Online Nutritional Management in Children with Congenital Heart Disease in the Context of COVID-19:A Prospective Study

Online Nutritional Management in Children with Congenital Heart Disease in the Context of COVID-19:A Prospective Study

ZHANG,Lufeng,LI,Yingjie

Chongqing Wudaokou General Hospital,Chongqing 404100,China

【Abstract】Objective:Children with congenital heart diseases(CHD)require multiple follow-ups at the hospital(including nutritional assessment),increasing the risk of nosocomial infection with the SARS-CoV-2.The study aimed to ex-amine the online control management model on the well-being of children with CHD during the COVID-19 pandemic.Methods:This prospective study was conducted in patients with CHD in the Department of Cardiology of Chengdu Women’s and Children’s Central Hospital between February and July 2020.Through the establishment of the NMT team and the adoption of the"Internet plus"approach,the families of the children with CHD were given professional counseling,intervention,guidance online,a service system of disease and psychological counseling,and self-assessment.The satisfaction survey on the family members of the CHD children were conducted using two microcodes of hospital standard satisfaction questionnaire.Results:There were 72 patients with CHD enrolled in this study.The online consultations prevented 18 children from visiting the hospital.Since they were always ac-companied by at least one relative,it effectively reduced at least 36 inpidu-als of being exposed to COVID-19.None of the 72 children suffered from delayed diagnosis and treatment or irregular long-term management due to the influence of the epidemic.The average satisfaction after the intervention was higher than before the intervention(98.3±2.8 vs.95.1±6.5,P=0.048).Conclusion:The online prevention and control management mode of the NMT team during the COVID-19 epidemic achieved a win-win situation of epidemic prevention and control and promoting the recovery of the children with CHD.

【Keywords】NMT;Novel coronavirus infection;Congenital heart disease;Online Man-agement model

1.Introduction

Thecoronavirusdisease

2019(COVID-19)isapandemicthathasmadeover 40 millioncasesand 1.1 million deathsgloballyasofOctober 18,2020[1].COVID-19 maybeasymptomatic,butmostpatientshavemildtomoderate symptoms[2,3],and some patients progress rapidly to severe or critical COVID-19[4].In those pa-tients,pneumonia,respiratory failure,and death may occur rapidly[4,5].Although the majority of symptomatic cases and deaths occur in older adults[2],the median age has been decreasing from May to August in some coun-tries[6].Nevertheless,all inpiduals are susceptible to COVID-19[7-10],and beside older people,other popula-tions susceptible to complications from COVID-19 include any inpidual with low immunity and comorbidities such as hypertension,diabetes,cardiovascular diseases,which may lead to adverse clinical outcomes and even increased mortality[2,11-15].

Children with congenital heart disease(CHD)belong to this group.CHD is a group of birth malformation in children,accounting for about 8‰-12‰of newborn babies[16].Children with CHD are prone to malnutrition due to the influence of their CHD[17].Long-term malnutrition increases the hospitalization frequency,surgical risk,and postoperative infection risks,and postoperative wound healing is delayed[18].

Nutrition is considered to play an important role in the comprehensive measures to prevent and treat corona-virus infection[19,20].The role of nutrition management in improving nutritional status and immunity,improv-ing clinical outcomes and quality of life,accelerating rehabilitation,and reducing the risk of recurrence should be highly valued,and nutrition management should be incorporated as a basic measure in the whole process of pre-vention,treatment and rehabilitation of COVID-19[9].

Children with CHD need regular outpatient follow-up ECG,cardiac ultrasound,nutritional assessment,and even long-term use of diuretics and cardiac stimulants.Children and their family members face a higher risk of SARS-CoV-2 infection and more anxiety than the general public due to repeated visits to the hospitals,which,in itself,is a risk factor for SARS-CoV-2 infection[7,8,21].The Nutritional Management Team(NMT)is a model of multidisciplinary collaboration completed during the COVID-19 epidemic and is designed to provide compre-hensive nutritional management to children with CHD.To lower the number of visits to the hospital,the NMT designed an online control management model to give nutritional counseling,intervention,and guidance to chil-dren with CHD and their families.The aim of this study is to examine the online control management model de-signed by the NMT on the well-being of children with CHD during the COVID-19 pandemic.

2.Methods

2.1 Subjects

This study was conducted in the Department of Cardiology of Chengdu Women’s and Children’s Central Hos-pital.From February to July 2020,all children with CHD diagnosed by cardiac color Doppler ultrasound were enrolled.

