key: cord-0775919-u1x2h1lj
authors: May, Rachael; Sehgal, Ashwini R.; Hand, Rosa K.
title: Changes in US Dialysis Dietitian Responsibilities and Patient Needs During the COVID-19 Pandemic
date: 2021-07-27
journal: J Ren Nutr
DOI: 10.1053/j.jrn.2021.07.006
sha: b0b144f599f418710a8da0d649252e9eb46d86f3
doc_id: 775919
cord_uid: u1x2h1lj

Objective This study described the job responsibilities and modalities of care among dialysis dietitians in the United States and their observations regarding the nutrition needs of their patients, during the COVID-19 pandemic. Design and methods: Cross-sectional online survey capturing: dietitian characteristics and responsibilities, dialysis facility characteristics, and patient needs. We recruited US dialysis dietitians. We used Chi-square tests to compare respondent stress and facility level policies regarding eating/drinking and oral nutrition supplements (ONS) based on facility ownership type. Results We received 191 complete or partial survey responses. 63% of respondents stated that their center banned eating/drinking during dialysis due to COVID-19 masking policies. DaVita and non-profit facilities were significantly more likely to still allow eating/drinking during dialysis (31% and 29%, respectively) compared to Fresenius facilities (7%). A common theme in open-ended responses regarding nutrition care for COVID-19-positive patients was providing less care to these patients. A majority of respondents admitted to stress from working in healthcare during COVID-19. The majority of respondents indicated that patients were taking precautions such as having a family member or friend grocery shop for them (69%) or going to the store less often (60%). Just over a quarter of respondents indicated that affordability of food was a concern among patients. 72% reported that patients were cooking at home more often, 60% had observed an increase in serum phosphorus and 72% an increase in interdialytic weight gain. Conclusions Due to the increased risk of malnutrition and symptoms that can affect dietary intake in COVID-positive patients, and the economic conditions leading to increased rates of food insecurity, dietitians must be proactive in preventing and/or treating malnutrition through adequate protein and energy intake. Eating/drinking bans should not become permanent and dialysis centers should take precautions to allow intradialytic meals and ONS protocols to continue during the pandemic.

The COVID-19 pandemic has been a period of rapid change in society and has particularly 3 impacted healthcare 1 and health behaviors 2 . Even before COVID-19, dialysis patients had intensive 4 nutrition needs, but these may be worsened during the pandemic. Due to the economic fallout from 5 COVID-19, more individuals are facing personal economic crises including a need for food assistance, 6 which the United States Department of Agriculture estimates tripled from 12% to 38% in March and 7

April 2020 3 . Early on in the pandemic (April 2020), survey respondents from a population participating in 8 a fruit and vegetable distribution program for children reported that the pandemic had decreased their 9 consumption of fruits and vegetables, their consumption of restaurant foods, and the frequency of their 10 grocery shopping trips, suggesting rapid changes in health behaviors due to both financial and safety 11 concerns 4 . 12

The COVID-19 pandemic may be impacting dialysis patient physical and mental health in other 13 ways. A small mixed methods study in Portugal suggested that during the pandemic, patients were 14 spending less time on dialysis, experiencing reduced dialysis adequacy, lower serum albumin, and higher 15 serum phosphorus 5 . Patients reported difficulty adhering to nutrition guidance during lockdown and 16

high levels of stress about their risk of contracting or experiencing morbidity or mortality from COVID-17 19 5 . While patients in this study were generally compliant with recommendations for protecting 18 themselves (masks etc), they were unhappy about some preventative strategies implemented in dialysis 19 centers such as prohibitions on intra-dialytic food/drink and exercise 5, 6 . 20

Patient stress about COVID-19 is valid, as dialysis patients are a high risk group for COVID-19 6 , 21 due to their underlying health condition as well as to the social inequities associated with end stage 22 renal disease in the United States 3 . Estimates of seropositivity rates for US dialysis patients are 8.3% 23 (95% CI .6%), with higher rates in expected higher-risk groups based on age and race 7 . Beyond the  24  1   underlying physical and social risk factors for contracting COVID-19, dialysis also requires patients to  25   come into relatively close contact with one another and health professionals on a frequent basis 6 and  26   most dialysis facilities are under-equipped with isolation rooms or barriers between chairs 8 .  27 Asymptomatic patients make the spread through dialysis facilities particularly risky-in one Spanish 28 dialysis center 18.7% of the patients were COVID-19 positive in one month, with 39% of those cases 29 being asymptomatic 9 . 30

