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Hospital Food Service



Hospital foodservice is complex and can be considered as one of the most complicated systems in the hospitality sector with many interrelated factors. Hospital menus should be based primarily on clinical needs as well as on patients’ preferences and other important characteristics such as variety, quality, aesthetics, and taste of the food. However, if food is regarded as medicine, then necessary dietary modifications can make meals unappealing (e.g., low-sodium diet). Barriers to adequate food intakes are multifactorial and complex and require multilevel interventions, including a change in the awareness and attitude toward food among healthcare staff and older hospital patients. To be successful, the priority interventions need to be feasible in practice, in terms of the availability of human resources, budget, infrastructure, and time. Menus are an important tool for the foodservice as they are the first point of contact with the patient. A therapeutic diet is modified from a “normal” diet and is prescribed to meet a medical or special nutritional need. It can be part of a clinical treatment, and in some cases can be the main treatment of a condition. Furthermore, food safety is a critical part of this whole process, particularly when preparing and serving food for hospitalized patients who are likely to be more susceptible to foodborne illness due to their health status and decreased immunity. Still, in all foodservice settings there is an increasing demand for greater attention to the environmental impact of the food production. These are factors that are likely to have increasing prominence, with a demand for the use of more locally sourced foods, recycling, and improved energy efficiency.
Hospital Food Service
Vinicius Andre do Rosario and Karen Walton
Hospital Foodservice .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Foodservice: An Overview .. . . . . . . . . . . . . . . . . . . . . . . . . . . . ...................................... 2
Foodservice in Hospitals ...................................................................... 3
Malnutrition Versus Nourishment in Hospitals .. ................................................ 5
Who Are we Feeding in Hospitals? .. ........................................................ 5
Aging Population and Increased Nutritional Risk ............................................ 6
Nutrition Requirements .. . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . 8
Length of Stay ................................................................................. 10
Hospital Foodservice Systems .................................................................... 11
Cook Fresh........................ ................................................ ............ 11
Cook Chill ..................................................................................... 11
Cook Freeze .. ................................................................................. 12
Other Foodservice Systems .. . . ............................................................... 12
Menus ............................................................................................. 13
Menu Planning and Recipe Development .. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . 13
Types of Menus . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 14
Therapeutic Diets.... ................................................. ............................ 15
Types of Diets ................................................................................. 16
Food Safety ................................................. ...................................... 19
Food Quality and Foodservice Satisfaction .. . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . 20
Barriers and Opportunities .. . ................................................................. 20
Sustainability, Environment, and Costing ........................................................ 22
Recommendations .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 23
Suggested Practices to Change the Culture of Nutrition Care ............................... 23
Conclusion .. . . . ................................................................................... 24
References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 25
V. A. do Rosario (*) · K. Walton
School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong,
Wollongong, NSW, Australia
© Springer Nature Switzerland AG 2019
H. L. Meiselman (ed.), Handbook of Eating and Drinking,
Hospital foodservice is complex and can be considered as one of the most
complicated systems in the hospitality sector with many interrelated factors.
Hospital menus should be based primarily on clinical needs as well as on patients
preferences and other important characteristics such as variety, quality, aesthetics,
and taste of the food. However, if food is regarded as medicine, then necessary
dietary modications can make meals unappealing (e.g., low-sodium diet). Bar-
riers to adequate food intakes are multifactorial and complex and require multi-
level interventions, including a change in the awareness and attitude toward food
among healthcare staff and older hospital patients. To be successful, the priority
interventions need to be feasible in practice, in terms of the availability of human
resources, budget, infrastructure, and time. Menus are an important tool for the
foodservice as they are the rst point of contact with the patient. A therapeutic
diet is modied from a normaldiet and is prescribed to meet a medical or
special nutritional need. It can be part of a clinical treatment, and in some cases
can be the main treatment of a condition. Furthermore, food safety is a critical part
of this whole process, particularly when preparing and serving food for hospital-
ized patients who are likely to be more susceptible to foodborne illness due to
their health status and decreased immunity. Still, in all foodservice settings there
is an increasing demand for greater attention to the environmental impact of the
food production. These are factors that are likely to have increasing prominence,
with a demand for the use of more locally sourced foods, recycling, and improved
energy efciency.
Hospital Foodservice
Foodservice: An Overview
Around the world, more and more meals are being consumed away from the home.
This phenomenon can be associated with the search for pleasure (e.g., in restaurants)
or through necessity, in settings where individuals, given a choice, would perhaps
choose not to be (e.g., hospital). There is a similar distinction between domestic
meal provision,where meals are provided to meet principally social goals and
personal needs, tastes, and comforts, and functional meal provision,where meals
are provided in a context of rules governing work and especially time constraints
(Williams 2009). This latter category encompasses a wide range of foodservices,
which can be considered as institutional settings, of which in addition to hospitals
also includes the following:
Other healthcare settings (nursing homes)
Schools and child care organizations
Military settings (canteens and combat rations)
2 V. A. do Rosario and K. Walton
Home-delivered meals
Workplace canteens
Despite the growth in meals eaten away from the home, as a proportion of all
foodservice, institutional meals in the USA have been progressively declining over
the past 50 years, from 30.8% in 1955 to 14.6% in 2005. This pattern is likely to be
broader than the USA because of the much higher growth in non-institutional meals
from fast food outlets and the general trend to more out of home recreational dining
(Williams 2009).
The meal experience is signicantly shaped by the individual living arrangements
in institutions and it has even been suggested that the word mealmay be inappro-
priate to some experiences, where food is provided, but the social and emotional
contexts of eating are missing (de Raeve 1994). Nonetheless, in all of these settings
one can distinguish two goals that they have in common with all other meal service
settings (a) meeting customer expectations and needs (e.g., safety, taste, price,
service) and (b) providing physical sustenance (e.g., satiation and nourishment)
(Williams 2009).
Foodservice is a broad area that incorporates the provision of food and drink to
individuals where this intake represents the majority of their daily requirements, or
where populations are vulnerable and/or have special requirements. The role of the
dietitian will vary depending on the service delivery model and the requirements set
out by the consumer and relevant legislation (DallOglio et al. 2015).
In institutions that provide all the daily meals for the clients, patients, or con-
sumers (e.g., hospitals, boarding schools), it is most common to provide three main
meals per day (breakfast, midday, evening), plus a number of mid-meal or snack
options. The latter may be served on trays, or from a beverage and snack trolley
wheeled around the ward areas. In other institutions, the mid-meals are less likely to
be delivered, but supplies may be available for self-service in common dining areas.
