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Improving opportunities for food service and dietetics practice in hospitals and residential aged care facilities
Abstract
Aim: Food is a phenomenon that everyone has an opinion on because eating is a frequent, often social occurrence, and as such the importance of mealtimes can be undervalued in healthcare settings. Some staff may not share our concerns about suboptimal dietary intakes as they assume that nutritional status will improve as people feel better. However, the provision and consumption of an appealing and adequate diet is a critical aspect of holistic health care. This review examines the role of dietitians in food services to improve the situation.
Methods: A narrative review was formed with reference to the literature.
Results: Labelling food service departments as a ‘hotel service’ or a ‘non-clinical service’ does little to assist the perception of these services by others; to enhance the knowledge and skills needed by others about optimising dietary intake opportunities by the sick and elderly; or to enhance the communication that is needed between stakeholders about food and mealtimes. The issue of addressing malnutrition, reviewing and improving menus, mealtime environments, feeding assistance, communication between staff, and acknowledgement of the important care role of food service providers becomes even more relevant as the population ages and the demand for health care grows.
Conclusion: This narrative highlights that the importance of dietitians building links with food services, leading high-quality research, and improving the profile and recognition of food and mealtimes as integral to care, has never been greater.
... 14 Strong role models are essential to inspire future leaders and engage new dietitians in foodservice. 16 It has been suggested that additional advanced training programmes may be needed to build the individuals' confidence in their abilities to manage. 16 It was also highlighted by Cluskey et al. that dietitians may want to advance their skills in management, but have limited professional development opportunities. ...
... 16 It has been suggested that additional advanced training programmes may be needed to build the individuals' confidence in their abilities to manage. 16 It was also highlighted by Cluskey et al. that dietitians may want to advance their skills in management, but have limited professional development opportunities. 13 This presents an opportunity for those experienced in foodservice and nutrition management to develop novel development programmes. ...
... 30 Walton also argues that further evidence regarding cost-benefit and cost-effectiveness is essential to foodservice dietetics and that significant prospects exist for dietitians to extend career opportunities within foodservice departments of hospitals. 16 Acute care hospital research dominates the published foodservice literature, whilst gaps in the evidence, particularly in some clinical cohorts 31 , remain. ...
... A number of researchers have identified an inability to access this food and beverage packaging as a contributing factor for malnutrition in hospitals amongst older and or disabled people Manning, Harris et al., 2012;Schenker, 2003;Walton 2006Walton , 2012. Within this context of packed food service, the challenge is encouraging dietary intakes in older adults, who have lower appetites and are less able to discern taste and smell (Nohra 2015;Teo 2001). ...
... Energy dense snacks such as cheese portions are an important source of protein for older people, and have been used to encourage intake in malnourished older adults and those at risk of malnourishment Walton, 2012). However, we found that the packaging of this important item inhibited consumption in the 'at risk of malnutrition' group. ...
Food and beverage packaging is increasingly used in hospital food service provision. Previous research has identified that the packaging used in New South Wales hospitals can be difficult to open by older adults. As older adults experience high rates of malnutrition, it is important to understand the effects of packaging on actual consumption of food and fluids. The aim of this study was to explore the impact of hospital food and beverage packaging on dietary intakes of 62 independently living older people (65 years and over) in a university simulated hospital ward in NSW, Australia. Participants were allocated to either a breakfast and snack meal or a lunch and snack meal on two occasions one week apart. Meals were served in a shared ward environment and each participant experienced a 'sealed' and 'pre-opened' meal and snack condition. The nutritional status of participants was measured using the Mini Nutritional Assessment - Short Form (MNA®-SF) and intake was estimated through an aggregated plate waste method. Overall findings were not significant for dietary intakes and the 'sealed' versus 'pre-opened' conditions. However, for the seven participants classified by the MNA®-SF as 'at risk' of malnutrition, packaging impeded intake for breakfast (η2 = -0.34) and the high protein snack (cheese and biscuits) (η2 = -0.24) meals. This finding has implications for the provision of packaged high protein snacks (cheese portions) and breakfast meals for the older inpatient. Further research is required for nutritionally compromised and frail older people in the hospital environment to investigate the impact of packaging on food and beverage consumption in detail.
... Such evidence reveals the need for SLPs not only to communicate and collaborate with food services staff, but to support development of knowledge about dysphagia within food services. Walton (2012), in an article reviewing opportunities for food services to improve practices in hospitals and residential aged care facilities, likewise suggested that health professionals need to build their knowledge of food services and challenge their perceptions of Food Services as "'non-clinical"'. Indeed, the perception of food services as a non-clinical service may have contributed to Ross, Mudge, Young, and Banks' (2011) finding of a lack of clear "'ownership"' regarding the nutritional intake of older hospitalised patients, ultimately impacting health and well-being outcomes. ...
... Currently, the clinical staff who most commonly engage with food services are dietitians. However, a recent review of the role of dietitians in food services (Walton, 2012) advocated for more health care professionals to work with food services, noting that "it is imperative the health care professionals of today and tomorrow have more than a common interest in food and mealtimes" (p. 224). ...
Journal of Clinical Practice in Speech-Language Pathology (19,2)
Speech-Language Pathologists (SLPs) often work with Food Services when managing issues related to texture modified diets and fluids.
To date, there is limited published evidence about the role of SLPs in Food Services. The project aimed to describe:
•The prevalence and practices of SLPs working in ‘dedicated’* Food Services roles;
•The nature of Food Services tasks undertaken by SLPs within existing general clinical roles and;
•SLP’s perceptions of an existing or hypothetical dedicated SLP role in Food Services
... A number of studies support the importance of collaborative work and a multidisciplinary approach. A holistic nutritional management of aged care residents [10,11] is a key message in the Maggie Beer Foundation (MBF) mission statement. The MBF has created a program entitled 'Creating an Appetite for Life', through which they hope to celebrate, empower and upskill cooks and chefs working in RAC. ...
... Författarna lyfter att kökspersonal som vårdpersonal behöver mer kunskaper kring hur mediciner kan påverka äldres smakupplevelser av maten. Walton (2012) skriver att det är dags att maten ses som medicin och att måltider är en del av en holistisk vård. Walton menar att vårdpersonal behöver se nutritionen och måltiden som viktig i relation till patienters behandling. ...
... In a study on perceived barriers for improving foodservices for older adults, Walton discusses a need for both clinical dietitians and foodservice managers (the latter comparable to foodservice dietitians in Sweden), due to their different roles. 31 In the present study, however, only 20% of all municipalities had access to a clinical/community dietitian showing a significant decline from 2006. This development raises concerns, because these key actors are needed to optimise the nutritional status of older adults. ...
Aim:
The aim was to explore the outcome, on a local level, of steering, organisation and practices of elderly care foodservice by Swedish municipalities, and changes relative to national actions.
Methods:
A survey using a web-based questionnaire about elderly care foodservice targeting all Swedish municipalities (n = 290) was conducted in 2006 and 2013/2014. The questionnaire included the topics: organisation of foodservice, its practice in elderly care and steering devices such as guidelines and policies. Based on the share of a rural population, municipalities were divided into groups: rural (≥50%), urban (<50%) and city (≤20%).
Results:
The response rate from municipalities was 80% in 2006 and 56% in 2013/2014; 45% participated in both surveys. The results showed increased use of local food policies (P = 0.03) and meal choice (P < 0.001), while access to clinical/community dietitians declined (P = 0.01) between the surveys. In home-help services, daily delivered cook-serve meals declined (P < 0.001) and chilled meals delivered three times a week increased (P = 0.002) between the surveys. City municipalities used private foodservice organisations the most (P < 0.001), and reported reduced use of cook-serve systems in favour of chilled. In rural municipalities, the use of public providers (98%) and a cook-serve system (94%) were firmly established. Urban municipalities were placed between the other groups.
Conclusions:
National actions such as soft governance and benchmarking appear largely to determine local level outcomes. However, conditions for adapting these measures vary between municipality groups. While efficiency enhancing trends were prominent, questions remain whether national actions should be expanded beyond performance to also examine their consequences.
