Advertisement

Changes in US Dialysis Dietitian Responsibilities and Patient Needs During the COVID-19 Pandemic

      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 captures 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 based on facility ownership type.

      Results

      We received 191 complete or partial survey responses. Sixty-three percent 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. Seventy-two percent 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 oral nutrition supplement protocols to continue during the pandemic.

      Introduction

      The COVID-19 pandemic has been a period of rapid change in society and has particularly impacted healthcare
      • Rozga M.
      • Handu D.
      • Kelley K.
      • et al.
      Telehealth during the COVID-19 pandemic: a cross-sectional survey of registered dietitian nutritionists.
      and health behaviors.
      • Karageorghis C.I.
      • Bird J.M.
      • Hutchinson J.C.
      • et al.
      Physical activity and mental well-being under COVID-19 lockdown: a cross-sectional multination study.
      Even before COVID-19, dialysis patients had intensive nutrition needs, but these may be worsened during the pandemic. Due to the economic fallout from COVID-19, more individuals are facing personal economic crises including a need for food assistance, which the US Department of Agriculture estimates tripled from 12% to 38% in March and April 2020.
      • Wolfson J.A.
      • Leung C.W.
      Food insecurity during COVID-19: an acute crisis with long-term health Implications.
      Early on in the pandemic (April 2020), survey respondents from a population participating in a fruit and vegetable distribution program for children reported that the pandemic had decreased their consumption of fruits and vegetables, their consumption of restaurant foods, and the frequency of their grocery shopping trips, suggesting rapid changes in health behaviors due to both financial and safety concerns.
      • Sharma S.V.
      • Chuang R.-J.
      • Rushing M.
      • et al.
      Social determinants of health-related needs during COVID-19 among low-income households with children.
      The COVID-19 pandemic may be impacting dialysis patient physical and mental health in other ways. A small mixed methods study in Portugal suggested that during the pandemic, patients were spending less time on dialysis, experiencing reduced dialysis adequacy, lower serum albumin, and higher serum phosphorus.
      • Sousa H.
      • Ribeiro O.
      • Costa E.
      • et al.
      Being on hemodialysis during the COVID-19 outbreak: a mixed-methods’ study exploring the impacts on dialysis adequacy, analytical data, and patients’ experiences.
      Patients reported difficulty adhering to nutrition guidance during lockdown and high levels of stress about their risk of contracting or experiencing morbidity or mortality from COVID-19.
      • Sousa H.
      • Ribeiro O.
      • Costa E.
      • et al.
      Being on hemodialysis during the COVID-19 outbreak: a mixed-methods’ study exploring the impacts on dialysis adequacy, analytical data, and patients’ experiences.
      Although patients in this study were generally compliant with recommendations for protecting themselves (masks, etc.), they were unhappy about some preventative strategies implemented in dialysis centers such as prohibitions on intradialytic food/drink and exercise.
      • Sousa H.
      • Ribeiro O.
      • Costa E.
      • et al.
      Being on hemodialysis during the COVID-19 outbreak: a mixed-methods’ study exploring the impacts on dialysis adequacy, analytical data, and patients’ experiences.
      ,
      • Ikizler T.A.
      COVID-19 and dialysis units: what do we know now and what should we do?.
      Patient stress about COVID-19 is valid, as dialysis patients are a high risk group for COVID-19,
      • Ikizler T.A.
      COVID-19 and dialysis units: what do we know now and what should we do?.
      due to their underlying health condition as well as to the social inequities associated with end-stage renal disease in the United States.
      • Wolfson J.A.
      • Leung C.W.
      Food insecurity during COVID-19: an acute crisis with long-term health Implications.
      Estimates of seropositivity rates for US dialysis patients are 8.3% (95% confidence interval 8-8.6), with higher rates in expected higher risk groups based on age and race.