Among the different types of meals covered by food services, there are food as
medicinemeals, which implies a therapeutic provision. This type of meal can be
seen in hospitals, nursing homes and to some extent in home-delivered meal services
such as Meals on Wheels. From Hippocrates in the fourth century BC to Florence
Nightingale in the nineteenth century, the provision of food suitable for sick patients
has been recognized as an important part of their care (Williams 2009).
Foodservice in Hospitals
The importance of hospital foodservice and the use of food as medicine are not new
concepts and can be traced back to one of the earliest medical works, the Hwang Ti
Nei-chang Su Wen (The Yellow Emperors Classic of Internal Medicine,
722721 BC). Concern with the role that food may play in the recovery of patients
was also highlighted by Florence Nightingale who wrote in her Notes on Nursing in
1859 that The most important ofce of the nurse, after she has taken care of the
patientsair, is to take care to observe the effects of his food. Hospital foodservice
Hospital Food Service 3
can present especially complex features and is often considered the most compli-
cated process in the hospitality sector with many interrelated factors impinging upon
the whole. The layout of hospital wards, often at considerable distances from the
kitchen, adds an additional logistics burden, and as a consequence, a long stream of
possible delays between production, service, delivery and consumption. This
stretched, continuous, and staggered food cycle can have potential negative effects
on the safety and quality of food, and presents a challenge to any hospital
foodservice manager (Williams 2009).
The goals of a hospital foodservice are to provide inpatients with nutritious meals
that are benecial for their recovery and health, and also to give them an example of
healthy nutrition with menus tailored to patientsspecic health conditions. When
meals are carefully planned and customized to meet patientsspecic needs, and
when patients consume what they are served, these goals can be considered as
achieved. Meal consumption by inpatients is related to nutritional status and satis-
faction with the foodservice, along with other factors such as health status, medical
conditions, appetite, the eating environment and dentition. Furthermore, foodservice
quality is known to inuence patient satisfaction with hospital stay. It is widely
recognized that food and other aspects of foodservice delivery are important ele-
ments in patientsoverall perception of their hospital experience and that healthcare
teams have a daily commitment to deliver appropriate food to patients. Provision of a
foodservice that not only meets but also exceeds the expectations of the patient is
considered essential for a quality service (DallOglio et al. 2015).
Dening quality for hospital foodservice requires a balance of many different
features. Hospital menus should be based primarily on clinical needs, as well as on
patientspreferences. Other important characteristics such as variety, quality, and
taste of food should also be included. Moreover, the hospital environment and a
pleasant helpful attitude from the nursing and food service staff are important
elements that should be considered in a quality approach to the complex problem
of inadequate dietary intakes by many hospital patients. Personal and sociocultural
aspects have also been identied as a main factor in the acceptance of food and in
predicting food consumption. Thus, customer satisfaction with hospital foodservice
is multifactorial and can be difcult to assess (DallOglio et al. 2015).
Foodservice professionals in hospitals can be compared with engineers in
manufacturing factories. Engineers continuously research, plan, and manage pro-
duction processes to improve the quality of products and the efciency of processes.
Once a dietitian set goals and standards by planning menus, they should manage and
control the processes to a point where the goals are met. Foodservice staff should be
trained and empowered as valued team members in hospital foodservice quality
management. Communicating with patients should be bidirectional, which involve
dietitians listening to patientsvoices and helping patients understand their nutri-
tional requirements (Kim et al. 2010).
In hospital the food provided to patients should not be viewed as just another
hotel function (like cleaning and laundry), it is a key part of the treatment, and
providing meals that are of high quality and which meet the individualsspecic
nutritional needs is an essential goal. However necessary dietary modications (e.
4 V. A. do Rosario and K. Walton
g., liquid or pureed food, low-salt or low-protein diets) can make meals particularly
unappealing. It is recognized that in these cases the medical requirements will
outweigh the normal culinary expectations, but every effort needs to be made to
maximize taste and appearance, in addition to nutrition. Parallel with concerns about
malnutrition, consumer expectations of hospitals have been increasing, so the
provision of food and the meal experiences are becoming increasingly
important within the range of medical and support services offered by hospitals
(Hartwell et al. 2016b).
Malnutrition Versus Nourishment in Hospitals
Who Are we Feeding in Hospitals?
Malnutrition is dened as a state in which deciency, excess, or imbalance of energy,
protein, and other nutrients causes adverse effects on body composition, function,
and/or other clinical characteristics (Bernstein et al. 2012). The prevalence of
malnutrition and poor dietary intakes have been evaluated by many studies in
different countries. The Australasian Nutrition Care Day Survey (ANCDS)
ascertained that malnutrition and poor food intake were independent risk factors
for health-related outcomes in Australian and New Zealand hospital patients. Of
3122 participants from 56 hospitals, 32% were malnourished and 23% consumed
25% of the offered food. Malnourished patients had a greater median length of stay
(15 days vs. 10 days) and readmission rates (36% vs. 30%). Median length of stay
for patients consuming 25% of the food was higher than those consuming 50%
(13 vs. 11 days). The odds of 90-day in-hospital mortality were two times greater for
malnourished patients and those consuming 25% of the provided food (Agarwal et
al. 2013). Furthermore, a study of 777 patients at Royal North Shore Hospital, in
Sydney, found that 51% of patients had some level of malnutrition. The average
length of stay for the malnourished patients was 30 days vs. 17 days for the well-
nourished patients. Similarly to other studies, a large proportion of patients identied
as being malnourished (43%) had not been referred on to a dietitian (Matthews et al.
2007). A further study reports that 30% of patients were malnourished on admission
to hospital in Victoria, with a further 61% at risk.Patients were often not referred
on to dietitians, further highlighting issues related to the recognition of malnutrition
by doctors and nurses. Symptoms such as reduced appetite and recent weight loss
were not followed up as expected (Adams et al. 2008). Furthermore, a Canadian
study found that 45% of patients admitted to a medical or surgical ward were
malnourished (Allard et al. 2016).