... Sound ergonomic design principles dictate that products should be accessible to 90% of the population and hence in the case of hospital food and beverage packaging, this includes the aged, ill, frail and disabled. Although recent research has reported concerns regarding the increasing use of food and beverage packaging in Australian hospitals (Walton, 2012;Walton et al., 2006;Wilton et al., 2004), few studies have examined the issues related to food and beverage packaging for hospitalised patients. Wilton et al. (2004) in an observational study found that patients were required to open between five and nineteen items at each meal; and that 31% of these patients had difficulty opening the items. ...
Aim:
Hospital foodservices provide an important opportunity to deliver valuable dietary support to patients, address hospital-acquired malnutrition risk and enhance patient satisfaction. Modifying the meal ordering process through the adoption of technology may actively engage patients in the process and provide an opportunity to influence patient and organisational outcomes. This systematic review was undertaken to evaluate the impact of electronic bedside meal ordering systems in hospitals on patient dietary intake, patient satisfaction, plate waste and costs.
Methods:
A systematic search following PRISMA guidelines was conducted across MEDLINE, CINAHL, EMBASE and Web of Science for randomised controlled trials and observational studies comparing the effect of electronic bedside meal ordering systems with traditional menus on dietary intake, patient satisfaction, plate waste and cost. The quality of included studies was assessed using the Quality Criteria Checklist for Primary Research tool.
Results:
Five studies involving 720 patients were included. Given the heterogeneity of the included studies, the results were narratively synthesised. Electronic bedside meal ordering systems positively impacted patient dietary intake, patient satisfaction, plate waste and costs compared with traditional menus.
Conclusions:
Despite the increase in healthcare foodservices adopting digital health solutions, there is limited research specifically measuring the impact of electronic bedside meal ordering systems on patient and organisational outcomes. This study highlights potential benefits of electronic bedside meal ordering systems for hospitals using traditional paper menu systems, while also identifying the need for continued research to generate evidence to understand the impact of this change and inform future successful innovations.
Aim
The present study describes the impact of a novel education program for food service staff from Australian aged care facilities (ACF) to facilitate improvements in food service practices. The purpose was to explore; (i) the impact of the intervention (ii) barriers and facilitators of the program from food service providers’ perspectives and (iii) make program planning and practice recommendations.
Methods
Participants completed pre‐ and post‐program questionnaires, attended two focus groups on program process and impact and 4 months later reported through individual interviews on changes they had implemented. Results were triangulated between the questionnaires, focus groups and interviews and impacts and outcomes identified through directed content analysis.
Results
Thirty senior‐level chefs and a cook participated from 27 ACF from Victoria, Australia. Participation impacted on the menu, dining experiences and food service practices. All of the participants were enacting changes in their workplace 4 months later as change agents. A focus on skilling the participants as ‘change agents’, brokering ongoing peer‐support and the celebrity and/or expert status of the facilitators were attributed to the success of the intervention.
Conclusions
This novel intervention empowered Victorian food service providers to make positive changes in ACF. Further research is required to measure if these self‐reported changes are sustainable and relevant to other facilities and to establish the effect on food experience, satisfaction and well‐being of residents.
Background:
Hospitalised and community dwelling older people (aged 65 years and over) have difficulties opening certain food and beverage items (e.g. cheese portions and tetra packs) served in public hospitals. Previously, the role of hand strength on successful pack opening has been explored in a seated position. However, because many people in hospital eat in bed, the present laboratory study examined the differences between participants opening a selection of products in a hospital bed and a chair.
Methods:
The present study used a qualitative method (satisfaction) and quantitative methods (grip and pinch strength, dexterity, time and attempts) in two conditions (bed; chair) in a sample of well older community dwelling adults (n = 34). Packs tested included foil sealed thickened pudding, foil sealed thickened water, tetra pack, dessert, custard, jam, cereal, honey sachet and cheese portions.
Results:
Honey sachets, cheese portions, foil sealed thickened pudding and tetra packs were the most difficult packs to open, with 15% of cheese portions unable to be opened in either the bed or chair posture. Although grip strength was consistent for each posture, pinch grips and dexterity were adversely affected by the bed posture. Lying in a hospital bed required greater pinch strength and dexterity to open packs.
Conclusions:
Eating in a seated position when in hospital has been shown to improve intake. The present study demonstrates that eating in a seated posture is also advantageous for opening the food and beverage packs used in the NSW hospital food service and supports the notion that patients should sit to eat in hospital.
Food is increasingly a packaged commodity, both in the community and in institutionalised settings such as hospitals, where many older people are malnourished. Previous research with patients aged over 65 years in NSW public hospitals identified difficulties opening milk, water, juices, cereal and tetra packs. The aim of this paper was to assess the ability of well older people living in the community to open food and beverage items routinely used in NSW hospitals in order to gain further insights into the older person/pack interaction and the role of hand and finger strength in pack opening. A sample of 40 older people in good health aged over 65 years from 3 community settings participated in the study. The attempts at pack opening were observed, the time taken to open the pack was measured and the correlation between grip and pinch strengths with opening times was determined. Tetra packs, water bottles, cereal, fruit cups, desserts, biscuits and cheese portions appeared to be the most difficult food products to open. Ten percent of the sample could not open the water bottles and 39% could not open cheese portions. The results were consistent with the previous research involving hospitalised older adults, adding emphasis to the conclusion that food and beverage packaging can be a potential barrier to adequate nutrition when particular types of packaged products are used in hospitals or the community. The ageing population is rapidly becoming a larger and more important group to consider in the provision of goods and services. Designers, manufacturers and providers of food and beverage products need to consider the needs and abilities of these older consumers to ensure good 'openability' and promote adequate nutritional intakes.
Objective: To determine the prevalence of malnutrition in a population of elderly hospitalised patients and to explore health professionals' perceptions and awareness of signs and risks of malnutrition and treatment options available.
Subjects and design: One hundred elderly patients and 57 health professionals from medical wards of a tertiary teaching hospital. Quantitative and qualitative study design using a validated malnutrition assessment tool (Mini Nutritional Assessment) and researcher‐designed questionnaire to assess health professionals' knowledge of nutrition risk factors.
Main outcome measures: Mini Nutritional Assessment score, nutrition risk category and themes in health professionals' knowledge and awareness of malnutrition and its risk factors.
Results: Thirty per cent of patients were identified as malnourished while 61% were at risk of malnutrition. Documentation by health professionals of two major risk factors for malnutrition—recent loss of weight and appetite—were poor with only 19% and 53% of patients with actual loss of weight or appetite, respectively, identified by staff and only 7% and 9% of these patients, respectively, referred for dietetic assessment. While health professionals' knowledge of important medical risk factors for malnutrition was good, their knowledge of malnutrition risk factors such as recent loss of weight and loss of appetite was poor. Medical staff focused on biochemical factors when assessing nutrition status, while nursing staff focused on skin integrity and turgor.
Conclusion: Malnutrition in elderly hospitalised patients remains a significant problem with low rates of recognition and referral by medical and nursing staff. Considerable scope exists to develop training and education tools and to implement an appropriate nutrition screening policy to improve referral rates to dietitians.
Background/objectives
Routine nutrition screening is recommended for all older patients admitted to hospital however data on the prevalence of malnutrition in rehabilitation settings is sparse. This study assessed the nutritional status of older patients admitted to rehabilitation hospitals over a 5 year period and described the association between nutritional status and length of hospital stay (LOS) in this context. The usefulness of a recently revised version of the shortened MNA (MNA-SF) was also investigated.
Methods
A retrospective analysis was conducted of patients aged 65 + y admitted to two rehabilitation hospitals in New South Wales, Australia between 1st March 2003–30th June 2004, and 11th January 2005–10th December 2008. Nutritional status was determined on admission by trained dieitians using the full MNA instrument and the MNA-SF. Information on diagnosis-related grouping and length of stay (LOS) was obtained.
Results
Data was available for 2076 patients with a mean age of 80.6 (27.7) y. Thirty-three percent and 51.5 % of patients were classified as malnourished and at nutritional risk, respectively. Controlling for date of admission and diagnosis related grouping, LOS was higher in malnourished and at risk groups compared to their well nourished peers (P<0.001) by 18.5 and 12.4 days, respectively. MNA-SF demonstrated high sensitivity but relatively low specificity against the full MNA.