Despite the intensive nutrition needs of the dialysis population (with or without COVID-19 31 infection) and the fact that the Centers for Medicare and Medicaid Services requires a dietitian in every 32 dialysis unit 10 , previous research demonstrates that a significant portion of the dialysis dietitian's time is 33 spent in indirect care and that many patient encounters are short 11 . As much of healthcare has shifted 34 to telehealth in response to the pandemic, and regulations have eased to allow telehealth under more 35 circumstances during the pandemic 1,12 , it is unclear whether dialysis dietitians are also providing virtual 36 care to in-center patients, or whether they are still seeing patients in person, given that patients still 37 must attend dialysis 8 . Whatever the modality of the encounter, it is important to investigate whether 38 dietitians are able to spend additional time with their patients given the increased nutrition burden they 39 may be facing during the pandemic. 40

Finally, COVID-19 has been a great stressor for healthcare providers 6, 13, 14 . Prior to the pandemic, 41 burnout was a concern in nephrology 15,16 , and the trends towards more indirect care responsibilities and 42 less patient interaction was associated with increased job dissatisfaction 17 . Whether this problem has 43 been exacerbated by the pandemic and related shifts in healthcare bears investigation. 44 Therefore, the aim of this cross-sectional survey study was to describe the job responsibilities 45 and modalities of delivering care among dialysis dietitians in the United States, as well as their 46 observations of the nutrition needs of their patients, approximately 10 months into the pandemic. Armonk NY). 73

Of 2106 emails sent, 241 individuals clicked on the survey invitation link, and 27 of these were 75 ineligible. Of the 204 eligible participants, 13 did not answer any questions after the screening question, 76 while 32 completed some but not all questions. Therefore, the final sample size was 159 complete 77 responses plus 32 partial responses (total n=191) and a response rate of 9%. 78

Participant characteristics are listed in Table 1 . Participants were evenly distributed among 79

Fresenius, not-for-profit, DaVita and other for profit ownership (Table 1 ). Facilities were located across 80 39 US states (data not shown). 81

The majority of participants were working in the dialysis center (81%), primarily communicating 82 with patients in person (87 %) and had not experienced a change in paid hours (91%); a plurality had not 83 experienced a change in patient census (39%) ( Table 2) . Respondents were using a variety of secondary 84 methods to communicate with patients (Table 2) , including postal mail and e-mail (mentioned in the 85 other write in responses). Respondents were communicating with other team members both in person 86 and remotely (Table 2) . 87

The majority of respondents (57%) reported no change in the amount of time they were 88 spending with patients compared to pre-COVID-19 (Table 2) . Of the 39% who reported spending less 89 time with patients the most common reasons were trying to limit one's own exposure by limiting time 90 with patients (57%) ( Table 2 ). Write-in responses for reasons for decreased patient time related to time 91 consumed by donning personal protective equipment (PPE) and being asked to take on other 92 responsibilities. Just over half of participants reported being asked to take on responsibilities not directly related to the dialysis dietitian role, for example screening employees and patients for COVID-19 94 at the entrance (Table 2) . DaVita and Fresenius dietitians were significantly more likely to report being 95 asked to take on additional roles (72% and 79%, respectively) than non-profit and other for-profit 96 dietitians (35% and 36% respectively) (p<0.001, data not shown). 97

Prior to COVID-19, 39% of respondents had been completing nutrition focused physical exam 98 (NFPE) or Subjective Global Assessment (SGA) on their patients; of those participants 60% were 99 completing NFPE/SGA in December 2020 (data not shown). 100

Use of all forms of PPE increased from pre-pandemic practices (Online Supplemental Table 1) . 101 42% of respondents reported that their facility had experienced PPE shortages during the pandemic 102 (data not shown). 103 99.4% of respondents reported that their facility had a mask wearing policy during dialysis. This policy 104 was generally well accepted by patients (Table 3) . A majority of facilities prohibited eating and drinking 105 in the dialysis chair as a result of COVID-19 and masking policies (62%). DaVita and non-profit facilities 106

were significantly more likely to still allow eating/drinking during dialysis (31% and 29%, respectively) 107 compared to Fresenius facilities (7%). Respondents reported that patients were concerned about not 108 being able to eat/drink on dialysis and were split between adhering and not adhering to the policy. 109

Respondents reported in write-in comments that the no eating/drinking policy was particularly difficult 110 for patients with dementia or diabetes. The plurality of respondents indicated that despite the 111 eating/drinking prohibition that oral nutrition supplements were still provided during dialysis (48% ,Table  112 3), although some indicated in write in responses that this varied based on the type of supplement-113 with concentrated protein liquids (eg LiquaCel®, Pro-Stat ®) being given during dialysis while bars or 114 larger volume drinks were sent home. 115 J o u r n a l P r e -p r o o f