      • Anand S.
      • Montez-Rath M.
      • Han J.
      • et al.
      Prevalence of SARS-CoV-2 antibodies in a large nationwide sample of patients on dialysis in the USA: a cross-sectional study.
      Beyond the
      • Rozga M.
      • Handu D.
      • Kelley K.
      • et al.
      Telehealth during the COVID-19 pandemic: a cross-sectional survey of registered dietitian nutritionists.
      underlying physical and social risk factors for contracting COVID-19, dialysis also requires patients to come into relatively close contact with one another and health professionals on a frequent basis
      • Ikizler T.A.
      COVID-19 and dialysis units: what do we know now and what should we do?.
      and most dialysis facilities are under-equipped with isolation rooms or barriers between chairs.
      • Suri R.S.
      • Antonsen J.E.
      • Banks C.A.
      • et al.
      Management of Outpatient hemodialysis during the COVID-19 pandemic: recommendations from the Canadian society of nephrology COVID-19 rapid response team.
      Asymptomatic patients make the spread through dialysis facilities particularly risky—in one Spanish dialysis center 18.7% of the patients were COVID-19 positive in 1 month, with 39% of those cases being asymptomatic.
      • Rincón A.
      • Moreso F.
      • López-Herradón A.
      • et al.
      The keys to control a COVID-19 outbreak in a haemodialysis unit.
      Despite the intensive nutrition needs of the dialysis population (with or without COVID-19 infection) and the fact that the Centers for Medicare and Medicaid Services requires a dietitian in every dialysis unit,
      • Medicare and Medicaid Programs
      Conditions for coverage for end-stage renal disease facilities; final rule.
      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.
      • Hand R.K.
      • Albert J.M.
      • Sehgal A.R.
      Quantifying the time used for renal dietitian's responsibilities: a Pilot study.
      As much of healthcare has shifted to telehealth in response to the pandemic, and regulations have eased to allow telehealth under more circumstances during the pandemic,
      • Rozga M.
      • Handu D.
      • Kelley K.
      • et al.
      Telehealth during the COVID-19 pandemic: a cross-sectional survey of registered dietitian nutritionists.
      ,
      • Lew S.Q.
      • Wallace E.L.
      • Srivatana V.
      • et al.
      Telehealth for home dialysis in COVID-19 and beyond: a perspective from the American Society of Nephrology COVID-19 home dialysis subcommittee.
      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.
      • Suri R.S.
      • Antonsen J.E.
      • Banks C.A.
      • et al.
      Management of Outpatient hemodialysis during the COVID-19 pandemic: recommendations from the Canadian society of nephrology COVID-19 rapid response team.
      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.
      Finally, COVID-19 has been a great stressor for healthcare providers.
      • Ikizler T.A.
      COVID-19 and dialysis units: what do we know now and what should we do?.
      ,
      • Cahan E.M.
      • Levine L.B.
      • Chin W.W.
      The Human touch — Addressing health care's workforce problem amid the pandemic.
      ,
      • Adams J.G.
      • Walls R.M.
      Supporting the health care workforce during the COVID-19 Global epidemic.
      Prior to the pandemic, burnout was a concern in nephrology,
      • Roberts J.K.
      Burnout in nephrology: implications on recruitment and the workforce.
      ,
      • Williams A.W.
      Addressing physician burnout: nephrologists, how safe are we?.
      and the trends toward more indirect care responsibilities and less patient interaction were associated with increased job dissatisfaction.
      • Sullivan C.
      • Leon J.B.
      • Sehgal A.R.
      Job Satisfaction among renal dietitians.
      Whether this problem has been exacerbated by the pandemic and related shifts in healthcare bears investigation.
      Therefore, the aim of this cross-sectional survey study is to describe the job responsibilities and modalities of delivering care among dialysis dietitians in the United States, as well as their observations of the nutrition needs of their patients, approximately 10 months into the pandemic.