Conclusion
The majority of older patients in the rehabilitation setting are nutritionally compromised which adversely influences LOS. In order to encourage more widespread screening, the MNA-SF may be able to replace the full MNA.
The prevalence of malnutrition and its predictive value for the incidence of complications were determined in 155 patients hospitalized for internal or gastrointestinal diseases. At admission, 45% of the patients were malnourished according to the Subjective Global Assessment (physical examination plus questionnaire), 57% according to the Nutritional Risk Index [(1.5 x albumin) + (41.7 x present/usual weight)], and 62% according to the Maastricht Index [(20.68 - (0.24 x albumin) - (19.21 x transthyretin (prealbumin) - (1.86 x lymphocytes) - (0 04 x ideal weight)]. Crude odds ratios for the incidence of any complication in malnourished compared with well-nourished patients during hospitalization were 2.7 (95% CI: 1.4, 5.3) for the Subjective Global Assessment, 2.8 (1.5, 5.5) for the Nutritional Risk Index, and 3.1 (1.5, 6.4) for the Maastricht Index. Odds ratios were reduced to 1.7 (0.8, 3.6), 1.6 (0.7, 3.3), and 2.4 (1.1, 5.4), respectively, after a multivariate analysis that included disease category and disease severity. Because the confounding factors adjusted for are not only a measure of the severity of the disease but may also be influenced by malnutrition itself, the actual risk for complications due to malnutrition could be higher than the adjusted odds ratios. In conclusion, malnutrition was frequent in patients with gastrointestinal disease and other internal diseases at the time of admission. The severity of malnutrition in the patients predicted the occurrence of complications during their hospital stay and this association was not completely explained by confounding factors.
Numerous studies have identified strong correlations between the severity of nutritional deficits and an increased risk of subsequent morbid events among the hospitalized elderly, but whether inadequate nutrient intake during hospitalization contributes to such nutritional deficits or the risk of adverse outcomes is not known.
To identify the distribution of average daily nutrient intake among the nonterminally ill hospitalized elderly, ascertain what factors contribute to persistently low intakes, and determine whether the adequacy of nutrient intake correlates with the risk of mortality.
Prospective cohort study conducted from 1994 to 1997.
University-affiliated Department of Veterans Affairs hospital.
A total of 497 patients 65 years or older (mean [SD] age, 74 [6] years; 97% male; 86% white) with a length of stay of 4 days or more.
Daily in-hospital nutrient intake, in-hospital mortality, and 90-day mortality.
A total of 102 patients (21%) had an average daily in-hospital nutrient intake of less than 50% of their calculated maintenance energy requirements. Admission illness severity, average length of stay, and admission albumin and prealbumin levels for this low nutrient group did not differ significantly from those of the remaining patients. However, the low nutrient group had lower mean (SD) discharge serum total cholesterol (154 [44] mg/dL [4 [1.1] mmol/L] vs 173 [42] mg/dL [4.5 [1.1] mmol/L]; P=.001), albumin (29.1 [6.7] vs 33.2 [6.1] g/L, P=.001), and prealbumin (162 [69] vs 205 [68] mg/L; P=.001) concentrations and a higher rate of in-hospital mortality (relative risk, 8.0; 95% confidence interval, 2.8-22.6) and 90-day mortality (relative risk, 2.9; 95% confidence interval, 1.4-6.1). Contributing to the problem of inadequate nutrient intake, patients were frequently ordered to have nothing by mouth and were not fed by another route. Neither canned supplements nor nutritional support were used effectively.
Throughout their hospitalization, many elderly patients were maintained on nutrient intakes far less than their estimated maintenance energy requirements, which may contribute to an increased risk of mortality. Given the difficulties reversing established nutritional deficits in the elderly, greater efforts should be made to prevent the development of such deficits during hospitalization.
This study was conducted to evaluate the ability of AN-DRG version 3.1 to predict variation in patients' length of stay in hospital (LOS) and identify other factors that can influence the LOS by using routinely collected hospital morbidity data. A total of 18 DRGs that comprised 4,589 episodes were analysed. Multiple regression was used to model length of stay as a function of a number of independent variables. Overall only 37.6% of variation in mean length of stay could be explained. DRGs predicted 30% of the total variation. Other factors such as age, payment classification, source of referral, specialty of doctor, and ethnic group also influenced patient length of stay. It was concluded that the limited explanation was a consequence of a lack of a better indicator of severity within DRGs.
In 1999 the Council of Europe decided to collect information regarding Nutrition programmes in hospitals and for this purpose a network consisting of national experts from eight of the Partial Agreement member states was established. The aim was to review the current practice in Europe regarding hospital food provision, to highlight deficiencies and to issue guidelines to improve the nutritional care and support of hospitalized patients. Five major problems seemed to be common in this context: 1) lack of clearly defined responsibilities; 2) lack of sufficient education; 3) lack of influence of the patients; 4) lack of co-operation among all staff groups; and 5) lack of involvement from the hospital management. To solve the problems highlighted, a combined 'team-effort' is needed from national authorities and all staff involved in the nutritional care and support, including hospital managers.
Shortened hospital average length of stay (ALOS) has been used to justify rationalisation of some services, but, by definition, some patients stay for longer than the average. The objective of this study was to explore lengths of stay and proportions of hospital occupied bed-days (OBDs) of those admitted for longer time periods to inform service planning.
The proportion and ALOS of overnight separations at an Australian tertiary hospital were assessed for admissions of up to 4 days and 4 days or more. This was repeated for 7, 14 and 28 days. The proportion of OBD's for each time period was determined.
While the proportion of total hospital patients staying for 4, 7, 14 and 28 days or more is relatively small (21.9%, 13.5%, 6.2%, 2.6%, respectively), they represent a large proportion of OBD's (74.9%, 67.2%, 50.8%, 34.2%) with an ALOS of 14.0, 20.3, 33.7, and 54.4 days, respectively. The majority of long-stay patients were in acute care.
Substantial proportions of OBD's are due to patients admitted for time periods far greater than reflected by ALOS. Hospitals need to rethink how to optimally accommodate the nutrition and food requirements of the large patient numbers admitted for longer time periods, many of whom are at increased risk of malnutrition.
Provision of adequate nutrition is recognized as essential, yet malnutrition continues to be reported in patients admitted to hospital. The effects of malnutrition in hospital patients have been well documented; however, most work relating to nutritional management has been produced by members of Nutrition Support Teams, nurse specialists and interested clinicians, whilst the majority of hospitals are still without such specialist posts. This study used two data collection methods to gain information about the attitudes, nutritional knowledge base and nutrition-related nursing care in a large trust hospital in the South of England. A survey of care plans for documentation of nutrition-related nursing activities, carried out on the day of discharge for all patients from five wards over a period of a fortnight (totalling 141 sets of documentation), was followed by a questionnaire to all qualified nurses on these and a further four wards (110 nurses). Results demonstrated that nurses generally felt that nutritional assessment was primarily their responsibility. Whilst there was evidence of knowledgeable and proactive nursing care, it also appeared that there were fairly widespread deficiencies in the knowledge, communication and co-ordination required to ensure consistent good practice.
Aim: The study aims to highlight barriers and feasible opportunities to enhance nutrition support of elderly, long-stay patients in Australian hospitals.
Methods: A total of 218 dietitians, nurse unit managers and food service managers from medical and rehabilitation wards of 184 hospitals completed a web-based survey about current practices, perceived barriers and priority opportunities to enhance nutrition support in their context.
Results: Cook-fresh food was the most commonly reported food-service system (50%). Eighty-eight percent still used paper menus and one- or two-week cycles were the most common menu cycle lengths. Lack of choice due to special diet, boredom arising from the length of stay, a lack of feeding assistance, limited variety and inadequate flexibility of food service were the key barriers identified. Food fortification, assistance with packaging, additional feeding assistance by nurses, non-nursing feeding assistance and further nutrition assessment were key priorities for improvement.
Conclusion: A ‘toolbox’ of strategies is needed as no one intervention will improve nutrition support of all patients. Further practice-based outcomes and cost-benefit studies are needed to enhance support and advocacy for feasible food service interventions in the future.