The prevalence of hospital malnutrition is also high in other countries, with
around 2050% of patients in acute care being malnourished, depending on the
population and criteria for determination. In the UK, Nutrition Screening Weeks
reported that approximately one in three patients were at medium to high risk of
malnutrition upon admission. Other work in this eld suggests that referral processes
Hospital Food Service 5
are ad hoc, often missing malnourished patients(Russell and Elia 2014.). These
studies demonstrated that nutrition care practices can vary and are inconsistent
regarding screening, referral for diagnosis and treatment of patients who are mal-
nourished (Allard et al. 2016).
Older patients have a higher prevalence of malnutrition, with patients above
80 years of age suggested to have ve times the rate of malnutrition as those patients
younger than 50 years. The frequency appears to increase with age, and those
patients above 80 years have a higher odds risk of being malnourished compared
with those between 61 and 80 years (Banks et al. 2007).
Aging Population and Increased Nutritional Risk
Several changes that occur in normal aging increase nutritional risk for older adults.
Aging is followed by diminished organ system functions and weakened homeostatic
controls. Nutritional requirements in this age range are determined by various
factors, including specic disease conditions and related organ system compromise.
The level of activity, energy expenditure, caloric requirements, ingestion, digestion,
absorption, and other nutritional factors also pay a role (Bernstein et al. 2012). Some
older adults living on their own may not achieve sufcient dietary intakes due to a
lack of desire in preparing single portion meals. Loneliness is one of the key factors
in decreased appetite and a major contributor to malnutrition. It is estimated that
about 30% and 50% of adults over 65 and 85 years old live alone, respectively,
which decreases food enjoyment and total energy and nutrient intake (Bernstein et al.
2012; Clegg and Williams 2018).
The prevalence of malnutrition in Europe and North America is 115% in
community-living older adults, 2560% in care facilities and 3565% in in hospitals
(Fávaro-Moreira et al. 2016). Malnutrition is associated with a decline in functional
status, impaired muscle function and immune function, decreased bone mass,
anemia, cognitive decline, poor wound healing, delayed recovering from surgery,
higher hospital admission and readmission rates, and risk of mortality. The average
daily dietary intake can decrease up to 30% between 20 and 80 years (Bernstein et al.
2012; Clegg and Williams 2018).
Insufcient dietary intake along with other metabolic changes present in order
adults may lead to conditions such as cachexia and sarcopenia. Cachexia is an
involuntary loss of fat-free mass (muscle, organ, tissue, skin, and bone) or body
cell mass. It is caused by catabolism (breakdown of body mass to produce energy)
and results in changes in body consumption. It is dened as a metabolic syndrome in
which inammation is the key feature and so cachexia can be an underlying
condition of sarcopenia, a multifactorial geriatric syndrome consisting of skeletal
muscle mass, quality, and strength (Ahmed and Haboubi 2010). Dietary intake in
older adults may be impaired due to a reduction in the proper ritual of eating,
reducing the quality and quantity of daily meals. Table 1summarizes many factors
involving impaired food intake and its respective determinants.
6 V. A. do Rosario and K. Walton
In addition to impaired intake, physiological changes in older adults may also
impair digestion and absorption. Neurodegeneration of the enteric nervous system
can lead to gastrointestinal manifestations such as dysphagia (difculty swallowing),
gastrointestinal reux, and constipation. Reduced gastric acid secretions increases
with aging, which inuences digestion and absorption (Ahmed and Haboubi 2010).
Another dietary factor that is increased in the aging population is dehydration.
Water is a coolant, lubricant, and transport agent. It is required to carry nutrients,
regulate body temperature and remove waste products. Dehydration prevalence is
higher in older adults and is a potential lethal problem among both institutionalized
and community-dwelling older adults. In the USA, in 1991 more than 189,000
patients over 65 years were discharged from acute care hospitals with a primary
diagnosis of dehydration. This translates into about 1.5% of community-living older
persons being hospitalized with dehydration each year. In community-living older
adults developing progressive disabilities, dehydration is one of the most common
diagnoses on hospital admission and readmission (World Health Organization and
Tufts University 2002).
Older adults are at risk of dehydration due to reduced uid intake and increased
uid loss, consequently making them more susceptible to develop problems with
uid and electrolyte balance. Fluid deprivation and repletion studies comparing
different age ranges have demonstrated that in spite of physiological needs, older
adults consume inadequate amounts of uids to maintain ideal plasma electrolyte
concentrations (World Health Organization and Tufts University 2002). Many age-
related diseases exacerbate the risk of dehydration, and at the same time dehydration
is a common complication of acute illness in this population (Ahmed and Haboubi
Table 1 Factors involved in impaired dietary intakes by older adults
Factors Determinants
Poor appetite Illness, pain or nausea when eating, reduced sense of taste or smell, food
aversion, beliefs regarding dietary restrictions, alcoholism, depression,
Inability to eat Confusion, cognitive decline or dementia, weakness or arthritis in the
arms or hands, dysphagia, vomiting, poor oral hygiene or dentition and
painful mouth conditions
Lack of food Insufcient resources, dependence to shop and cook
Polypharmacy Anorexia, decreased or altered sense of taste, dry mouth, confusion,
nausea, vomiting, diarrhea, constipation, dyspepsia. Incorrect use of
Altered metabolic demands due to illness, surgery, organ dysfunction,
and/or treatments
Excess nutrient
Vomiting, diarrhea, stulae, stomas, and colostomy
Chronic kidney, respiratory, gastrointestinal and liver diseases,
malignancies, HIV, AIDS, stroke, and surgeries
Eating environment Social isolation, bereavement, or other signicant life event
Hospital Food Service 7
Nutrition Requirements
There needs be some exibility in the provision of hospital meals and the involve-
ment of the patients in this process. Although adequate amounts may be provided, a
substantial amount of patients consume less than half of their estimated daily
requirements (Agarwal et al. 2013), due to a range of reasons as outlined in Table 1.
Using dietary reference values (DRVs) to plan the food provision in hospitals is
needed alongside nutritional screening procedures that have clear nutritional man-
agement guidelines to support those individuals identied at-risk.It is essential
that a hospital menu is capable of meeting the nutrient standards (energy on a daily
basis, protein on a daily basis and reference nutrient intake (RNI) for micronutrients
on a weekly basis), as appropriate for the patient population it is foodservice for. This
pragmatic approach allows menus to be planned with greater exibility. It is unlikely
that a free-living individual at home will meet the RNI for all nutrients on a daily
basis, with most being met on average over a week (NHS 2016, p. 38).