The majority of respondents (52%) indicated that patients who test positive for COVID-19 are 116 transferred to another designated facility, while 27% retained their usual patients even if positive (Table  117 4). A small number of respondents (8%) worked at facilities that received positive patients, and 6% were 118 not aware of any patients testing positive from their facilities. Among those who reported patients from 119 their facility had tested positive, 36.0% indicated that the nutrition care of positive patients varied from 120 the care of other patients (Table 4) evenly split between concern about COVID-19-related work stressors or worries (11%) and due to 128 balancing working and home responsibilities (9%) (data not shown). The plurality of respondents 129 admitted to stress from working in healthcare during COVID-19 and worry about becoming infected 130 themselves (Table 5) . However, they also mostly agreed that their employers had done as much as 131 possible to keep them safe (74% agreed or strongly agreed) ( Table 5 ). There were no differences in 132 stress levels or consideration for leaving based on facility ownership type. 133

While 16% of respondents stated that patients had not verbalized any changes to their ability to 134 access healthy affordable food during the pandemic, the majority of participants indicated that their 135 patients were taking precautions such as having a family/friend grocery shop for them (69%), going to 136 the store less often (60%) (Online Supplemental Table 2 ). Just over a quarter of respondents indicated 137 that affordability of food was a concern-patients using foodbanks/pantries and or SNAP more 138 frequently (31 %), patients discussing food price increases (28%) or sharing that they have less money 139 for food (28%) (Online Supplemental Table 2 ). 140

Respondents reported relatively few changes in patient health behaviors and nutrition related 141 biomarkers (Table 6) . Behaviors for which the majority of respondents observed a change were patients 142 cooking at home (more often, 72%) and patients engaging in physical activity (less often, 64.8%) (Table  143 6). Biomarkers for which the majority of respondents observed an increase were serum phosphorus 144 (60%) and interdialytic weight gain (51%)( Table 6 ). In general, respondents did not report changes in 145 medication compliance among their patients (86%) (data not shown). 88% of respondents had noticed 146 an increase in patient stress levels during COVID-19 (data not shown). 147

would remain after COVID-19. The most common theme from these responses was that additional PPE 149 would stay (53%). 14% of responses indicated that telehealth would continue to be used, and 9.8% 150 believed that they would still be able to work from home. 4% of write in responses indicated that they 151 expected to maintain an increased caseload and 4% anticipated a continuation of the no eating/drinking 152 policy. 153

In this study, we describe the job responsibilities and modalities of care delivery among dialysis 155 dietitians in the U.S., as well as the nutrition needs of their patients, approximately 10 months into the 156 COVID-19 pandemic. While most respondents continue providing care in person, with additional PPE, 157 reduction in nutrition care for COVID-19-positive patients was also reported. This is a major concern 158 because infectious diseases such as COVID-19 can increase the risk of malnutrition 18 surprised that these themes were not more common in the responses to our survey. It is possible that if 185 dialysis patients are already receiving disability benefits as their primary source of income that the 186 pandemic was less disruptive to their household budgets. However, other patients who newly 187 experience food insecurity may feel shame and not admit this unless asked. Dialysis dietitians and other 188 health professionals must be willing to raise these concerns in a compassionate manner to ensure that 189 patients have access to benefits. One limitation of our study is that participants may not be honest when responding to sensitive 205 topics such as job satisfaction. The survey was anonymously completed to protect participants' privacy 206 and to encourage honest responses. Another limitation is that we asked dietitians to report on their 207 observations of group trends regarding patient needs and behavior changes limiting comparability to 208 other studies that have used individual data collected directly from patients 4,5 . 209 Another limitation of our research study is that the language describing different types of PPE 210 may have been unclear and misinterpreted by respondents. An unusually small percentage of 211 respondents answered that they wore goggles prior to the pandemic. It seems possible that 212 respondents understood this specifically as "goggles" rather than our more general meaning of "eye 213 protection." 214

We exceeded our goal response rate of 8%, achieving a rate similar to that seen in most 215 electronic surveys of dietitians 25, 26 , and reflecting the relatively low response rates among health 216 professionals in general 27 . Evidence-based strategies for increasing response rate among health 217 professionals were used: the recruitment message was sent from an organization with which the 218 respondents have an affiliation, reminder messages/deadlines for participation, and incentives for 219 participation 27,28 (described above). When these strategies are used, response rate has not been 220 demonstrated to be a good indicator of non-response bias 28 ; therefore we believe we are able to draw 221 conclusions despite a low response rate. 222

Future research should monitor whether trends observed in this survey become permanent. 224

Beyond the concerns about permanent eating/drinking prohibitions discussed above, other trends to 225 monitor include increased patient loads for dietitians, increased responsibilities such as screening, and 226 other external factors (PPE, fear of infection) influencing the already limited time for direct patient care. 227

The nutrition status of COVID-19 positive dialysis patients, and potential COVID-19 "long haulers" should 228 also be monitored. 2 (2%) Stopped ONS protocol 1 (1%) ONS-oral nutrition supplements * Other responses included that patients sometimes "sneak" food or drink during treatment despite the prohibition or that the prohibition was particularly difficult for patients with dementia to understand and led to low blood sugar among patients with diabetes. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

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