalised due to COVID-19.
  • Clinicians and/or nurses who triage could find out how many people with COVID-19 there are in the practice and how they are getting on. They can also flag up issues with GPs when relevant. According to CG-32 (NICE) it is important to screen for malnutrition.
  • Healthcare staff who have first patient contact (e.g. Nurses, Occupational Therapists, Physiotherapists) to disseminate information about appropriate evidence-based resources. To know more, go to section useful resources (identification and assessment).
  • Telephone help lines (e.g. NHS 111).
  • Publicity through: TV and radio ads or interviews in relevant shows.
  • Leaflets in public areas: pharmacies, waiting rooms, supermarket, schools, gyms. Post these to patients.
  • Healthcare worker home visits and agencies.
  • COVID app, Zoe app.

Useful knowledge hub links

Improving the continuity of care

Enabling staff to provide nutritional support can be challenging in a pandemic when staff shortages and stress among others are a daily issue. The following provides guidance to overcome those challenges.

  • Review the process of care you are using to assess what approaches to support COVID-19 recovery work and why.
  • Consider all elements of the pathway and any resource requirements and what organisational approvals are needed.
  • Clear governance structures which approve and develop decision making and ownership in organisation are useful.
  • Involvement of the MDT is important, and training may be needed.
  • Transition to different care settings can be a challenge for continuity of care; assess how this transition will be managed.
  • Updating GPs and/or community services with aspects of care provided in acute settings is advisable to avoid duplication of effort or failure to pick up patients. (Lawrence et al., 2021)
  • Assign clear responsibility for follow up. For instance, some responsibility for monitoring nutrition can be delegated to physiotherapists, nurses, pharmacists, and so on. Training may be needed.
  • A system thinking approach can be helpful but requires learning how to triage from the first phone call. (Carson et al., 2021; Lawrence et al., 2021)
  • Resistance to policy change can be challenging and training may be needed to help resolve it.
  • There is a risk of potential overlap of services in acute and community. Clarity and agreement on responsibilities is needed.
  • Covid increases the risk of malnutrition so consider facilitating training packages for primary care, social services and third sector agencies to identify when people need nutritional support through malnutrition screening.

For more examples of good practice for nutritional care see BAPEN and British Dietetic Association (BDA) websites.

Consider the patients’ perspectives

Aspects to consider from a patient perspective:

  • Aim to work in partnership with patients to address their needs.
  • Provide patients with clear information on pathways of care, and advice on how to seek help from health care professionals to tailor health goals.
  • Helping patients to identify reputable information online and in social media channels may be particularly important in the context of telehealth (see our page on Understanding the Evidence).

Lockdowns and accessibility

During lockdowns, whilst social distancing measures are still in place and to deal with patients with accessibility issues, healthcare staff should aim to:

  • use short phone and video calls and frequently assess the provision of recommendations and resources
  • inform patients what services can support them and what referral processes are to self refer. Thus, this will educate and empower patients to self-manage their conditions
  • adapt resources for people with learning disabilities
  • listen to patient desires and concerns – do not dismiss due to their age or due to recognising more mental health symptoms. A differential diagnosis should be undertaken to rule out post-COVID syndrome before dismissing this as a symptom.
  • protect time to support patient recovery
  • be mindful of cultural and ethnic aspects associated with diet
  • avoid using medical jargon to communicate with patients
  • be mindful of social isolation and the impacts of this on mental health, diet and nutrition.

Raising awareness

There is a lack of awareness (particularly across vulnerable groups and ethnic minority groups) about support resources available across the UK. Some potential solutions are:

  • weekly newsletters sent out with a COVID-19 related topic
  • to confirm via telephone or multidisciplinary team meetings, matrons, lead nurses
  • posters in GP surgeries and other healthcare facilities
  • include useful links and resources on hospital discharge letter, where appropriate.  
  • to increase levels of resourcing on wards
  • peer learning support and research (Lawrence et al., 2021)
  • to supply training on how to support clinicians on post COVID-19 symptoms and longer-term impacts on nutritional management
  • to increase networking at an organisational level
  • to recognise unpaid carers and how their feedback can improve health and social care – more information can be found on the Care Quality Commission website.

Contact us

This knowledge hub is constantly being reviewed and updated. We welcome your comments or feedback about it.

Please contact abigail.troncohernandez@plymouth.ac.uk and we will get back to you promptly.

References

Africa CDC (no date) ‘Guidance on Diagnosis and Management of People with Post-Acute COVID-19 Syndrome’, Africa CDC. Available at: https://africacdc.org/download/guidance-on-diagnosis-and-management-of-people-with-post-acute-covid-19-syndrome/ (Accessed: 11 March 2022).