Plate waste in hospitals refers to the served food that remains uneaten by patients. High levels of plate waste contribute to malnutrition-related complications in hospital, and there are also financial and environmental costs. Plate waste is typically measured by weighing food or by visual estimation of the amount of food remaining on the plate, with results presented as the percentage by weight of the served food, or by calculating the protein, energy or monetary value of the waste. Results from 32 studies in hospitals show a median plate waste of 30% by weight (range: 6–65%), much higher than in other foodservice settings. Levels are lower in hospitals using a bulk food delivery system compared to plated meal delivery. Reasons for these high levels can relate to the clinical condition of patients, food and menu issues (such as poor food quality, inappropriate portion sizes, and limited menu choice), service issues (including difficulty accessing food and complex ordering systems), and environmental factors (such as inappropriate meal times, interruptions, and unpleasant ward surroundings). Strategies to minimize waste include reduced portion sizes with food fortification, bulk meal delivery system, feeding assistance, provision of dining rooms, and protected meal times.
While there is considerable anecdotal evidence and some research indicating poor nutritional intake and high levels of food wastage in hospitals, there have been no studies relating these issues to the catering system used. The overall purpose of this study was, therefore, to measure food wastage and nutritional intake in selected hospital catering systems. Data were collected from three types of ward (elderly, medical and surgical) in four hospitals (nine wards), two in London and two in Southern England. Three wards used food cooked mainly in the hospital kitchen, six used cook-chill and cook-freeze dishes bought in ready prepared. Five of the wards used a bulk system where food is transported to the ward and plated, in the others, food is plated in the hospital kitchen then transported to the ward. Food sent to the ward, served to patients, and that which remained uneaten or left on the service trolley was weighed for a minimum of 24 hours in each ward; 966 patient-meal-days. This data enabled food wastage and nutritional intake to be calculated. Results indicate that food wastage was lower at the breakfast meal, than the midday and evening meal, 23.10 per cent, 39.99 per cent and 42.35 per cent, respectively; female wastage was higher than male, 33.91 per cent and 27.26 per cent, respectively; wastage was higher where food was plated in wards rather than in the kitchen, 57.75 per cent and 35.28 per cent, respectively; and wastage was higher where food was purchased-in ready prepared, rather than prime cooked in the hospital kitchen. Nutritional intake was calculated for five wards and in all, energy intake was below the recommendations, the highest deficit being 58 per cent. Deficiencies were also noted for other nutrients.
Aim: Up to 60% of older medical patients are malnourished with further decline during hospital stay. There is limited evidence for effective nutrition intervention. Staff focus groups were conducted to improve understanding of potential contextual and cultural barriers to feeding older adults in hospital.
Methods: Three focus groups involved 22 staff working on the acute medical wards of a large tertiary teaching hospital. Staff disciplines were nursing, dietetics, speech pathology, occupational therapy, physiotherapy, pharmacy. A semistructured topic guide was used by the same facilitator to prompt discussions on hospital nutrition care including barriers. Focus groups were tape-recorded, transcribed and analysed thematically.
Results: All staff recognised malnutrition to be an important problem in older patients during hospital stay and identified patient-level barriers to nutrition care such as non-compliance to feeding plans and hospital-level barriers including nursing staff shortages. Differences between disciplines revealed a lack of a coordinated approach, including poor knowledge of nutrition care processes, poor interdisciplinary communication, and a lack of a sense of shared responsibility/coordinated approach to nutrition care. All staff talked about competing activities at meal times and felt disempowered to prioritise nutrition in the acute medical setting. Staff agreed education and ‘extra hands’ would address most barriers but did not consider organisational change.
Conclusions: Redesigning the model of care to reprioritise meal-time activities and redefine multidisciplinary roles and responsibilities would support coordinated nutrition care. However, effectiveness may also depend on hospital-wide leadership and support to empower staff and increase accountability within a team-led approach.
Objective: To observe patients at meal times in order to determine the type and amount of feeding assistance required by hospitalised elderly patients and the adequacy of assistance nursing staff provide to patients.
Methods: The study was an observational study. Patients admitted to the ward were observed over a one-week period encompassing all meals (breakfast, lunch, dinner and snacks) served on a 14-day menu cycle.
Subjects: A total of 46 hospitalised elderly patients with mean age 86.5 ± 4.8 years admitted to the ward.
Setting: The study was undertaken in a general teaching hospital geriatric ward in Sydney.
Results: A high percentage of patients required some assistance with feeding at meals (70%, n = 32). The partially dependent patients had their needs basically fulfilled by ward staff. However, of the nine totally dependent patients, three were observed lacking any assistance (33%). The amount of assistance time from nursing staff was found shorter than that from non-nursing staff, 123 and 137 minutes, respectively. Nursing assistants were the main providers of assisted eating in the ward. However, little attention and time were given to that task by registered nurses.
Discussion: Provision of assisted eating by nursing staff presents many problems. More than 40% of hospital food was wasted and patients' recommended intakes for preserving health were not met. Hospital feeding policies and staff arrangements therefore need reviewing.
Conclusions: Although assisting patients who are unable to feed themselves is a time-consuming process, it is a vital and necessary part of nursing care.
Objectives:
To identify predictors and consequences of nutritional risk, as determined by the Mini Nutritional Assessment (MNA), in older recipients of domiciliary care services living at home.
Design:
Baseline analysis of subject characteristics with low MNA scores (<24) and follow-up of the consequences of these low scores.
Setting:
South Australia.
Participants:
Two hundred fifty domiciliary care clients (aged 67-99, 173 women).
Measurements:
Baseline history and nutritional status were determined. Information about hospitalization was obtained at follow-up 12 months later.
Intervention:
Letters suggesting nutritional intervention were sent to general practitioners of subjects not well nourished.
Results:
At baseline, 56.8% were well nourished, 38.4% were at risk of malnutrition, and 4.8% were malnourished (43.2% not well nourished). Independent predictors of low MNA scores (<24) were living alone, and the physical and mental component scales of the 36-item Short Form Health Survey. Follow-up information was obtained for 240 subjects (96%). In the ensuing year not well-nourished subjects were more likely than well-nourished subjects to have been admitted to the hospital (risk ratio (RR) = 1.51, 95% confidence interval (CI) = 1.07-2.14), have two or more emergency hospital admissions (RR = 2.96, 95% CI = 1.15-7.59), spend more than 4 weeks in the hospital (RR = 3.22, 95% CI = 1.29-8.07), fall (RR = 1.65, 95% CI = 1.13-2.41), and report weight loss (RR = 2.63, 95% CI = 1.67-4.15).
Conclusion:
The MNA identified a large number of subjects with impaired nutrition who did significantly worse than well-nourished subjects during the following year. Studies are needed to determine whether nutritional or other interventions in people with low MNA scores can improve clinical outcomes.
There is a nutritional component to most illnesses (whether poor nutrition leads to disease or disease adversely affects nutritional status) and their treatment, often involving all the health care professions. Undernutrition can adversely affect every system of the body such as the muscular system (resulting in fatigue, lethargy and decreased peripheral and respiratory muscle strength), the immune system (predisposing to and delaying recovery from infection) and psycho-social function (causing anxiety, depression and self-neglect).
Objectives: To determine the prevalence of malnutrition and whether the malnourished participants were being identified and documented as malnourished. To evaluate the impact of poor documentation on financial reimbursement to the hospital.
Subjects: Three hundred and twenty-four inpatients from a total of 690 randomly selected patients consented to participate in the study.
Design and setting: Subjective Global Assessment (SGA) was used to assess the nutritional status of inpatients. There were 1906 patients were admitted over a three-month period. Of these, 1860 were eligible and 690 were randomly selected from computer generated ward lists. The referral rate for nutrition intervention of malnourished participants was determined by viewing the patient medical records retrospectively. The Australian National Diagnostic Related Group (AN-DRG) of the malnourished subjects, not documented in the medical record as malnourished, were redetermined with the addition of the malnutrition code. The potential shortfall in financial reimbursement to the hospital was calculated by subtracting the average costing based on original AN-DRGs from the average costing based on the revised AN-DRGs.