      Methods

      Survey

      We drafted a series of open-ended questions related to dialysis dietitian characteristics and responsibilities, dialysis facility characteristics, and dialysis patient needs and experiences related to the COVID-19 pandemic and conducted 5 key informant interviews with currently practicing dialysis dietitians. We used their responses to develop a survey consisting of both closed-ended and opened-ended questions on work and facility characteristics since COVID-19, patient needs/experiences with COVID-19, other observations, and dietitian characteristics. 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.

      Participants

      Dialysis dietitians who are actively practicing in the United States and belong to the Renal Practice Group within the Academy of Nutrition and Dietetics were invited by email to participate. We asked that the survey link not be forwarded by respondents, in order to calculate an accurate response rate. The survey was open for 2 weeks from December 7 to December 18, 2020. Two email invitations were sent; each one on Monday during the recruiting period. Entry into a drawing for one of five $50 Amazon.com gift cards was provided as an incentive to promote participation in this study. We received an exempt determination from the Case Western Reserve University Institutional Review Board.

      Statistical Analysis

      Mean and standard deviation, or number and percent, were used to describe the demographic and facility characteristics of participants and to describe patient needs and experiences related to the COVID-19 pandemic. Reponses to open-ended questions within the online survey were grouped into themes and then the frequency of each theme was counted. We used chi-squared tests to compare respondent stress and facility-level policies regarding eating/drinking and oral nutrition supplements (ONS) based on facility ownership type. Statistical analyses were conducted using SPSS version 26 (IBM, Armonk, NY).