2.2 NMT intervention

Our department has established an NMT team with medical,nursing,nutrition,echocardiography,pharmacy,and psychology cooperation.The organizational structure is shown in Figure 1.The NMT management team is composed of the pision Director and the head nurse of the pediatric cardiology department.The work content and responsibilities include 1)formulate the work responsibilities and procedures of each group,and carry out whole-process control,2)unify the online training team's about COVID-19 knowledge,continuously update the training materials,and timely organize team members to learn the national,provincial,and municipal COVID-19 prevention and control management norms,3)nutritional risk screening and nutritional status assessment for pa-tients,4)develop inpidualized nutrition management plans for patients with nutritional risk and/or malnutrition and conduct standardized nutritional support treatment,5)quality control and efficacy monitoring for nutritional support treatment,6)collect internal opinions in real-time and optimize workflow,7)nutrition education and fol-low-up are conducted for the recovered and discharged patients,8)timely collating popular science materials,combing common questions and answers in epidemic consultation,and developing standardized templates,and 9)coordinate and open the green clinic.

Prevention and control group

The prevention and control group is from the pediatric cardiovascular internal medicine and is composed of two specialist nurses with a work experience of>10 years.A special consultation telephone is set up,and a trained nurse will give telephone consultation to children with CHD who are registered and followed in our department every day.The nurse inquiries about the epidemiological history and clinical symptoms of COVID-19 of the chil-dren and their families and recorded the information.Children or family members with epidemiological history and no clinical symptoms will be recorded in the Home Observer Follow-up Form and reported to the online ex-pertgroup

.Childrenorfamilymemberswithepidemiologicalhistoryandclinicalsymptomswillbereportedtoan onlineexpertgroupforfollow-up.Thechildrenandtheirfamiliesareguidedbytheonlinemedicaltreatmentpro-cessintheepidemicareaofourhospital,andtheconsultationtelephonenumberisgiven.COVID-19 givesfree consultationtotheDepartmentofChildren'sCardiovascularMedicine.Oneaimistoincreasetheawarenessof COVID-19 amongchildrenandtheirfamiliestoguidethemtoconductcorrectself-observationandhomeman-agement.

Theinformationofthechildrenrequiringoutpatientfollow-upvisitsduringtheepidemicperiodisrecorded,suchasmedicationadjustment,cardiaccolorultrasound,ECG,andotheroutpatientexaminations,inthe"Regis-trationFormoffollow-upvisitsforchildrenwithcongenitalheartdiseaseduringtheepidemicperiod"andsub-mittedtotheonlineexpertgroup.Thegroupalsocarriesouttheoutpatientfollow-upofchildrenintheepidemic areafordiseaseknowledge,homecare,andotherhealtheducation.Theinformationofthechildrenwhoneedspe-cialguidanceonmedicationisrecordedinthe"RegistrationFormofmedicationconsultationforchildrenwith congenitalheartdiseaseduringtheepidemicperiod"andreportedtothepharmacistgroup.Intheprocessof counseling,ifthenervousandanxiousfamilymembersfailtoachievegoodresultsafterpsychologicalcomfort,theirinformationisrecordedinthe"RegistrationFormofpsychologicalCounselingforfamilymembersofchil-drenwithcongenitalheartdiseaseduringtheepidemicperiod"andreportedtothepsychologicalintervention group.

Figure1.TheorganizationalstructureoftheNutritionalManagementTeam.

Onlineexpertgroup

Theonlineexpertgroupconsistsofthreepediatriccardiologists(twoassociatechiefphysiciansandonechief physician).Thefamilymembersofthesickchildcanconsultwiththeonlineexpertgroupofpediatriccardiovas-cularMedicinethroughthehospital'sInternetplatform.Withoutleavingtheirhome,theycanobtainthepreven-tionandtreatmentknowledgeofCOVID-19,professionalguidanceforhomepreventionandcontrol,anddiagno-sisandtreatmentofcommonchildhooddiseases.Theonlineexpertgrouptakesadvantageofitsownfragmented timetoconsultonline

.Theonlineexpertgroupconductsonlineconsultationaccordingtothe"RegistrationForm ofre-visitofchildrenwithcongenitalheartdiseaseduringtheepidemicperiod",communicateswiththefamily membersindetailtounderstandtheconditionandtreatmentofthechildren,makesonlinediagnosisandtreatment,adjuststhemedicationtreatmentplan,andcarriesoutdiseasepublicityandeducation.Thechildrenwhomustbe re-visitedon-siteareregisteredforanappointment,andtheappointmentinformationisreportedtothemanage-mentgroup.Paymentsforhealthcarearemadeonline.

Theonlineexpertgroupfollowshome-basedobserversbytelephoneonceaweekaccordingtothe"Home-basedobserverfollow-upTable,"includingtheheight,weight,temperature,foodintake,urinevolume,vomiting,activity,andspiritofthechildrenwithCHDandconducthome-basedobservationguidance.Theonline expertgrouprecommendsmedicaltreatmentforanonlinediagnosisofsuspectedCOVID-19 cases.Thepatientsand their families are conducted to the nearest COVID-19 screening facility for nucleic acid testing.The group guides the children and family to perform self-protection when going out for medical treatment.The telephone follow-ups are recorded.