Main outcome measures: Prevalence of malnutrition, levels of malnourished patients identified and documented, revenue losses under case payment system.
Statistical analyses: Logistic regression analyses were used to evaluate group differences in sex across SGA categories and to investigate predictors of referral versus non referral. Analysis of variance was used to evaluate group differences in age across SGA categories.
Results: One hundred and twenty-seven (42.3%) of the 324 subjects were malnourished. Only one of 137 malnourished patients was documented as malnourished in the medical records and only 21 (15.3%) were referred for nutrition intervention. The inclusion of the malnutrition code to the AN-DRG of the identified malnourished patients highlighted a shortfall of $125 311 in reimbursements to the hospital.
Conclusions: The degree of malnutrition in this hospital is similar to that found internationally. Malnourished patients are not being identified using the current referral method. Failure to flag malnourished patients requiring nutrition intervention potentially impacts on length of stay, hospital costs and patient outcomes and ultimately results in a shortfall for case payment funded institutions.
Background Malnutrition affects between 25 and 40% of all hospitalized patients, the majority of whom receive their main nutritional intake from the food provided by the hospital catering system. There is currently very little published information concerning the nutritional impact on patients of different methods of catering service.
Objective In the current study the effects of two catering service systems, plated and bulk service, on food and nutrient intake of hospital patients were compared.
Methods One-hundred and eight patient meals were surveyed, 51 on the plated meal and 57 on the bulk meal services. Patients were either on a general medical or an orthopaedic ward. Weighed food intake data were collected by weighing food served and comparing it to the weight of food left on the plate. Equal numbers of lunch and supper dishes were weighed. Also, a number of weekend surveys were carried out to take into account variation in service at weekends.
Results Food wastage was greater with the plated system. Comparing the amount of energy and nutrients consumed by patients according to meal system: energy intakes were significantly lower with the plated system (414 ± 23 kcal vs. 319 ± 22 kcal, P < 0.004). Protein, fat and carbohydrate intakes were also significantly lower. The main reason for the observed differences was the higher total food intake of the main course of the bulk service meals. Energy intake from the main course was significantly higher among patients receiving bulk service meals (227 ± 10 kcal vs. 165 ± 14 kcal, P < 0.006).
Conclusion Catering service systems can have a major impact on the nutritional intake of hospitalized patients.
The prevalence of malnutrition within hospital set-tings is a major concern to all health care workers. The recent development of a simple screening tool for use in such settings has increased the opportunity to identify at-risk patients in a reasona-ble time frame during their admission. This paper outlines the implementation of a routine nutrition screening and assessment, performed completely by dietitians, across both acute and rehabil-itation settings. Dietitians were able to screen, on average, 72% of eligible patients, which ensured timely dietetic intervention. The routine malnutrition screening and assessment process highlighted differences (P < 0.01) in the rates of malnutrition between the acute wards (range 7 to 14%) and rehabilitation ward (49%). Sig-nificant differences between acute and rehabilitation patients were also found within the majority of individual diagnostic groups, including all surgery, fractures, cardiovascular incidents and respi-ratory illness (P < 0.01). The identification of rates of malnutrition between different wards, diagnoses and institutional settings pro-vides dietetic managers with a sophisticated tool that can assist in the allocation of dietetic resources. This operational framework for routine screening of nutritionally at-risk patients in hospital, enables dietitians to develop patient outcomes and an effective nutrition care model. (Aust J Nutr Diet 2001;58:92–97)
Aim: To determine the prevalence of malnutrition in Queensland public acute and residential aged care facilities, and explore effects of variables associated with malnutrition in these populations.
Methods: A multicentre, cross‐sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single‐day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same‐day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression.
Results: A mean of 34.7 ± 4.0% and 31.4 ± 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, male (in residential aged care facilities), metropolitan location of facility and medical specialty, in particular, oncology and critical care.
Conclusion: Malnutrition is significant in public acute and residential aged care facilities in Queensland. Action must be taken to increase the recognition, prevention and treatment of malnutrition especially in high‐risk groups.
Background Malnutrition among elderly hospitalised patients is widespread and has been shown to lead to adverse health outcomes. The effectiveness of interventions to minimise undernutrition in elderly inpatients is not well documented.
Objectives To identify the best available practices, in the hospital setting, that minimise undernutrition or the risk of undernutrition, in the acute care patient especially for the older patient. The review will assesses the effectiveness of a range of interventions designed to promote adequate nutritional intake in the acute care setting, with the aim of determining what practices minimise malnutrition in the elderly inpatients.
Search strategy English language articles from 1980 onwards were sought using Medline, Premedline, Cinahl, Austrom-Australasian Medical Index and AustHealth, Embase and Science Citations Index.
Selection criteria For inclusion the study had to include an intervention aiming to minimise undernutrition in hospitalised elderly patients aged 65 years or older. All study designs were included.
Data collection and analysis Two independent reviewers assessed the eligibility of each study for inclusion into the review, critically appraised the study quality and extracted data using standardised tools. For each outcome measure results were tabulated by intervention type and discussed in a narrative summary. Results from randomised controlled trials were pooled in meta-analyses where appropriate.
Main results Twenty-nine studies met the inclusion criteria, with a total of 4021 participants. The focus of 15 interventions was the supplying of oral supplements to the participants, six focused on enteral nutrition therapy, four interventions made changes to the foods provided as part of the hospital diet, one included the services of an additional staff member and three incorporated the implementation of evidence-based guidelines. Ten meta-analyses were conducted from which the main findings were: significant improvements in weight status and arm muscle circumferences with an oral supplement intervention, P < 0.05.
Reviewers’ conclusions The findings of the review support the use of oral supplements to minimise undernutrition in elderly inpatients. The results also emphasise the need for more high-quality research using appropriate outcome measures in the area of minimisation of undernutrition, particularly interventions that make alterations to the hospital diet and address support for feeding patients at the ward level.
• There have been numerous reports that the nutritional intake of many hospitalized patients is sub‐optimal, but there is little published information about patients’ diets in Australian hospitals.
• In this study, the nutritional intake of patients in general medical wards of an Australian acute care hospital was assessed.
• Although the hospital diet can provide adequate energy and nutrients, many patients may not consume sufficient food to meet their needs.
• The estimated energy intake of about one‐third of patients was very low, and vitamin C, calcium and zinc intakes were also of concern.
• The implications are discussed and recommendations for improved nutritional care are suggested.
Hospital foodservice does not operate in isolation but requires the cooperation and integration of several disciplines to provide the ultimate patient experience. The objective of this research was to explore the antecedents to patient satisfaction and experience, including the service element. Accordingly, focus groups were conducted with doctors (n = 4), nurses (n = 5), ward hostesses (n = 3) and patients together with their visitors (n = 10), while open-ended interviews were conducted with the foodservice manager, facilities manager, chief dietitian, orthopaedic ward dietitian and chief pharmacist. Themes centred on ‘patients’, ‘foodservice’ and ‘mealtimes’, and results show that food qualities, particularly temperature and texture, are important factors impinging on patient satisfaction, and the trolley system of delivery is an acceptable style of service. Service predisposition demonstrates little relevance to patient satisfaction towards overall meal enjoyment. A theoretical model has been developed that identifies hospital foodservice in a cyclic relationship with the community primary healthcare team.
Provision of adequate nutrition is recognized as essential, yet malnutrition continues to be reported in patients admitted to hospital.
The effects of malnutrition in hospital patients have been well documented; however, most work relating to nutritional management has been produced by members of Nutrition Support Teams, nurse specialists and interested clinicians, whilst the majority of hospitals are still without such specialist posts.
This study used two data collection methods to gain information about the attitudes, nutritional knowledge base and nutrition‐related nursing care in a large trust hospital in the South of England.
A survey of care plans for documentation of nutrition‐related nursing activities, carried out on the day of discharge for all patients from five wards over a period of a fortnight (totalling 141 sets of documentation), was followed by a questionnaire to all qualified nurses on these and a further four wards (110 nurses).
Results demonstrated that nurses generally felt that nutritional assessment was primarily their responsibility.