      Results

      Of 2,106 emails sent, 241 individuals clicked on the survey invitation link, and 27 of these were ineligible. Of the 204 eligible participants, 13 did not answer any questions after the screening question, while 32 completed some but not all questions. Therefore, the final sample size was 159 complete responses plus 32 partial responses (total n = 191) and a response rate of 9%.
      Participant characteristics are listed in Table 1. Participants were evenly distributed among Fresenius, not-for-profit, DaVita, and other for-profit ownership (Table 1). Facilities were located across 39 US states (data not shown).
      Table 1Characteristics of Renal Dietitians and Dialysis Facilities
      CharacteristicNn (%) or Mean ± SD
      Years as registered dietitian15723.4 ± 13.9
      Years in renal nutrition15713.8 ± 12.5
      Years at current dialysis facility1559.2 ± 9.2
      Highest level of education completed158
       Bachelors83 (53%)
       Masters73 (46%)
       Doctoral2 (1%)
      Specialist certifications191
       None146 (76%)
       Certified Specialist in Renal Nutrition36 (19%)
       Certified Diabetes Care and Education Specialist6 (3%)
       Certified Nutrition Support Clinician3 (2%)
      Dialysis facility community characteristics156
       Urban62 (40%)
       Suburban58 (37%)
       Rural36 (23%)
      Dialysis facility characteristics157
       Freestanding123 (64%)
       Hospital-based28 (15%)
       Connected to a nursing home6 (3%)
      Dialysis facility ownership157
       Fresenius47 (30%)
       Not-for-profit46 (29%)
       DaVita Inc.36 (23%)
       Other for-profit28 (18%)
      SD, standard deviation.
      The majority of participants were working in the dialysis center (81%), primarily communicating with patients in person (87%) and had not experienced a change in paid hours (91%); a plurality had not experienced a change in patient census (39%) (Table 2). Respondents were using a variety of secondary methods to communicate with patients (Table 2), including postal mail and email (mentioned in the other write-in responses). Respondents were communicating with other team members both in person and remotely (Table 2).
      Table 2Work Characteristics of Renal Dietitians
      CharacteristicNn (%)
      Work location183
       Working from dialysis center149 (81%)
       Working a combination of in-center and remotely30 (16%)
       Working remotely from home4 (2%)
      Change in paid hours183
       No change166 (91%)
       Paid/scheduled hours increased9 (5%)
       Paid/scheduled hours decreased8 (4%)
      Primary method of patient interaction (limited to one response)183
       In person while patients in dialysis chair160 (87%)
       By phone while patients at home9 (5%)
       By video call while patients are home2 (1%)
       By phone while patients in dialysis chair2 (1%)
      Other methods used for patient interaction (multiple responses allowed)191
       By phone while patients are home113 (59%)
       In person while patients are in dialysis chair69 (36%)
       By video call while patients are home43 (23%)
       By phone while patients are in dialysis chair23 (12%)
       Other15 (8%)
      Time with patients (limited to one response)180
       I am spending about the same amount of time with patients102 (57%)
       I am spending less time with patients70 (39%)
       I am spending more time with patients8 (4%)
      Of those spending less time, why? (multiple responses allowed)70
       No official policy but I am trying to limit time with patients40 (57%)
       Other18 (26%)
       I feel rushed15 (21%)
       A policy about spending less time with patients at my center6 (9%)
      Of those spending more time, why? (multiple responses allowed)8
       Difficult to communicate through PPE6 (75%)
       Patients need more counseling/resources6 (75%)
       Other2 (25%)
      Interacting with team members in person191156 (82%)
      Interacting with other team members remotely19192 (48%)
      Have been asked to take on other responsibilities not related to dialysis dietitian role183103 (54%)
      Census change161
       No change63 (39%)
       Census has increased52 (32%)
       Census has decreased46 (24%)
      The majority of respondents (57%) reported no change in the amount of time they were spending with patients compared to pre-COVID-19 (Table 2). Of the 39% who reported spending less time with patients the most common reasons were trying to limit one’s own exposure by limiting time with patients (57%) (Table 2). Write-in responses for reasons for decreased patient time related to time consumed by donning personal protective equipment (PPE) and being asked to take on other 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 at the entrance (Table 2). DaVita and Fresenius dietitians were significantly more likely to report being asked to take on additional roles (72% and 79%, respectively) than non-profit and other for-profit dietitians (35% and 36%, respectively) (P < .001, data not shown).
      Prior to COVID-19, 39% of respondents had been completing Nutrition Focused Physical Exam or Subjective Global Assessment on their patients; of those participants 60% were completing Nutrition Focused Physical Exam/Subjective Global Assessment in December 2020 (data not shown).
      Use of all forms of PPE increased from pre-pandemic practices (Supplemental Table 1).Forty-two percent of respondents reported that their facility had experienced PPE shortages during the pandemic (data not shown).
      About 99.4% of respondents reported that their facility had a mask wearing policy during dialysis. This policy was generally well accepted by patients (Table 3). A majority of facilities prohibited eating and drinking in the dialysis chair as a result of COVID-19 and masking policies (62%). 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%). Respondents reported that patients were concerned about not being able to eat/drink on dialysis and were split between adhering and not adhering to the policy. Respondents reported in write-in comments that the no eating/drinking policy was particularly difficult for patients with dementia or diabetes. The plurality of respondents indicated that despite the eating/drinking prohibition that ONS was still provided during dialysis (48%; Table 3), some indicated in write-in responses that this varied based on the type of supplement—with concentrated protein liquids (e.g., LiquaCel®, Pro-Stat ®) being given during dialysis while bars or larger volume drinks were sent home.
      Table 3Masking and Eating Policies at Dialysis Facilities During COVID-19
      CharacteristicNn (%)
      Acceptance of masking policy160
       Generally accepting156 (98%)
       Generally resistant4 (3%)
      Eating and drinking policy159