Psychological intervention group

The psychological intervention group consists of one professional psychological consultant.According to the"Registration of psychological Consultation for family members of children with congenital heart disease during the epidemic period",the psychological intervention group assesses the psychological status of family members of children with CHD by using the self-assessment form of psychological status and carry out personalized profes-sional psychological counseling according to the parents'worry and anxiety once a week.It also carries out sci-ence popularization and education,popularizes knowledge,answers doubts,expedites information,and provides psychological support.

Pharmacist group

The pharmacist group is composed of one professional clinical pharmacist who provides telephone counseling according to the"children with congenital heart disease outbreak period medication consultation registration form"to the families of children two times a week and determines the medical situation according to the illness,drug effects,and side effects.

Nutrition group

The nutrition group is composed of one nutrition professor and one gastroenterologist,who provides nutrition knowledge support to the NMT team and provides personalized nutritional diet guidance to the families of the children during the epidemic period.Nutritional risk screening for children with CHD is performed using a screening tool for the risk of nutritional status and growth(STRONGkids)[22].The group performs nutritional status assessment(including weight,muscle status,routine hematuria,liver and kidney function,blood lipids,and blood glucose)for children at nutritional risk.According to the assessment results of the nutritional status,the group develops an inpidual nutritional support treatment plan.The groups performed quality control and effec-tive monitoring of nutritional support treatment,adjustment of the nutritional support treatment regimen,or ter-mination of nutritional support treatment[23,24].All long-term follow-up children with CHD are routinely mon-itored once a week for nutritional status indicators,metabolic indicators,and infection-related indicators,such as body weight,muscle status,hematuria routine,liver,and kidney function,blood lipid and blood glucose,etc.Family nutritional support is provided when necessary.

2.3 NMT model online control closed management

The NMT model is based on the Plan-Do-Check-Action(PDCA)cycle to check each encountered difficulty,collecting and combing problem reports after a unified management group,and form a closed-loop work inspec-tion,to provide rapid response and process optimization.The management team organizes and coordinates to deal with problems and constantly improves the team's overall cooperation ability and sense of cooperation.

2.4 Effect of NMT

Before and 1 week after consultation,the nurses conduct a satisfaction survey on the family members of the sick children using two microcodes of hospital standard satisfaction questionnaire.The satisfaction questionnaire of our hospital is evaluated from five aspects(medical service,nursing service,service attitude,health education,and hospital environment),with a total of 10 items.Each item is scored from 0 to 10 points,with 0 indicating ex-tremely dissatisfied and 10 indicating very satisfied.The satisfaction score is 0-100,with 0 representing extreme dissatisfaction.The higher the score,the better the patient satisfaction.

2.5 Statistical analysis

SPSS 17.0(SPSS Inc,Chicago,USA)was used for statistical analysis of the data.Continuous data are present-ed as means±standard deviations and were analyzed using Student’s t-test.P-values<0.05 are considered statis-tically significant.

3.Results

3.1 The risk of SARS-CoV-2 infection among children and their family members

The NMT team implemented the online prevention and control management in 72 children with CHD(58.3%female;mean age,1.2±0.5y)who were followed for one year since 2019.Eighteen on-site follow-up visits were canceled.Since one child is accompanied by at least one family member,the cancellation of the on-site follow-up visits in 18 cases avoided the risk of SARS-CoV-2 exposure in at least 36 inpiduals(Table 1).The green clinic was opened for 10 children who could not cancel the follow-up visits,and seamless patient management was im-plemented to improve the medical treatment efficiency,reduce the waiting time,and reduce the risk of nosocomial infection.

Table 1.Characteristics of the patients with CHD

3.2Standardizationofthelong-termmanagementofchildren

All72 childrenwerefollowedbytelephoneasrequiredbytheirlong-termmanagement.Theonlineexpert groupprovidedonlineassessment,diagnosis,andtreatment.Amongthe 18 casesthatcanceledtheiron-sitevisit,onlineconsultationwiththeexpertgrouponline,onlinenutritionalriskscreening,nutritionalriskassessmentof nutritionalstatuswasperformedforall 18 childrentodevelopinpidualizednutritionalsupporttreatmentand guidingmedicationanddisease.(Table 1)Agreenchannelwasopenedfor 10 childrenwhohadtovisiton-siteto ensurethesafetyofthetreatment.ThetreatmentplanwasdeterminedaccordingtotheresultsofECG,cardiac ultrasound,andnutritionalassessment.Aftertheon-sitefollow-upvisit,thepatientsreturnedhomeandwere managedastheotherchildren.Fourchildreninthepharmacistgroupweregivenmedicationguidance

.Duringthe epidemicperiod,noneofthe 72 childrensufferedfromdelayeddiagnosisandtreatmentorirregularlong-term managementdue to the influence of the epidemic.This ensured the treatment effect and drug safety of the children duringtheepidemicperiodandpromotedrehabilitation.