Whilst there was evidence of knowledgeable and proactive nursing care, it also appeared that there were fairly widespread deficiencies in the knowledge, communication and co‐ordination required to ensure consistent good practice.
This study aimed to elicit concerns of key stakeholders regarding foodservice provision for long-stay hospital patients. Seventeen focus groups and four individual interviews were conducted involving six stakeholder groups: dietitians, nutrition assistants, patients, nurses, foodservice assistants and foodservice managers. Ninety-eight participants (20 male, 78 female) were recruited from public and private hospitals in New South Wales, Australia. Each of the focus groups and individual interviews was conducted in a hospital setting where free and open discussions could be digitally recorded. Transcripts were prepared from the digital recordings and QSR Nvivo 2.0 qualitative analysis software (QSR International, Melbourne, Australia) was used to code the transcripts prior to content and thematic analysis. Themes were identified by relative frequency in the discussion, number of issues raised within each theme and the importance placed on the issues raised. Five major themes emerged from 37 discussion topics: the foodservice system, menu variety, preparation to eat and feeding assistance, packaging and portion size. Participants were particularly concerned about the increased packaging of food products, perceived lack of meal set up and feeding assistance, limited menu variety especially when considering longer stay hospital inpatients, and the increased use of cook-chill operations. These findings lend themselves well to testing in a wider sphere via quantitative means in a proposed national survey. The results of this survey may produce a position on the main barriers to effective foodservice provision for long-stay patients in the Australian context, and enable identification of practical solutions.
In a series of studies, attitudes of military and civilian consumers toward military and other institutional foods, e.g. foods served in school cafeterias, hospitals, military dining halls, on airlines, etc., were examined. The goals of this research were to (1) quantify the extent and nature of these attitudes in terms of expected acceptability and expected quality of the food; (2) determine whether these attitudes can be classified as stereotypical; (3) assess the relative importance of presumed causes of poor quality and acceptability in institutional food, e.g. skills of food preparers, ingredient quality, consumption environment, etc.; (4) identify the specific aspects of perceived food quality, e.g. flavor, texture, nutritive value, etc., that most differentiate commercial from military institutional food; (5) quantify the relationship between expectations of acceptability and actual acceptability ratings of military institutional food; and (6) detail the empirical effect of institutional vs. brand name food labeling on hedonic acceptability ratings. The results of these studies showed broad and significant effects of institutional food stereotypes on food acceptance and food quality ratings. The results were interpreted within the context of a psychological model of the role of consumer expectations on food acceptability. The implications of the data for institutional and brand name food marketing are discussed.
Background Malnutrition among elderly hospitalised patients is widespread and has been shown to lead to adverse health outcomes. The effectiveness of interventions to minimise undernutrition in elderly inpatients is not well documented. Objectives To identify the best available practices, in the hospital setting, that minimise undernutrition or the risk of undernutrition, in the acute care patient especially for the older patient. The review will assesses the effectiveness of a range of interventions designed to promote adequate nutritional intake in the acute care setting, with the aim of determining what practices minimise malnutrition in the elderly inpatients. Search strategy English language articles from 1980 onwards were sought using Medline, Premedline, Cinahl, Austrom-Australasian Medical Index and AustHealth, Embase and Science Citations Index. Selection criteria For inclusion the study had to include an intervention aiming to minimise undernutrition in hospitalised elderly patients aged 65 years or older. All study designs were included. Data collection and analysis Two independent reviewers assessed the eligibility of each study for inclusion into the review, critically appraised the study quality and extracted data using standardised tools. For each outcome measure results were tabulated by intervention type and discussed in a narrative summary. Results from randomised controlled trials were pooled in meta-analyses where appropriate. Main results Twenty-nine studies met the inclusion criteria, with a total of 4021 participants. The focus of 15 interventions was the supplying of oral supplements to the participants, six focused on enteral nutrition therapy, four interventions made changes to the foods provided as part of the hospital diet, one included the services of an additional staff member and three incorporated the implementation of evidence-based guidelines. Ten meta-analyses were conducted from which the main findings were: significant improvements in weight status and arm muscle circumferences with an oral supplement intervention, P < 0.05. Reviewers' conclusions The findings of the review support the use of oral supplements to minimise undernutrition in elderly inpatients. The results also emphasise the need for more high-quality research using appropriate outcome measures in the area of minimisation of undernutrition, particularly interventions that make alterations to the hospital diet and address support for feeding patients at the ward level.
Aim: This systemic review aimed to investigate the effects of various methods of point of service meal provision on patient satisfaction and energy intakes of hospital patients.
Methods: ‘Medline’ and ‘Wiley Interscience’ online databases (1999–2008) were consulted using search terms such as ‘food service’ and ‘food delivery in hospital’. Cross‐referencing was also used to select studies that compared the provision of full diets to hospital patients using two different methods of food service delivery.
Results: Searching yielded 268 studies, of which 18 met the inclusion criteria (hospitals, all ages, oral intake only). Patient satisfaction was measured in 12 studies, while 9 studies measured energy intake, 9 measured food wastage and 4 studies measured costs.
Conclusion: There is evidence to suggest that a more personalised meal service system in hospitals has the ability to improve energy intakes and patient satisfaction. Further research is necessary to evaluate the long‐term implications on cost‐effectiveness.
Background & aims: This study aimed to determine the amounts of energy and protein required, ordered and consumed daily by long stay rehabilitation inpatients. Methods: A quantitative, weighed plate waste study. Thirty inpatients (16 females, 14 males; mean age 79.2 years; mean length of stay 52 days) from three rehabilitation hospitals in the Illawarra region of Australia. Data were collected over two days, including nutrition assessment details and weighed plate waste. Daily energy and protein requirements, amounts ordered and consumed were the outcome measures. Statistical analyses included paired t-tests, Wilcoxon Signed Rank tests and Spearman correlations. Results: Although adequate amounts of energy and protein were provided, significantly less was consumed than was required or ordered (p<0.05). Fifty-seven percent of the supplements were wasted, although they contributed 21.5% of energy and 20.6% of protein to the intakes of those who were prescribed them. Conclusions: Promising areas for interventions to improve intakes include the use of targeted supplement usage, food fortification, designated ward feeding assistants and ongoing nutrition surveillance.
In a population of 473 inpatients, a profile of nutritional status from obesity to marasmic-kwashiokor was observed. Thirty-two per cent of the population were overweight or obese (n = 153), forty-five per cent were of normal weight (n = 211), 8% were at risk of protein-energy malnutrition (n = 39), and 15% (n = 70) had grades of protein-energy malnutrition from marasmus to marasmic-kwashiokor. The implications for improved nutritional support services for hospitalised patients are discussed.
Good nutrition is undoubtedly central to optimum health and to the recovery from illness yet research and clinical surveys repeatedly demonstrate an unacceptably high incidence of malnutrition in hospital patients in whom it delays recovery, increases the incidence of complications and significantly increases the cost of treatment; the human cost is inestimable.
The objectives of the present study were to determine: (i) the prevalence of malnutrition in two Sydney teaching hospitals using Subjective Global Assessment (SGA), (ii) the effect of malnutrition on 12-month mortality and (iii) the proportion of patients previously identified to be at nutritional risk.
A prospective study using SGA to assess nutritional status of eligible inpatients, from April to September 1997, with a 12-month follow-up to assess mortality. A total of 819 patients was systematically selected from 2,194 eligible patients. Patients were excluded if they were under the age of 18, had dementia or communication difficulties, or were under obstetric or critical care. The main outcome measures were prevalence of malnutrition, 12-month incidence of mortality, proportion of patients identified with malnutrition, and hospital length of stay (LOS).
The prevalence rate of malnutrition was 36%. The proportion of malnourished patients was not significantly different between the two hospitals (P = 0.4). The actuarial incidence of mortality at 12 months after assessment was 29.7% in malnourished subjects compared with 10.1% in well-nourished subjects (P < 0.0005). Malnourished subjects had a significantly longer median LOS (17 days vs 11 days, P< 0.0005) and were significantly older (median 71 years vs 63 years, P < 0.0005) than well-nourished subjects. Only 36% of the malnourished patients had been previously identified as being at nutritional risk.