Two sets of nutrient standards, based on the Scotland example for Food in
Hospitals, have been specied in Table 2. This is acknowledgement of the extremes
of the core nutritional requirements in the hospital setting. One set of standards is
applicable to the needs of nutritionally vulnerablepatients; those with poor
appetites, poor food intakes, undernourished. The other set of nutrient standards is
in line with the requirements of the healthy balanced diet and thus are applicable to
the needs of those patients who are considered to be nutritionally well.Provision
of a menu that meets the nutritional requirements outlined for hospital patients, must
also be a menu that provides choices of dishes that tempt patients to eat, and which
they will enjoy (NHS 2016, p. 18).
Appropriate foodservice provision is essential for the nutritional support of
hospitalized patients. This is particularly important for long stay older patients,
who are increasing in number at a time when malnutrition is also a signicant
concern and consumer expectations of hospital patients are heightened (Williams
2009). The issue of addressing hospital malnutrition and being vigilant in continu-
ously reviewing and improving foodservice systems and feeding assistance becomes
even more relevant as the population ages (Clegg and Williams 2018).
The hospital mealtime situation and the provision of food is not planned by the
patients and it is felt that more attention should be paid to the organization of food
provision. Mealtime situations should respect individuality and preferences
and consider the cognitive, social and environmental impacts on dietary intakes
(Hartwell et al. 2016b).
Patients sometimes require complete feeding assistance, while others may require
help positioning themselves for a meal, accessing the tray table and/or opening food
and beverage items. This has traditionally been the role of nurses, however there are
many reasons why they may not always be available to provide timely assistance to
patients who require this, including competing duties such as medication rounds, a
lack of skills and/or knowledge in screening and agging patients at risk, meal
breaks, and increased responsibilities and increased numbers of patients requiring
support on some wards (Walton et al. 2012).
8 V. A. do Rosario and K. Walton
Aging is associated with a decreased total energy intake followed by a concom-
itant increased risk for low micronutrient consumption. In particular, despite all of
the potential nutritional issues present in aging, recommended dietary allowances for
older adults are similar (Maggini et al. 2018). In the healthy condition, the dietary
energy requirements are diminished and although the recommended dietary allow-
ance for protein is the same for older adults in many countries (0.8 g/kg), recent
evidence points to a dietary intake of 1.0 to 1.3 g/kg appear to optimize physical
Table 2 Essential criteria for the provision of nutrients for hospitalized adults
Nutrient (per day)
Frequency of
Energy (kcal) 22502625 18002400 Daily
Protein (g) 6075 56 Daily
Total fat (% food energy) Not specied 35 Averaged
over a week
Saturated fat (% food energy) Not specied 11 Averaged
over a week
Carbohydrate (% food energy) Not specied 50 Averaged
over a week
Non-milk extrinsic sugars
(NMES) (% food energy)
Not specied 10 Averaged
over a week
Fiber (g) Not specied 30 Daily
Sodium (mg) <2400 <2400 Daily
Vitamin A (μg) 700 700 Averaged
over a week
Vitamin D (μg) 10 10 Averaged
over a week
Calcium (mg) 700 700 Averaged
over a week
Potassium (mg) 3500 3500 Averaged
over a week
Magnesium (mg) 300 300 Averaged
over a week
Iron (mg) 14.8 14.8 Averaged
over a week
Vitamin B12 (μg) 1.5 1.5 Averaged
over a week
Folate and folic acid (μg) 200 200 Averaged
over a week
Vitamin C (mg) 40 40 Averaged
over a week
Zinc (mg) 9.5 9.5 Averaged
over a week
Fluid (liters) 1.5 Male 2,000 ml,
female 1,600 ml
Male 2,000 ml,
female 1,600 ml
Hospital Food Service 9
function, particularly while undertaking resistance exercise recommendations
(Bauer et al. 2013). Additionally, some micronutrients have their dietary intake
requirements increased such as calcium, vitamins D and B6 (Table 3), while others,
even presenting equal requirements, are crucial for healthy aging and are associated
with lower intake in older adults such as vitamin B2 (riboavin), B9 (folic acid) and
B12 (Otten et al. 2006).
Length of Stay
Malnutrition on admission is an independent risk factor for complication-related
readmissions, prolonged hospital stay, and hence increased healthcare costs. One
study assessed whether protein intake relative to requirements at day one predicts
complications and hospital length of stay. A post hoc analysis of a prospective cohort
study was conducted in adult patients admitted to the wards of Orthopedics, Urology,
Gynecology, and Gastroenterology (n =637). Intake was determined at day one of
full oral intake by subtracting the weight of each dish at the end of each mealtime
from the weight at serving time. Protein requirements were calculated as 1.2 g/kg
body weight. Data on complications and length of stay were reported using patients
medical records. In total, 92 patients (14.4%) had a complication and median length
of stay was 5 days. A 10% increase of protein intake relative to requirements
relatively reduced the complication risk by 9.4%. Also, each increase of 10% in
protein intake relative to requirements predicted a shorter LOS by 0.25 days. These
results show that protein intake relative to requirements at the rst day of full oral
intake is a predictor for the risk of complications and length of stay (Ijmker-Hemink
et al. 2018).
A further study was conducted with 18 Canadian inpatients 18 years who were
admitted for 2 days. One thousand and fteen patients were enrolled and based on
the Subjective Global Assessment (SGA), 45% were malnourished, and based on
BMI (>30 kg/m
), 32% were obese. The median (range) length of stay was 6
(1117) days. After controlling for demographic, socioeconomic, and disease-
related factors and treatment, malnutrition at admission was independently associ-
ated with prolonged length of stay. Other nutrition-related factors associated with
prolonged length of stay were lower handgrip strength at admission, receiving
nutrition support and food intake <50% (Allard et al. 2016).