       No eating/drinking because of COVID-1999 (63%)
       Eating/drinking allowed31 (20%)
       Prohibited eating/drinking prior29 (18%)
      Patient response to new eating/drinking prohibition (multiple responses allowed)99
       Patients are concerned about not eating/drinking46 (47%)
       Patients adhere to the no eating/drinking policy42 (42%)
       Patients do not adhere and eat/drink41 (41%)
       Patients do not mind not eating/drinking15 (15%)
       Other
      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.
      10 (10%)
      How has new eating/drinking prohibition impacted ONS protocol? (limited to one response)99
       ONS protocol goes on47 (48%)
       ONS is sent home39 (39%)
       Other10 (10%)
       No ONS pre-COVID-192 (2%)
       Stopped ONS protocol1 (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.
      The majority of respondents (52%) indicated that patients who test positive for COVID-19 are transferred to another designated facility, while 27% retained their usual patients even if positive (Table 4). A small number of respondents (8%) worked at facilities that received positive patients, and 6% were not aware of any patients testing positive from their facilities. Among those who reported patients from their facility had tested positive, 36.0% indicated that the nutrition care of positive patients varied from the care of other patients (Table 4). This care was described in write-in responses, with the most common themes being contact with positive patients via phone or video (47%). Another theme (36% of open-ended responses) was providing less care to positive patients—either because the dietitian only follows up after return to the usual unit, because the dietitian limits in-person contact, or because the dietitian relies on nursing to pass on nutrition information to COVID-19-positive patients. Eleven percent of write-in responses indicated that positive patients receive additional nutrition care.
      Table 4Nutrition Care of COVID-19 Patients
      CharacteristicNn (%)
      Where COVID-19-positive patients receive dialysis191
       COVID-19-positive patients remain at usual facility52 (27%)
       Receive positive patients from other facilities15 (8%)
       Usual patients who test positive are transferred to other facilities99 (52%)
       Not aware of any positive patients11 (6%)
      Confirmed positives treated at facility151
       1-544 (29%)
       6-1053 (35%)
       11-2030 (20%)
       >2024 (16%)
      Care of COVID-19-positive patients has varied from that of other patients15054 (36%)
      Twenty percent of respondents considered leaving their position or employer during COVID-19, evenly split between concern about COVID-19-related work stressors or worries (11%) and due to balancing working and home responsibilities (9%) (data not shown). The plurality of respondents admitted to stress from working in healthcare during COVID-19 and worry about becoming infected themselves (Table 5). However, they also mostly agreed that their employers had done as much as possible to keep them safe (74% agreed or strongly agreed) (Table 5). There were no differences in stress levels or consideration for leaving based on facility ownership type.
      Table 5COVID-19-Related Stressors Among Dialysis Dietitians
      COVID-19 Related StressornStrongly DisagreeDisagreeNeither Agree Nor DisagreeAgreeStrongly Agree
      I am currently very stressed as a healthcare professional working during COVID-1916311 (67%)28 (17%)34 (21%)66 (41%)24 (15%)
      I am currently very worried about becoming at work and/or bringing infection home to my family16113 (8%)28 (17%)27 (17%)68 (42%)25 (16%)
      My employer has done as much as possible to keep me safe during COVID-191624 (3%)17 (11%)21 (13%)73 (45%)47 (29%)
      Although 16% of respondents stated that patients had not verbalized any changes to their ability to access healthy affordable food during the pandemic, the majority of participants indicated that their patients were taking precautions such as having a family/friend grocery shop for them (69%) and going to the store less often (60%) (Supplemental Table 2). Just over a quarter of respondents indicated that affordability of food was a concern—patients using foodbanks/pantries and/or Supplemental Nutrition Assistance Program more frequently (31%), patients discussing food price increases (28%) or sharing that they have less money for food (28%) (Supplemental Table 2).
      Respondents reported relatively few changes in patient health behaviors and nutrition-related biomarkers (Table 6). Behaviors for which the majority of respondents observed a change were patients cooking at home (more often, 72%) and patients engaging in physical activity (less often, 64.8%) (Table 6). Biomarkers for which the majority of respondents observed an increase were serum phosphorus (60%) and interdialytic weight gain (51%) (Table 6). In general, respondents did not report changes in medication compliance among their patients (86%) (data not shown). Eighty-eight percent of respondents had noticed an increase in patient stress levels during COVID-19 (data not shown).
      Table 6Changes in Patient Health Behaviors and Biomarkers According to 191 Respondents to a Survey About US Renal Dietitian Job Responsibilities and Patient Needs During COVID-19 Pandemic
      Patient Health BehaviornLess OftenNo ChangeMore Often
      Choosing convenience foods (canned, frozen, boxed)1615 (3%)90 (56%)66 (41%)
      Cooking at home1612 (1%)43 (27%)116 (72%)
      Eating take out/fast food15958 (36%)64 (40%)39 (24%)
      Engaging in physical activity159103 (65%)56 (35%)0
      Skipping dialysis treatment1605 (3%)124 (78%)31 (19%)
      Staying for the entire dialysis treatment1599 (6%)148 (93%)2 (1%)
      Patient Nutrition-Related BiomarkersnDecreasedNo ChangeIncreased
      Serum potassium1613 (2%)123 (76%)35 (22%)
      Serum phosphorus1608 (5%)56 (35%)96 (60%)
      Serum sodium1588 (5%)139 (88%)11 (7%)
      Dry weight15610 (6%)94 (61%)52 (33%)
      Interdialytic weight gain1604 (3%)75 (47%)81 (51%)
      Serum albumin15748 (3%)95 (61%)14 (9%)
      Protein catabolic rate15117 (11%)124 (82%)11 (7%)
      The most common response category for each behavior or biomarker is in bold.
      One hundred twenty-two participants responded to an open-ended question regarding what changes they expected would remain after COVID-19. The most common theme from these responses was that additional PPE would stay (53%). Fourteen percent of responses indicated that telehealth would continue to be used, and 9.8% believed that they would still be able to work from home. Four percent of write-in responses indicated that they expected to maintain an increased caseload and 4% anticipated a continuation of the no eating/drinking policy.