3.3Psychologicalcareduringtheepidemic

Duringthisperiod,psychologicalinterventionswerecarriedoutonthefamiliesof 11 children,whichalleviated orrelievedtheirpanic,tension,andanxiety,establishedapositiveattitude,andrationallyrespondedtotheepi-demic situation.

3.4Familymembers'satisfaction

Theaveragesatisfactionaftertheinterventionwashigherthanbeforetheintervention(98.3±2.8 vs.95.1±6.5,P=0.048,Table 2).

Table2.ComparisonofthesatisfactionofthefamiliesofthechildrenbeforeandaftertheonlinepreventionoftheNMTteam

4.Discussion

Children with CHD require multiple follow-ups at the hospital(including nutritional assessment),increasing the risk of nosocomial infection with the SARS-CoV-2.Therefore,in order to reduce their exposure to possible noso-comial infections,this study aimed to examine the online control management model designed by the NMT on the well-being of children with CHD during the COVID-19 pandemic.The results suggested that the online preven-tion and control management mode of the NMT team during the COVID-19 epidemic achieved a win-win situa-tion of epidemic prevention and control and promoted the recovery of the children with CHD.It is a new model of high-quality prevention and control service with low risk,low cost,and high efficiency under difficult epidemic situation.

AccordingtotherequirementsofChina'sNationalHealthCommissionduringthepandemic,itisnecessaryto givefullplaytotheadvantagesofInternetmedicalservicesandvigorouslydevelopInternetdiagnosisandtreat-mentservices[9].TheoutbreakperiodNMTonlinecontrolmodecombinedmedicalservicesandtheInternetto participateinonlineepidemicpreventionandcontrol,medical,nutritionassessment

,psychologicalcounseling,medicationguidance,openedthefast-track(“green”)channel,andstronglypromotetheInternetmedicalconsult-ingservices,allofwhichplayanimportantroleinCOVID-19 preventionandcontrolandallowingthechildren withCHDandtheirfamiliestoeffectivelyreceivenutritionalassessmentandprofessionalguidanceintime,re-ducethepersonnelgatheredtogether,andeffectivelyreducetheriskofcross-infectiontopreventthefurther spreadoftheepidemic.

Usingthismode,facetofacecontactisavoided,theriskofSARS-CoV-2 exposurecanbereduced,andthe safetyofchildren,familymembers,andmedicalstaffcanbeeffectivelyprotected.Ontheotherhand,itensures thestandardlong-termmanagementofchildrenwithCHDduringtheepidemicperiod,promotestheirrehabilita-tion,andensuresthesafetyofthechildren'slives.

Thesatisfactiondegreecanbeusedasaneffectivemeanstoevaluatemedicalactquality[25].Themanagement modeoftheNMT'sonlinepreventionandcontrolimprovedthesatisfactionofthefamiliesofthechildrenwith CHDandenabledthemedical,nursing,andotherprofessionalstoformamultidisciplinaryteam,whichisanew modelofprovidinghigh-qualityepidemicpreventionandcontrolservicesintegratingmedicaltreatment,nursing,nutrition,psychologyandpharmacyforthefamiliesofthechildren.

Theadvantagesofthismodelareasmallcapitalinvestment,reliesonthehospitalnetworkplatform,carriesout thepreventionandcontrolworkbymeansofonline/telephoneconsultationandinformatization,andhasstrong operability.Nevertheless,therearelimitationstothisstudy.Itwascarriedoutatasinglehospitalandinasmall groupofactivepatients.Therefore,theexportabilityandgeneralizabilityofthemodelareunknown.Inaddition,it ispossiblethatcomplianceisloweraftertheonlineconsultation,butthereisnomeanstoevaluatethis.

5.Conclusion

Nutritionmanagementplaysanimportantroleinthelong-termfollow-upofchildrenwithcongenitalheartdis-ease.TheestablishmentofanNMTandtheimplementationoftheNMTmanagementmodeofonlinecontrol onlineforchildrenwithCHDeffectivelyreducedtheriskofexposuretoSARS-CoV-2 ofchildrenandtheirfami-lies,withoutdecreasingtheservicesofferedtothepatientsandtheirfamily

.Thisnewmodelisawin-winscenario and has low risk,low cost,and high efficiencyforhigh-qualityservicesinthecontextoftheCOVID-19 epidemic.

Acknowledgments

The authors acknowledgetheinvaluablecontributionofthechildrenandtheirfamilies.

Competinginterests

Allauthorsdeclarethattheyhavenocompeting interests.

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