Table 3 Specic nutrient requirements for older adults >50 years
Nutrient Recommendation (daily)
Protein 1.01.3 g/kg of ideal body weight
Calcium 1300 mg
Vitamin D 10.0 μg for >50 yr
15.0 μg for >70 yr
Vitamin B6 1.7 mg (male); 1.5 mg (female)
10 V. A. do Rosario and K. Walton
Hospital Foodservice Systems
Meals may be chosen ahead of time and plated in a central kitchen, either hot (cook
fresh) or cold (cook chill or cook freeze) for later retherm. Alternately hot food may
be sent to the ward areas in a mobile trolley so that patients can select their choices at
the point of service. This has numerous advantages including: selections can be
made based on current appetite, different serving sizes are available, the aroma and
appearance of the meal may assist appetite, more nursing staff may be involved in
alerting patients to the arrival of the trolley and thus further socialization and
encouragement of patients. Disadvantages may include: patients need to be mobile
to access the trolley, therapeutic diets are difcult to manage this way as the
foodservice staff are not trained in this area and there is often more food waste
(from the bulk trolley, but not the individual patient meal plates) due to the number
of options that need to be included in the trolley to cover the menu (Hartwell and
Edwards 2003; Hartwell et al. 2016b).
Foodservice departments may utilize cook-fresh, cook-chill, cook-freeze, or a
combination of several of those, and other systems.
Cook Fresh
In a cook fresh system, food is prepared close to the meal time and the hot food is
plated hot after some time in hot holding,which usually involves holding bulk
gastronorm trays of food over a customized hot water bath (bain-marie style). To
maximize nutrient retention, quality, color, and avor the time in hot holding
should be kept short (ideally <30mins, but certainly <90mins) (Williams 1996). For
these reasons, it has been reported that hospital using cook-fresh systems are
signicantly more likely to offer choices of portion size and optional sauces and
gravies with meat compared to cook-chill hospitals (Williams 2009).
Cook Chill
A cook-chill system involves food being cooked in advance and then rapidly chilled
for retherming at a later stage. Advantages with this system may include: the
availability of further main meal choices at the evening meal because the meals
are prepared in advance, improved temperature control, cost savings due to bulk
buying and because no cooks are required in the evening, or on the weekends when
additional wage penalties would be in place. Disadvantages include that some items
are not available as they do not retherm well (e.g., boiled eggs, crumbed items,
steak); some foods dry out so sauces or gravies are usually required; and for this
reason more wet dishes are often used (Spears and Gregoire 2007).
In pre-plated tray service systems that use the cook-chill system, a third disad-
vantage is the general requirement to standardize portion sizes and the amount of
food on plates as much as possible; for example, baked potatoes may have to be cut
Hospital Food Service 11
into smaller pieces to facilitate even reheating. Menu choices can also be affected. To
prevent drying out of meats, almost always they need to be served covered with a
sauce or gravy. Wet entrée dishes that reheat well are usually favored when cook-
chill systems are used over dishes such as grilled meats or eggs, which are more
likely to dry out (Williams 2009).
Cook Freeze
Cook freeze is similar to cook chill, except that the meals that are cooked in advance
are quickly frozen (rather than chilled) in a blast freezer for use at a later stage. Items
may be frozen in bulk or as individual portions to provide greater menu exibility,
particularly for patients with special dietary requirements (i.e., gluten free). Each
method of food preparation and delivery has their own advantages and disadvan-
tages in terms of nutrient losses, exibility, wastage, food safety, staff skills required,
and food appearance and palatability (Spears and Gregoire 2007; Williams 2009).
Other Foodservice Systems
Food service systems throughout the second half of the twentieth century started to
move away from patient meal services using bulk delivery trolleys in the ward areas
(with food served by nursing staff) and toward centralized meal plating and distri-
bution of individual trays by foodservice staff. Recently, there has been some
reversal of this trend with several recent trials of a return to bulk food trolleys
particularly in nursing home situations. Such systems may result in less waste and
greater patient satisfaction but it is unclear how they affect nutritional intake
(Williams 2009).
Room service is a foodservice model that has been increasingly implemented
across healthcare facilities in an effort to improve patient satisfaction and reduce
food waste. As there is a paradigm shift to more personalized, patient-centered care,
patient satisfaction has increasingly become a driver of high-quality care. In this type
of service, patients are able to order meals of their choice from a menu that is suitable
for them, according to their dietary recommendation and restrictions. Foodservice
quality has been linked to patient satisfaction and, in the USA, room service is
increasingly being seen as the foodservice model for hospitals to meet this outcome
(Marcason 2012). Increased dietary intakes, improved patient satisfaction, and
reduced plate waste and patient meal costs were reported for room service when
compared to a traditional foodservice model.
Comparison of nutritional intake between a traditional foodservice model and
room service showed increases with room service in both energy and protein intake,
as well as energy and protein intake as a percentage of requirements. Total mean
plate waste decreased from 29% (traditional foodservice model) to 12% (room
service). Patient satisfaction ratings indicated improvements with room service for
quality of foodand for avor of food.The patient meal costs also decreased by
12 V. A. do Rosario and K. Walton
15% with room service (McCray et al. 2018). Another hospital study, conducted in
the Netherlands, evaluated a meal service concept with a restaurant style menu and
room service. There was improved patient satisfaction, nutritional status, and food
intake compared to the traditional three meals per day service. There was a decrease
in the risk of malnutrition followed by an increase in patient food service satisfaction
among those who received this new foodservice (Doorduijn et al. 2016).
Food provision should be planned in order to be responsive to patientsneeds, not
those of medical, nursing, and other healthcare staff and should be managed as an
integral component of clinical care rather than a hotelfunction. Before considering
menu planning or the development of a recipe database, menu planning groups need
to consider the wider issues that can affect patient food choice and hence food
intakes. Gathering of information about the differing dietary needs of different
hospital patient groups can help menu planners develop an appropriate foodservice
that is in a form that is familiar to patients (The British Dietetic Association 2017,
p. 70).
Menu Planning and Recipe Development
Different foods provide different nutrients; some nutrients are only found in suf-
cient quantities if specic foods or food groups are included in adequate amounts in
the diet. Thus, in order to meet the nutrient standards specied in section two,
patients will need to be provided with a diet that is made up of a combination and
balance of foods from all of the ve food groups (and additional protein, fats, and
sugars where required), namely:
Breads, other cereals, and potatoes
Milk and dairy foods
Meat, sh, and alternatives
The balance of each of these food groups in the diets of hospital patients will vary
depending on the dietary and nutritional needs of the different patient populations.
The provision of different types of foods or choices of food items within each food
group needs to recognize the differing dietary needs that are to be catered. Patients
provided with foods that they are familiar with and enjoy will be more likely to
consume it, ensuring that they receive the nutrition provided on the plate. Provision
of greater choice is more likely to meet individual food preferences and individuals
dietary needs. The inclusion, preparation and cooking of a variety of foods specied
Hospital Food Service 13
in the ve food groups needs to remain exible if the diverse needs of the hospital
population are to be met with ordinary food(NHS 2016, p. 32).