      Discussion

      In this study, we describe the job responsibilities and modalities of care delivery among dialysis dietitians in the United States, as well as the nutrition needs of their patients, approximately 10 months into the COVID-19 pandemic. Although most respondents continue providing care in person, with additional PPE, reduction in nutrition care for COVID-19-positive patients was also reported. This is a major concern because infectious diseases such as COVID-19 can increase the risk of malnutrition.
      • Handu D.
      • Moloney L.
      • Rozga M.
      • Cheng F.W.
      Malnutrition care during the COVID-19 pandemic: considerations for registered dietitian Nutritionists.
      Multiple possible symptoms of COVID-19 such as shortness of breath, loss of sense of taste and/or smell, diarrhea, nausea and vomiting, fatigue/weakness also affect nutritional status and dietary intake.
      • Handu D.
      • Moloney L.
      • Rozga M.
      • Cheng F.W.
      Malnutrition care during the COVID-19 pandemic: considerations for registered dietitian Nutritionists.
      Dialysis dietitians must be aware of the additional barriers of achieving adequate dietary intake and heightened risk of malnutrition in COVID-19-positive dialysis patients. Recommendations for the nutrition care of COVID-19-positive patients in general include proactive prevention and treatment of malnutrition via adequate protein and energy intake, including the use of ONS, when necessary, and routine assessment of weight and nutritional status.
      • Handu D.
      • Moloney L.
      • Rozga M.
      • Cheng F.W.
      Malnutrition care during the COVID-19 pandemic: considerations for registered dietitian Nutritionists.
      Prior to the pandemic, eating during dialysis was becoming a more accepted practice in the United States,
      • Benner D.
      • Burgess M.
      • Stasios M.
      • et al.
      In-center nutrition practices of clinics within a large hemodialysis provider in the United States.
      supported by the publication of the 2018 International Society of Renal Nutrition and Metabolism consensus statement supporting intradialytic meals and/or ONS to improve nutritional status
      • Kistler B.M.
      • Benner D.
      • Burrowes J.D.
      • et al.
      Eating during hemodialysis treatment: a consensus statement from the International Society of Renal Nutrition and Metabolism.
      and data demonstrating reductions in mortality and hospitalizations with an intradialytic ONS protocol.
      • Benner D.
      • Brunelli S.M.
      • Brosch B.
      • Wheeler J.
      • Nissenson A.R.
      Effects of oral nutritional supplements on mortality, missed dialysis treatments, and nutritional markers in hemodialysis patients.
      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. Recent suggestions for eating during dialysis while centers have a universal masking policy include providing patients with a limited amount of time to eat their meal instead of allowing them to graze, drawing curtains between dialysis stations, providing patient with hand sanitizer to remove mask and clean hands prior to eating, providing additional PPE (e.g., protective eyewear) to staff to wear when in contact with an unmasked patient, having patient be seated in an upright position to reduce risk of choking, and disposing of food wrappers in a no-touch receptacle.
      • de Waal D.
      Re-evaluation of the in-center hemodialysis “No eating policy” during the COVID-19 pandemic.
      Given the increases in food insecurity in the general population as a result of COVID-19, we were surprised that these themes were not more common in the responses to our survey. It is possible that if dialysis patients are already receiving disability benefits as their primary source of income that the pandemic was less disruptive to their household budgets. However, other patients who newly experience food insecurity may feel shame and not admit this unless asked. Dialysis dietitians and other health professionals must be willing to raise these concerns in a compassionate manner to ensure that patients have access to benefits.
      Previous researchers who investigated the mental health effects of other epidemics (Ebola, SARS, MERS) have found that healthcare professionals face symptoms of anxiety, post-traumatic stress disorder, exhaustion, burnout, and depression in all stages of an outbreak.
      • Giorgi G.
      • Lecca L.I.
      • Alessio F.
      • et al.
      COVID-19-Related mental health effects in the workplace: a narrative review.
      Researchers have suggested that healthcare professionals will face work-related problems, depression, and anxiety during the COVID-19 pandemic.
      • Giorgi G.
      • Lecca L.I.
      • Alessio F.
      • et al.
      COVID-19-Related mental health effects in the workplace: a narrative review.
      In our study, the majority of respondents admitted to stress from working in healthcare during the COVID-19 pandemic, demonstrating that dialysis dietitians are not immune to these concerns. Even with the rollout of COVID-19 vaccines, the end of the pandemic in the United States is not yet in sight. The effects that working in healthcare during the pandemic can have on mental health should be addressed by healthcare professionals and/or their employers particularly given longer term concerns about burnout. Realistic workplace solutions for stress management in health providers include providing opportunities to speak with team members about how stress during the pandemic is affecting work, setting clear expectations with input from team members, and making mental health resources more accessible.
      • Centers for Disease Control and Prevention
      Employees: how to cope with job stress and build resilience during the COVID-19 pandemic. COVID.