Malnutrition in Australian hospitals is a continuing health concern and is associated with increased LOS and decreased survival after 12 months. The present study revealed that malnourished patients were not regularly identified. Further studies are required to determine whether routine identification of malnutrition and subsequent nutritional intervention are effective in improving clinical outcomes in these individuals.
Most hospitalised patients are dependent on hospital food for their nutritional requirements. We surveyed hospitalised patients to obtain their opinions of hospital food in order to improve menu planning and food delivery.
Three hundred and seventeen questionnaires were distributed to patients on an oral diet in two Swiss hospitals. Questions assessed eating habits, appetite, satisfaction with menus, food preferences and presentation, understanding of choices available and preferred choices.
Three hundred and nine (97.5%) questionnaires were completed and analysed. Two hundred and sixty-five (86%) respondents were satisfied or very satisfied with hospital food. Two hundred and forty-one (78%) were satisfied with the way in which the food was served. There was a negative correlation (P=0.005) between duration of hospital stay and satisfaction with the food provided: 121 (39%) respondents stated that their appetite was the same as at home, and 50% stated that it had decreased during their time in the hospital. Eighty-seven (28%) patients said they ate all the food served, 148 (48%) ate most of it, and 68 (22%) ate only a small proportion. Patients felt that the temperature, appearance and aroma of the food were particularly important.
Based on the findings of this survey we have made recommendations for improvements in hospital food and its presentation.
Concerns have been raised that patients' nutrition is a neglected aspect of care. Accordingly, 'nutrition screening tools' have been devised to ensure that all patients are assessed by nurses and, where appropriate, referred to dieticians. The tool adopted in our hospital was the 'Nursing Nutritional Screening Tool'.
To investigate the impact of this screening tool on: nutrition-related nursing documentation; patient care at mealtimes; dietician referral.
This study was conducted on two similar general medical wards in a United Kingdom (UK) district general hospital, with the help of staff and patients (n = 175) admitted during two study periods, May 1999 and January 2000. Data were collected over 28 days before and after introduction of the screening tool on one of the wards. For both wards, in each stage of the study, data were collected b: review of patients' notes, non-participant observations of mealtimes. Frequencies of dietician referral and documentation of weight were compared by cross-tabulations and chi2 tests. Nine months later, the findings were discussed with ward sisters in a group interview.
Introduction of the screening tool impacted on the process but not the outcomes of screening. Use of the screening tool increased the frequency of nutrition-related documentation: the proportion of patients with weights recorded increased on the intervention ward (P < 0.001), and decreased on the comparator ward. Frequency of dietician referral decreased on both wards, but differences were statistically insignificant. There was no observable change in patient care at mealtimes. The nurses in charge of the wards felt that introduction of the screening tool had raised awareness of nutrition-related care.
Meeting patients' nutritional needs is a complex aspect of care which may benefit from introduction of structured guidelines. However, the potential of screening tools to improve care is limited by diverse factors, which warrant further exploration.
Malnutrition is associated with poor outcomes in older adults and those admitted to rehabilitation may be particularly at risk. Objective To assess the nutritional status and outcomes of older adults in rehabilitation.
We recruited 133 adults > or = 65 years from consecutive rehabilitation admissions. Nutritional status was assessed using the mini nutritional assessment, body mass index (BMI) and corrected arm muscle area (CAMA). Outcomes measured included length of stay, admission to higher level care, function and quality of life (QOL).
Sixty-two (47%) subjects were well nourished, 63 (47%) at risk of malnutrition and eight (6%) malnourished. Twenty-two (17%) and 27 (20%) were below the desirable reference values for BMI and CAMA respectively. Subjects at risk of malnutrition/malnourished had longer length of stay (P = 0.023) and were more likely to be admitted to higher level care (P < 0.05). These subjects also had poorer function on admission (P < 0.001) and 90 days (P = 0.002) and QOL on admission (P < 0.008) and 90 days (P = 0.001). Those with low CAMA were twice as likely to be admitted to higher level care (P < 0.05) and had poorer function at 90 days (P = 0.017).
Over half our sample was identified as at risk of malnutrition or malnourished and this was associated with poorer clinical outcomes.
The extent of malnutrition in hospitalised stroke patients and its influence on outcomes including hospital complications, length of stay and discharge destination are important issues. The aim of this study was to determine the nutritional status of patients admitted to an acute stroke unit and the association between nutritional status and health outcomes.
Nutritional status was determined prospectively using the scored patient generated subjective global assessment (PG-SGA) in patients (n=73) admitted to an acute stroke unit within 48 h of admission to an Australian private hospital. Outcome data were collected by retrospective audit.
On admission, 19.2% of patients were malnourished and this was associated with a significantly greater PG-SGA score (15 vs. 5) and lower body weight (59.8 kg vs. 75.8 kg) compared to well-nourished patients. In terms of health outcomes, malnourished patients had longer length of stay (13 vs. 8 days), increased complications (50% vs. 14%), increased frequency of dysphagia (71% vs. 32%) and enteral feeding (93% vs. 59%). No association was found between nutritional status and serum albumin level or discharge destination.
Malnutrition on admission to hospital after acute stroke is associated with poor outcomes including increased length of stay and increased prevalence of dysphagia and complications. The scored PG-SGA is a nutrition assessment tool that allows quick identification of malnourished stroke patients.
Malnutrition is highly prevalent in hospitalized patients and is often not identified by the medical staff. Clinical nutrition and nutritional assessment are often neglected components of the curriculum of medical schools. The effect of instruction of nutritional assessment early in medical school on nutritional practice in clinical training is unknown. Four years after the introduction of nutritional assessment in the medical school curriculum, we assessed the knowledge of medical students and residents of nutritional assessment and the practice of this clinical skill in hospitalized medical patients.
We determined the nutritional status of 69 patients on a general medical ward within 10 d of their hospital admission. Hospital records were reviewed to determine the documentation of nutrition-related issues and practices. A questionnaire was then administered to the housestaff to determine their knowledge of assessment of nutritional status.
Significant malnutrition was found in 69% of patients. Only one patient was identified as being malnourished by the housestaff. References to nutritional status were recorded in two patient charts. History of weight loss, appetite status, current oral intake, and functional status were recorded for fewer than 33% of patients. Although measurements of visceral protein stores (albumin and prealbumin) did not correlate with nutritional status, medical students and residents considered these to be the best markers of nutritional status.
Malnutrition is common in hospitalized patients. Instruction of second-year medical students in assessment of nutritional status does not result in improved knowledge or practice of nutritional assessment in the clinical training years as medical housestaff. Additional instruction in nutritional assessment during clinical training needs to be emphasized. Hospitals need to develop standardized protocols for assessment of nutritional status.
Social facilitation and meal ambiance have beneficial effects on food intake in healthy adults. Extrapolation to the nursing home setting may lead to less malnutrition among the residents. Therefore, we investigate the effect of family-style meals on energy intake and the risk of malnutrition in Dutch nursing home residents.
In 2002 and 2003, a randomized controlled trial was conducted among 178 residents (mean age 77 years) in five Dutch nursing homes. Within each home, two wards were randomized into an intervention (n = 94) and a control group (n = 84). For 6 months, the intervention group received their meals family style, and the control group received the usual individual preplating services. Outcome measures were intakes of energy (kJ), carbohydrates (g), fat (g), and protein (g) and Mini Nutritional Assessment (MNA) score (0-30).
The change in daily energy intake between the control and intervention group differed significantly (991 kJ; 95% confidence interval [CI], 504-1479). The difference in intake of macronutrients was 29.2 g (95% CI, 13.5-44.9) for carbohydrate, 9.1 g (95% CI, 2.9-15.2) for fat, and 8.6 g (95% CI, 3.4-13.6) for protein. The percentage of residents in the intervention group classified by the MNA as malnourished decreased from 17% to 4%, whereas this percentage increased from 11% to 23% in the control group.
Family-style meals stimulate daily energy intake and protect nursing home residents against malnourishment. Therefore, replacement of the preplating meal services with family-style meals in nursing homes is recommended.
This paper describes the findings of a descriptive study about what nurses do at mealtimes in relation to monitoring/assisting the eating practices of older patients in an acute care facility.