When developing a standardized recipe the following process should be followed
(U. S. Department of Agriculture 2002, p. 9; Fig. 1):
There are several studies that have shown that many patients in hospital do not eat
all the food they are served (Bannerman et al. 2016). Reducing portion size and
increasing the energy and nutrient density of meals can encourage oral intake for
patients with decreased appetite. This can ensure patients are not over-whelmed by a
large meal and thus are more likely to eat what is provided, in turn increasing energy
and nutrient intakes (Kim et al. 2010).
Types of Menus
In most institutional foodservices, the menus are either an a la carte type (offering a
wide range of choices, but remaining the same each day), or a cycle menu (a series of
daily menus on a weekly or longer cycle, after which the cycle is repeated). Cycle
menus are commonly used in healthcare, prison, and school settings to offer variety
with some degree of predictability for ordering, budgeting, and production schedul-
ing. One or 2 week cycles are common in acute hospitals; 34 week cycles are more
common in longer-care facilities (Williams 2009).
Menus are an important tool for the foodservice manager as they are the rst point
of contact with the patient and can be used both for communication and marketing
purposes. However, a negative message can be portrayed if menus are not easy to
read or interpret. Traditionally hospital menus have been implemented using a paper-
based system where printed menus are manually distributed and meal orders col-
lected and processed by foodservice staff. Advances in technology have seen the
introduction of newer computerized systems where patients can view and order
Review the recipe and its existing format/content against the required information.
Any variations made to the original recipe - record directly onto the working recipe
Information noted as missing during the review process.
Weighing the final product or measuring its volume will determine the yield.
Ingredient product quality, preparation techniques, and cooking times and
temperatures affect yields.
Determine the portion size or weight by taking the weight of the total final product and
dividing by the number of servings the recipe makes
Is appropriate for the patient group it is serving?; Does it go well with the rest of the meal?
Product appearance on the plate and in bulk form as appropriate; product taste and
taste suitability to consumer group.
Product texture; Product suitability to foodservice production and distribution type.
Fig. 1 Process to develop a standardized recipe
14 V. A. do Rosario and K. Walton
their meals using a bedside ordering system (Hartwell et al. 2016a; Ottrey and
Porter 2016).
While the traditional paper menus are still available in many settings, food
management systems are used in some settings to generate paper menus, or to
facilitate a spoken menu via palm pilots that are operated by nutrition assistants.
Meal choice at the point of service is also used occasionally (e.g., bulk hot meal
trolleys in some wards). The method of offering options can subtly alter the variety
that is offered, which has ramications for resources, both human and otherwise. A
patient sees all the available options allowed on a paper menu, while a spoken menu
means that patients may just say yes to the rst option, or alternately the last one
offered, which they may remember.
A review found that modications in menu design and menu ordering processes
were associated with improvements in clinical and non-clinical outcomes in hospital.
Outcomes such as intake, satisfaction, perception, cost and meal tray accuracy were
analyzed. Standardized menu formatting and the spoken menu system were found to
improve meal tray accuracy. The spoken menu and computerized interactive menu
selector system enhanced aspects of patient satisfaction without cost increases.
Descriptive menus may increase food consumption. Branding food items was not
well supported by patients. Taken together, these ndings show that the use of an
electronic menu management system can create efciencies in menu planning and
meal production and provides a repository for standard recipes, menu, and allergen
information. Many systems include nutrient catalogues, which can simplify the
nutrition analysis of recipes (Ottrey and Porter 2016).
Therapeutic Diets
A therapeutic diet is modied from a normaldiet and is prescribed to meet a
medical or special nutritional need. It can be part or the principle clinical treatment of
a condition, which comprises 17.22% of overall diets in hospitals (Thibault et al.
2011). Whenever a patient has a therapeutic diet prescribed by a dietitian or by
medical staff, all hospitals and Health Boards must be able to provide this. In
addition, when planning therapeutic diets it is essential to have accurate knowledge
of the nutrient and ingredient composition of all dishes and individual menu items to
determine their suitability. This makes the use of standardized, analyzed recipes
crucial in the delivery of appropriate food.
Menus should reect local population needs and healthcare organizations need to
develop their own protocol for the requirement and provision of therapeutic diets for
their population.
There must be a hospital protocol for the provision of all therapeutic diets.
Patients must be given choice for all food and uid options suitable for their diets,
including therapeutic and/or texture modied diets.
Hospitals whose populations require certain therapeutic diets irregularly and in
minimal numbers must include in their policy a formal contingency for the
Hospital Food Service 15
provision of these diets in the event they are required, for example an a la carte
Therapeutic diets must be capable of meeting the dietary requirements of patients
using them.
Where relevant, foodservice service contracts must be sufciently detailed and
cover the provision of both therapeutic and special diets (The British Dietetic
Association 2017, p. 70).
Diets must not automatically be ordered for patients with the medical or surgical
indications noted in the specications, because a very restrictive diet may prevent
good nutritional recovery for patients who are undernourished or eating poorly.
Appropriate health professionals may alter the diets to meet individual patients
needs. For example, some patients on soft diets may not tolerate bread, and this
would need to be noted at the time of ordering that diet. Combinations of diets can be
ordered (e.g., low saturated fat and sodium restricted), but there is no need to specify
a full diet where it is to be combined with other therapeutic diets (Agency for
Clinical Innovation 2011, p. 7).
Types of Diets
Therapeutic diets is an umbrella term used for a wide range of diets for patients with
specic requirements, such as texture-modied diets, allergy and intolerance diets,
diabetic diets, dietdrug interaction diets, macronutrient modied diets (fat, protein,
and carbohydrates), ber-modied diets, uid diets, and many others. The most
commonly used therapeutic diets are described further (The British Dietetic Asso-
ciation 2017, p. 65).
Higher-Energy, High-Protein, and Nutrient-Dense Diet
Energy- and nutrient-dense diets are indicated for patients with a small or poor
appetite who nd it difcult to eat sufcient foods to meet their energy and nutrient
requirements. These diets are also indicated for those patient groups with increased
energy and protein requirements, including those who have had a major trauma such
as a head injury; burns patients; cancer patients and undernourished patients. These
individuals require additional energy and protein to meet their increased needs or to
enable them to replace lost body weight and improve their nutritional status (The
British Dietetic Association 2017, p. 65). The provision of substantial snacks three
times a day is likely to be necessary to meet individual requirements.