      Limitations

      One limitation of our study is that participants may not be honest when responding to sensitive topics such as job satisfaction. The survey was anonymously completed to protect participants’ privacy and to encourage honest responses. Another limitation is that we asked dietitians to report on their observations of group trends regarding patient needs and behavior changes limiting comparability to other studies that have used individual data collected directly from patients.
      • Sharma S.V.
      • Chuang R.-J.
      • Rushing M.
      • et al.
      Social determinants of health-related needs during COVID-19 among low-income households with children.
      ,
      • Sousa H.
      • Ribeiro O.
      • Costa E.
      • et al.
      Being on hemodialysis during the COVID-19 outbreak: a mixed-methods’ study exploring the impacts on dialysis adequacy, analytical data, and patients’ experiences.
      Another limitation of our research study is that the language describing different types of PPE may have been unclear and misinterpreted by respondents. An unusually small percentage of respondents answered that they wore goggles prior to the pandemic. It seems possible that respondents understood this specifically as “goggles” rather than our more general meaning of “eye protection.”
      We exceeded our goal response rate of 8%, achieving a rate similar to that seen in most electronic surveys of dietitians,
      • Augustine M.B.
      • Swift K.M.
      • Harris S.R.
      • Anderson E.J.
      • Hand R.K.
      Integrative medicine: education, perceived knowledge, attitudes, and practice among academy of nutrition and dietetics members.
      ,
      • Dougherty C.M.
      • Burrowes J.D.
      • Hand R.K.
      Why registered dietitian nutritionists are not doing research—Perceptions, barriers, and participation in research from the academy's dietetics practice-based research network needs assessment survey.
      and reflecting the relatively low response rates among health professionals in general.
      • VanGeest J.
      • Johnson T.
      • Welch V.
      Methodologies for improving response rates in surveys of physicians: a systematic review.
      Evidence-based strategies for increasing response rate among health professionals were used: the recruitment message was sent from an organization with which the respondents have an affiliation, reminder messages/deadlines for participation, and incentives for participation
      • VanGeest J.
      • Johnson T.
      • Welch V.
      Methodologies for improving response rates in surveys of physicians: a systematic review.
      ,
      • Groves R.M.
      • Peytcheva E.
      The impact of nonresponse rates on nonresponse bias: a meta-analysis.
      (described above). When these strategies are used, response rate has not been demonstrated to be a good indicator of non-response bias
      • Groves R.M.
      • Peytcheva E.
      The impact of nonresponse rates on nonresponse bias: a meta-analysis.
      ; therefore we believe we are able to draw conclusions despite a low response rate.

      Next Steps

      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. The nutrition status of COVID-19-positive dialysis patients, and potential COVID-19 “long haulers” should also be monitored.

      Practical Application

      Dialysis dietitians should be aware that dialysis patients who are COVID-19-positive may be experiencing additional barriers to achieving adequate dietary intake and are at an increased risk for developing malnutrition. Dietitians must be proactive in the prevention and treatment of malnutrition through adequate protein and energy intake and the use of ONS, when necessary.
      Dietitians and dialysis centers should be vigilant in not allowing an eating/drinking ban to become permanent. Special precautions can be taken to allow intradialytic meals and ONS protocols while protecting patients and staff members from the spread of COVID-19-19.
      Dialysis dietitians are not immune from the mental health effects of working as a healthcare professional during the COVID-19-19 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.

      Acknowledgments

      The use of Research Electronic Data Capture (REDCap®) in this project was supported by the Clinical & Translational Science Collaborative of Cleveland which is funded by the National Institutes of Health, USA , National Center for Advancing Translational Science (NCATS) , Clinical and Translational Science Award (CTSA) grant, UL1TR002548 . The content is solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

      Credit Authorship Contribution Statement

      Rachael May: Conceptualization, Data curation, Methodology, Writing – original draft, Writing – review & editing. Ashwini R. Sehgal: Conceptualization, Methodology, Supervision, Writing – review & editing. Rosa K. Hand: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.