The prevalence of under nutrition is known to be high in hospitalized older patients and insufficient dietary intake is regarded as a major cause. However, most of the research tends to concentrate on the nursing home setting. Little is known about the situation in acute care facilities.
Two medical wards participated in the study. Ward 1 had introduced a change of nurses' meal break time and ward 2 continued with normal practice. Convenience sampling was used. Fifty nurses and 48 patients were observed at different mealtimes during two weeks. Four nurses and four patients who were observed were also interviewed. Data were analysed using descriptive statistics and thematic analysis.
Kitchen staff delivered all meals and collected the majority of the meal trays. Older patients did not receive enough assistance during mealtimes. Interruptions happened frequently and social interaction was neglected. About one-third of patients observed left more than two-third of their meals.
Nutrition issues appeared to receive less priority in the ward than other nursing care activities and nurses' assistance was generally insufficient and not provided in a timely manner. Relevance to clinical practice. Findings highlight the deficiency in practice that should suggest to nurses that they examine their practice and put into place strategies to ensure older patients are properly/adequately hydrated and receive sufficient nutrient intake.
Effects of combined nutritional treatment of patients at risk of protein-energy malnutrition (PEM) discharged from a geriatric service were evaluated.
Patients (n=108, age 85+/-6 years) at risk of malnutrition according to the short form of the mini nutritional assessment were randomly allocated to dietary counseling, including liquid and multivitamin supplementation, i.e. intervention (I, n=51) and to controls (C, n=57). Body weight, biochemical indices (e.g. insulin-like growth factor I (IGF-I)), Katz activities of daily living (ADL) index, mini mental status examination (MMSE) and quality of life (QoL) by SF-36 were assessed at the start of the study and after 4 months. Statistical analyses were performed on "intention-to-treat" and on "treated-as-protocol" bases.
Fifty-four patients, 29 in the I-group (86+/-7 years, 66% females) and 25 in the C-group (85+/-7 years, 72% females) completed the study according to the protocol. Both modes of analysis revealed a significant positive effect of the combined nutritional intervention on weight maintenance. Treated-as-protocol analyses showed that Katz ADL index improved in the I-group (p<0.001; p<0.05 between the groups). Serum IGF-I levels increased in the I-group (p<0.001), but were unchanged in the C-group (p=0.07 between the groups). QoL was assessed to be low and had not changed after nutritional treatment.
Combined nutritional intervention prevented weight loss and improved ADL functions in discharged geriatric patients at risk of malnutrition.
The aim of this research was to compare plate with bulk trolley food service in hospitals in terms of patient satisfaction. Key factors distinguishing satisfaction with each system would also be identified.
A consumer opinion card (n = 180), concentrating on the quality indicators of core foods, was used to measure patient satisfaction and compare two systems of delivery, plate and trolley. Binary logistic regression analysis was used to build a model that would predict food service style on the basis of the food attributes measured. Further investigation used multinomial logistic regression to predict opinion for the assessment of each food attribute within food service style.
Results showed that the bulk trolley method of food distribution enables all foods to have a more acceptable texture, and for some foods (potato, P = 0.007; poached fish, P = 0.001; and minced beef, P < or = 0.0005) temperature, and for other foods (broccoli, P < or = 0.0005; carrots, P < or = 0.0005; and poached fish, P = 0.001) flavor, than the plate system of delivery, where flavor is associated with bad opinion or dissatisfaction. A model was built indicating patient satisfaction with the two service systems.
This research confirms that patient satisfaction is enhanced by choice at the point of consumption (trolley system); however, portion size was not the controlling dimension. Temperature and texture were the most important attributes that measure patient satisfaction with food, thus defining the focus for hospital food service managers. To date, a model predicting patient satisfaction with the quality of food as served has not been proposed, and as such this work adds to the body of knowledge in this field. This report brings new information about the service style of dishes for improving the quality of food and thus enhancing patient satisfaction.
To compare energy intakes in seniors with cognitive impairment residing in long-term care and receiving meals by bulk (cafeteria style with waitress service) vs traditional tray delivery systems and determine subject characteristics that identify responsiveness to type of foodservice provided. DESIGN AND SUBJECTS/SETTING: Usual energy intakes were compared in subjects residing in cognitive impairment units in either the old (tray delivery, n=23) or new (bulk delivery, n=26) nursing home at Baycrest, a teaching facility associated with University of Toronto Medical School.
Changes to foodservice and physical environment (from institutional to more home-like environment).
Twenty-one consecutive day investigator-weighed energy and macronutrient intakes and behavioral function (London Psychogeriatric Rating Scale).
Analysis of variance determined mean differences in intake and regression analyses identified predictors of sensitivity to type of food delivery systems.
Higher 24-hour total (P<0.001) and dinner (P<0.001) energy intakes in subjects receiving bulk compared to tray delivery were predominantly associated with greater carbohydrate intakes (P<0.001). Higher energy, carbohydrate, and protein, but not fat intakes, with bulk delivery were more apparent in individuals with lower body mass indexes (BMIs) (food delivery by BMI interaction, all P values <0.05).
High-risk, cognitively impaired individuals with low BMI benefited the most from the changed foodservice and physical environment, whereas individuals with higher BMIs did not show substantive changes in intake. Bulk foodservice and a home-like dining environment optimize energy intake in individuals at high risk for malnutrition, particularly those with low BMIs and cognitive impairment.
The Redesigning Care initiative at Flinders Medical Centre aimed to improve access to timely, consistent, quality care. This led to the creation of an Acute Assessment Unit (AAU) where all patients are assessed by the Allied Health team on admission. This study aimed to: (i) determine the nutritional status of patients admitted to the AAU using the scored Patient Generated-Subjective Global Assessment (PG-SGA); and (ii) determine the association between nutritional status and length of stay (LOS).
A prospective, observational study was conducted in 64 patients (mean age 79.9 +/- 11 years, 76% female). Nutritional status was assessed within 48 h of admission and LOS data were collected prospectively.
According to PG-SGA global rating, 53% (n = 34) of patients were malnourished. There was a weak association between PG-SGA score and LOS (r = 0.250, P = 0.046). The malnourished patients had a longer LOS by 1 day compared to well-nourished patients, and while this did not reach statistical significance (Z = -0.988, P = 0.323), it has implications for health care costs. LOS overall was short at a median of 4.5 days (range 1-24).
A significant proportion of patients admitted to the AAU is malnourished. There was a trend for these patients to have a longer LOS, indicating a critical need for nutritional management; however LOS as a whole was short. While nutrition support in hospital is useful in reinforcing dietary education, the short LOS emphasized the importance of discharge education and follow-up.
Embedding Nutrition into Clinical Governance: Getting Doctors on Board Proceedings of the Food as Treatment: Making the Links Conference Nutrition: a hard nut to crack. An exploration of the knowledge, attitudes and activities of qualified nurses in rela-tion to nutritional nursing care
- P Kopelman
Kopelman P. Embedding Nutrition into Clinical Governance: Getting Doctors on Board. Proceedings of the Food as Treatment: Making the Links Conference; 21 January, London, England. 2004. 48 Perry L. Nutrition: a hard nut to crack. An exploration of the knowledge, attitudes and activities of qualified nurses in rela-tion to nutritional nursing care. J Clin Nurs 1997; 6: 315–24.
Practical strategies for better understanding and implementation of ‘Food as Treatment
- Stroudm
Stroud M. Practical strategies for better understanding and imple-mentation of 'Food as Treatment'. Proceedings of the Food as Treatment: Making the Links Conference; 21 January, London, England. 2004.
Nutrition and 'payment by results Proceedings of the Food as Treatment: Making the Links Conference Improving opportunities for food service and dietetics practice © 2012 The Author Nutrition & Dietetics © 2012 Dietitians Association of Australia
- Morgan
49 Morgan G. Nutrition and 'payment by results'. Proceedings of the Food as Treatment: Making the Links Conference; 21 January London, England. 2004. Improving opportunities for food service and dietetics practice © 2012 The Author Nutrition & Dietetics © 2012 Dietitians Association of Australia
Nutrition and ‘payment by results
- Morgang
Briefing Paper. Undernutrition in the UK
- Schenker