Barazzoni, R. et al. (2020) ‘ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection’, Clinical Nutrition, 39(6), pp. 1631–1638. doi:10.1016/j.clnu.2020.03.022.

Brugliera, L. et al. (2020) ‘Nutritional management of COVID-19 patients in a rehabilitation unit’, European Journal of Clinical Nutrition, 74(6), pp. 860–863. doi:10.1038/s41430-020-0664-x.

Carducci, B. et al. (2021) ‘Food systems, diets and nutrition in the wake of COVID-19’, Nature Food, 2(2), pp. 68–70. doi:10.1038/s43016-021-00233-9.

Carson, R.C. et al. (2021) ‘Balancing the needs of acute and maintenance dialysis patients during the COVID-19 pandemic: A proposed ethical framework for dialysis allocation’, Clinical Journal of the American Society of Nephrology, 16(7), pp. 1122–1130. doi:10.2215/CJN.07460520.

Cawood, A.L. et al. (2020) ‘A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community’, Nutrients, 12(11), p. 3230. doi:10.3390/nu12113230.

Daum, T. et al. (2020) Between pandemics and famines: Towards nutrition-sensitive lockdowns during Covid-19 and beyond. doi:10.13140/RG.2.2.28221.28641.

Eekholm, S. et al. (2020) ‘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 Infectious Diseases, 20(1), p. 73. doi:10.1186/s12879-019-4742-4.

Iannaccone, S. et al. (2020) ‘Role of Rehabilitation Department for Adult Individuals With COVID-19: The Experience of the San Raffaele Hospital of Milan’, Archives of Physical Medicine and Rehabilitation, 101(9), pp. 1656–1661. doi:10.1016/j.apmr.2020.05.015.

Lawrence, V. et al. (2021) ‘A UK survey of nutritional care pathways for patients with COVID-19 prior to and post-hospital stay’, Journal of human nutrition and dietetics: the official journal of the British Dietetic Association, 34(4), pp. 660–669. doi:10.1111/jhn.12896.

Lee, P.S., Koo, S. and Panter, S. (2021) ‘The value of physical examination in the era of telemedicine’, Journal of the Royal College of Physicians of Edinburgh, 51(1), pp. 85–90. doi:10.4997/JRCPE.2021.122.

Miles, A. et al. (2020) ‘Dysphagia Care Across the Continuum: A Multidisciplinary Dysphagia Research Society Taskforce Report of Service-Delivery During the COVID-19 Global Pandemic’, Dysphagia [Preprint]. doi:10.1007/s00455-020-10153-8.

NHS (2020) National guidance for post-COVID syndrome assessment clinics (6 November 2020), Patient Safety Learning - the hub. Available at: https://www.pslhub.org/learn/coronavirus-covid19/guidance/national-guidance-for-post-covid-syndrome-assessment-clinics-6-november-2020-r3465/ (Accessed: 9 January 2021).

NICE (2020) ‘COVID-19 rapid guideline: managing the long-term effects of COVID-19’, p. 35.

Patel, J.J., Martindale, R.G. and McClave, S.A. (2020) ‘Relevant Nutrition Therapy in COVID-19 and the Constraints on Its Delivery by a Unique Disease Process’, Nutrition in Clinical Practice, 35(5), pp. 792–799. doi:10.1002/ncp.10566.

Public Health England (2021) COVID-19: wider impacts on people aged 65 and over, GOV.UK. Available at: https://www.gov.uk/government/publications/covid-19-wider-impacts-on-people-aged-65-and-over (Accessed: 5 November 2021).

Why we created this page

In creating the knowledge hub we worked with expert panels to form a consensus on the nutritional care for people recovering from COVID-19 infection. Each section of the knowledge hub includes a consensus statement produced by the relevant expert panel. For information on the background of the Nutrition and COVID-19 recovery knowledge hub project visit the 'about us' page.

Consensus statements

  • Joint work is necessary to refer and receive referrals by recognising and prioritising nutrition and assessing dietary-related issues and nutritional needs.
  • Remote working must include user friendly instruments to enable dietitians and healthcare professionals navigate recovery hand-in-hand with patients.
  • Given the emerging field, some lessons can be learned from evidence in palliative care, cancer, immunological functions (e.g. role of histamine and mast cells), neurological implications and anecdotal reports from post-COVID syndrome support groups.
  • To improve health services, healthcare staff should gather generalised and specific information, it is also important to refer to the evidence base and learning generated from other countries.
  • To involve healthcare professionals effectively we can empower nurses to be first-line contact and other healthcare professionals across health and social care services for further support.
  • There is a need for improved education and training, greater awareness and leadership from healthcare professionals beyond COVID-19, and to recognise and tackle biases and prejudices.