      References

        • Rozga M.
        • Handu D.
        • Kelley K.
        • et al.
        Telehealth during the COVID-19 pandemic: a cross-sectional survey of registered dietitian nutritionists.
        J Acad Nutr Diet. 2021; (In press)https://doi.org/10.1016/j.jand.2021.01.009
        • Karageorghis C.I.
        • Bird J.M.
        • Hutchinson J.C.
        • et al.
        Physical activity and mental well-being under COVID-19 lockdown: a cross-sectional multination study.
        BMC Public Health. 2021; 21: 988
        • Wolfson J.A.
        • Leung C.W.
        Food insecurity during COVID-19: an acute crisis with long-term health Implications.
        Am J Public Health. 2020; 110: 1763-1765
        • Sharma S.V.
        • Chuang R.-J.
        • Rushing M.
        • et al.
        Social determinants of health-related needs during COVID-19 among low-income households with children.
        Prev Chronic Dis. 2020; 17: E119
        • Sousa H.
        • Ribeiro O.
        • Costa E.
        • et al.
        Being on hemodialysis during the COVID-19 outbreak: a mixed-methods’ study exploring the impacts on dialysis adequacy, analytical data, and patients’ experiences.
        Semin Dial. 2021; 34: 66-76
        • Ikizler T.A.
        COVID-19 and dialysis units: what do we know now and what should we do?.
        Am J Kidney Dis. 2020; 76: 1-3https://doi.org/10.1053/j.ajkd.2020.03.008
        • Anand S.
        • Montez-Rath M.
        • Han J.
        • et al.
        Prevalence of SARS-CoV-2 antibodies in a large nationwide sample of patients on dialysis in the USA: a cross-sectional study.
        Lancet. 2020; 396: 1335-1344
        • Suri R.S.
        • Antonsen J.E.
        • Banks C.A.
        • et al.
        Management of Outpatient hemodialysis during the COVID-19 pandemic: recommendations from the Canadian society of nephrology COVID-19 rapid response team.
        Can J Kidney Health Dis. 2020; 7 (2054358120938564. https://doi.org/10.1177/2054358120938564)
        • Rincón A.
        • Moreso F.
        • López-Herradón A.
        • et al.
        The keys to control a COVID-19 outbreak in a haemodialysis unit.
        Clin Kidney J. 2020; 13: 542-549
        • Medicare and Medicaid Programs
        Conditions for coverage for end-stage renal disease facilities; final rule.
        • Hand R.K.
        • Albert J.M.
        • Sehgal A.R.
        Quantifying the time used for renal dietitian's responsibilities: a Pilot study.
        J Ren Nutr. 2019; 29: 416-427
        • Lew S.Q.
        • Wallace E.L.
        • Srivatana V.
        • et al.
        Telehealth for home dialysis in COVID-19 and beyond: a perspective from the American Society of Nephrology COVID-19 home dialysis subcommittee.
        Am J Kidney Dis. 2021; 77: 142-148
        • Cahan E.M.
        • Levine L.B.
        • Chin W.W.
        The Human touch — Addressing health care's workforce problem amid the pandemic.
        N Engl J Med. 2020; 383: e102
        • Adams J.G.
        • Walls R.M.
        Supporting the health care workforce during the COVID-19 Global epidemic.
        JAMA. 2020; 323: 1439-1440
        • Roberts J.K.
        Burnout in nephrology: implications on recruitment and the workforce.
        Clin J Am Soc Nephrol. 2018; 13: 328-330
        • Williams A.W.
        Addressing physician burnout: nephrologists, how safe are we?.
        Clin J Am Soc Nephrol. 2018; 13: 325-327
        • Sullivan C.
        • Leon J.B.
        • Sehgal A.R.
        Job Satisfaction among renal dietitians.
        J Ren Nutr. 2006; 16: 337-340
        • Handu D.
        • Moloney L.
        • Rozga M.
        • Cheng F.W.
        Malnutrition care during the COVID-19 pandemic: considerations for registered dietitian Nutritionists.
        J Acad Nutr Diet. 2021; 121: 979-987
        • Benner D.
        • Burgess M.
        • Stasios M.
        • et al.
        In-center nutrition practices of clinics within a large hemodialysis provider in the United States.
        Clin J Am Soc Nephrol. 2016; 11: 770-775
        • Kistler B.M.
        • Benner D.
        • Burrowes J.D.
        • et al.
        Eating during hemodialysis treatment: a consensus statement from the International Society of Renal Nutrition and Metabolism.
        J Ren Nutr. 2018; 28: 4-12
        • Benner D.
        • Brunelli S.M.
        • Brosch B.
        • Wheeler J.
        • Nissenson A.R.
        Effects of oral nutritional supplements on mortality, missed dialysis treatments, and nutritional markers in hemodialysis patients.
        J Ren Nutr. 2018; 28: 191-196
        • de Waal D.
        Re-evaluation of the in-center hemodialysis “No eating policy” during the COVID-19 pandemic.
        Ren Nutr Forum. 2020; 39: 9-12
        • Giorgi G.
        • Lecca L.I.
        • Alessio F.
        • et al.
        COVID-19-Related mental health effects in the workplace: a narrative review.
        Int J Environ Res Public Health. 2020; 17: 7857
        • Centers for Disease Control and Prevention
        Employees: how to cope with job stress and build resilience during the COVID-19 pandemic. COVID.
        • Augustine M.B.
        • Swift K.M.
        • Harris S.R.
        • Anderson E.J.
        • Hand R.K.
        Integrative medicine: education, perceived knowledge, attitudes, and practice among academy of nutrition and dietetics members.
        J Acad Nutr Diet. 2016; 116: 319-329
        • Dougherty C.M.
        • Burrowes J.D.
        • Hand R.K.
        Why registered dietitian nutritionists are not doing research—Perceptions, barriers, and participation in research from the academy's dietetics practice-based research network needs assessment survey.
        J Acad Nutr Diet. 2015; 115: 1001-1007
        • VanGeest J.
        • Johnson T.
        • Welch V.
        Methodologies for improving response rates in surveys of physicians: a systematic review.
        Eval Health Prof. 2007; 30: 303-321
        • Groves R.M.
        • Peytcheva E.
        The impact of nonresponse rates on nonresponse bias: a meta-analysis.
        Public Opin Q. 2008; 72: 167-189