A high-energy, high-protein, and nutrient-dense diet can be achieved by increas-
ing the overall amount of food eaten by:
Increasing portion sizes (larger amount of food in one meal is less effective in
patients with poor appetite, prefer options below)
Increasing the number of foods offered, for example increasing the number of
times snacks are provided between meals
16 V. A. do Rosario and K. Walton
Providing greater choice of energy- and nutrient-dense foods on the menu
Increasing the energy and nutrient content of foods already consumed
Texture-Modified Diets
The requirement for texture modied or modied consistency food and uid,
usually results from difculties in chewing and/or swallowing food (also known as
dysphagia). It is generally the result of a disease process and may be caused by either
a mechanical, neurological or a psychological problem. An older persons ability to
adapt and compensate for an inadequate swallow is further reduced by less saliva
or chewing difculties, and inadequate lip seal causing dribbling of liquids. A
reduced ability to manipulate food in the mouth can cause loss of sensation and
poor tongue control.
Providing food and uid of an inappropriate consistency increases the risk of food
or uid going into the lungs, a major cause of chest infection, lung abscesses, and
aspiration pneumonia in hospitalized patients; it can also cause asphyxiation. Aspi-
ration can be silent, causing no outward signs of distress but still capable of causing
pulmonary complications. The International Dysphagia Diet Standardisation Initia-
tive (IDDSI) provides a practical framework to approach patients with dysphagia
(International Dysphagia Diet Standardisation Initiative 2019).
Allergen-Free Diets
Food Allergy
True food allergy is an immune reaction to food that triggers the release of hista-
mines and other substances into the tissues. Food allergy may be caused by numer-
ous different foods or additives and symptoms can be triggered by minute amounts
of these. Allergic reactions may range in severity from relatively short-lived dis-
comfort through to anaphylactic shock, which may be fatal. Therefore, there are
signicant risks to patients if allergen-free diets are not provided when required.
Food Intolerance
Food intolerance differs from food allergy in that it does not involve the immune
system. Food intolerances may arise in a number of ways (e.g., by dietary compo-
nents acting as irritants or due to enzyme deciencies which may result in an
inability to digest or metabolize certain food components). Reactions due to food
intolerance may be severe but they are not generally life-threatening. However, they
can affect long-term health and do represent a health risk if not taken into account
when required and thus these patientsdietary needs should be catered for in the
hospital setting.
People who suffer from food allergies and food intolerances need to know the
exact ingredients in the food that they eat as even a small amount of allergen can
make them very ill or in some cases could be fatal. The use of food product labels is
fundamental to identify foods appropriate for patientsdiets when exclusion of
specic foods is required due to an allergy or food intolerance.
Hospital Food Service 17
Where an allergenic ingredient or its derivative is not clearly identied in the
name of the food (e.g., malt vinegar), the allergenic ingredient should always be
clearly identied in the labeling, for example malt vinegar (from barley).All
added ingredients and components of added ingredients are covered by the new
labeling regulations if they are present in the nished product, even in an altered
form. This includes carryover additives, additives used as processing aids, solvents,
and media for additives or avoring and any other substance used as a processing
Gluten-Free Diet
Celiac disease is caused by an autoimmune reaction to a component of gluten, which
is a protein that is found in certain cereals, namely, wheat, barley, and rye. A gluten-
free diet is used as the treatment for coeliac disease and the skin condition dermatitis
herpetiformis (DH). Consumption of even a minute quantity of gluten by someone
with coeliac disease can result in malabsorption, gastrointestinal symptoms, and
fatigue. Patients with intolerance to gluten can also benet from this type of diet by
reducing symptoms such as bloating and low-grade inammation.
Special and Personal Diets
Special diets refer to those meeting cultural or religious needs, while personal diets
are those meeting personal preferences. Any organizational structures, policies,
procedures, and practices are required to treat ethnic minorities fairly and equally.
This applies to all public bodies and is therefore applicable to the hospital
foodservice service. Although a standard hospital menu meets the majority of
patientscultural and religious food needs, there are some patient groups with
alternative needs. A patients personal dietary needs must be met when they also
require a therapeutic diet.
Vegetarianism and Veganism
People from a variety of backgrounds adopt vegetarian dietary practices for a
number of reasons including religion and culture, for example Hindus and Bud-
dhists; moral or ethical beliefs, health, environment, ecological and economical
concerns. Vegetarian dietary practices can vary quite considerably in terms of what
foods will be eaten and what foods are excluded. The extent to which foods are
excluded needs to be determined with the individual patient. Many of the principles
of a vegetarian diet follow national targets for healthy eating, which is higher intakes
of complex carbohydrates, bers, and fruits and vegetables. If well planned, the
vegetarian diet can be nutritionally adequate. However, exclusion of certain foods or
food group items requires careful planning to ensure that alternative foods are
included in the diet to prevent any nutritional inadequacies. A hospital menu has
traditionally provided a lacto-ovo vegetarian option for patients. Any variants of this
diet must be planned for the individual patient by the foodservice department in
conjunction with a dietitian as per the local protocol.
18 V. A. do Rosario and K. Walton
Food Safety
Food safety is critical, particularly when preparing and serving food for hospitalized
patients who are likely to be more susceptible to foodborne illness due to their ill
health and decreased immunity. Anyone involved in handling food should receive
appropriate food safety training. Depending on the level of risk this can be either at a
local level or by a course accredited by an organization. All caterers are legally
required to carry out a full risk assessment of their food production and service
procedures and practices, and to put in place management systems and control
measures to reduce the major risks in food manufacture. These set out what is, and
what is not, permissible, and will take account of issues such as stafng and
equipment availability in each individual unit (Abdullah Sani and Siow 2014;
Food and Drugs Administration 2019).
The dietitian has a role to play in the assessment team, by providing specialized
advice to the caterer about the vulnerability of specic patient groups. What is
possible to do in one unit might not be safe to do in another, due to differing systems.
The procedure manuals and staff training will all be based on the original hazard
analysis, and the assumption that the control systems remain unchanged at ward
level. The cooking process does not kill all food poisoning bacteria spores, and those
that do survive are then controlled by the rigid time and temperature controls, so that
their potential for growth is kept within safe limits (The British Dietetic Association
2017, p. 90).
Every year, more than one-third of the total population in developing countries is
affected by foodborne illness. European Food Safety Authority (European Food
Safety Authority 2010) reported that in year 2010 alone, approximately 48.7% of
foodborne diseases are associated with the foodservice or foodservice establishments
which prove the importance of basic food safety practices in these areas (ESFA
2010). Mishandling food may be implicated in 97% of all food-borne illness
associated with foodservice outlets. In spite of food handlers having the skills and
knowledge to handle food safely, yet human handling errors have been associated
with most incidence of food poisoning. Hence, to reduce the risk of cross-contam-
ination, serious attention should be given to train and supervise food handlers to
ensure proper hand washing, adequate cleaning and good sanitation procedures
(Abdullah Sani and Siow 2014; Food and Drugs Administration 2019).
The Hazard Analysis and Critical Control Points(HACCP) is a preventative
food safety system in which every step in the manufacture, storage and distribution
of a food product is scientically analyzed for microbiological, physical and chem-
ical hazards. Its principles and application guidelines can be found at https://www.
Hospital Food Service 19
Food Quality and Foodservice Satisfaction
Consumer expectations of hospitals have been increasing, so that the provision of
food and the meal experience are becoming increasingly important within the range
of medical and support services offered by hospitals. One study explored the
antecedents to patient satisfaction and experience, including the service element.
Accordingly, focus groups were conducted with doctors, nurses, ward hostesses, and
patients together with their visitors, while open-ended interviews were conducted
with the foodservice manager, facilities manager, chief dietitian, orthopedic ward
dietitian, and chief pharmacist. Themes centered on patients,”“foodservice,and
mealtimes,and results show that food qualities, particularly temperature and
texture, are important factors impinging on patient satisfaction (Hartwell et al.
2006). A review also assessed which factor are more important for meal experience
in Hospitals. Food quality, food temperature, taste of food, variability, time of food
distribution, and staff service were among the most important factors for patients
(Hartwell et al. 2016b).
Furthermore, Navarro et al. investigated if improved meal presentation, supported
by gastronomy expertise, would have an effect on the food intake. This prospective
open labeled, non-randomized controlled design study analyzed the meal experience
satisfaction of 206 hospitalized patients, in two different periods lasting 3 weeks
each. Patients who received the meal with the improved presentation showed
signicantly higher food intake than those who received the standard meal, despite
reported loss in appetite. More participants from the experimental group reported
their meal to be tasty in comparison to those in the control group. Length of stay was
not different but readmission rate decreased signicantly in the study group from
31.2% to 13.5% (Navarro et al. 2016).
Barriers and Opportunities
Barriers to Improve Dietary Intake
Barriers to adequate food intakes by hospital inpatients are multifactorial and
complex, and require multilevel interventions, including a change in the awareness
and attitude toward food among healthcare staff and older hospital patients (Hope et
al. 2017). The main theme with regard to foodservice management is the fragmen-
tary nature and difculty of communication between the kitchen and wards.
Foodservice managers have to rely on kitchen porters for the delivery of food to
the ward; and ward staff may have difculty in communicating with foodservice
staff and dietitians. Financial constraints were a prominent part of the concern of the
foodservice and facilities managers, with budgets continually being reduced and not
ring fenced(protected) (Hartwell et al. 2006).
While nurses may view the nutritional care of patients as an important aspect of
their job, increased time pressures and competing tasks may mean that they are not
able to prioritize feeding above other duties, such as the distribution of medicines at.
Most research in this area has reported common themes of time restraints and staff
20 V. A. do Rosario and K. Walton
shortages. A further study investigated the most common barriers in food intake of
long-stay, older adult patients in Australian hospitals. The key barriers identied
were lack of choice due to special diet, boredom arising from the length of stay, a
lack of feeding assistance, limited variety, and inadequate exibility of food service
(Walton et al. 2012).
Another factor that may be a crucial barrier to a proper dietary intake in older
adults is the packaging. One study has demonstrated that ddlypackaging (i.e.,
packaging that appears to require dexterity to access the contents) and decreased
hand strength are shown to inuence the ability of hospitalized patients to open food
and beverage packaging. Staff are aware of many problematic packages and
acknowledge that many patients require assistance to open food and beverages,
however a signicant proportion of staff are also unable to open these packages.
This study also identied several key recommendations on the service delivery of
packaged food and beverages at meal times (Bell et al. 2013). These are as follows:
Offering alternative solutions such as decanting contents
Identifying alternative package solutions, that is, that some packages are easier to
access than others and those package forms could be encouraged
Designating staff to assist in opening packages at mealtimes and training staff in
understanding the difculties users may have
Improving Nutrition in Hospital Foodservice
To be successful the priority interventions need to be feasible in practice, in terms of
the availability of human resources, budget, infrastructure, and time. The need for
additional feeding assistance (nursing and non-nursing), assistance in setting up with
meals, assistance to open food and beverage packaging and socialization are issues
to be considered. The same study aforementioned which highlighted the main barrier
for food intake, also investigated feasible opportunities to enhance nutrition support
of older, long-stay patients in Australian hospitals. Food fortication, assistance with
packaging, additional feeding assistance by nurses, non-nursing feeding assistance
and further nutrition assessment were key priorities in order to improve food intake
(Walton et al. 2012).
Furthermore, a UK hospital study evaluated if the menu was able to meet energy
and protein standards recommendations, as well as to determine the contribution of
oral nutrition supplements and additional snacks. Energy and protein contents of
food selected from the menu (menu choice), menu food consumed (hospital
intake) and total food consumed including snacks (overall intake) were calcu-
lated. In total, 93 patients were included and were categorized as nutritionally well
or nutritionally vulnerable.For nutritionally wellpatients, energy and protein
standards were met by 11.1% and 33.3% (menu choice); 7.4% and 22.2% (hos-
pital intake); and 14.8% and 28.4% (overall intake). For nutritionally vulnera-
blepatients, energy and protein standards were met by 0% and 8.3% (menu
choice); 0% and 8.3% (hospital intake); and 8.3% and 16.7% (overall intake).
Ten percent of patients consumed oral nutrition supplements. Patients who
Hospital Food Service 21
consumed hospital snacks (34%) were more likely to meet the nutrient standards
(Pullen et al. 2018).
Several other studies investigated new strategies to improve nutrition in hospitals.
A new concept comprising six protein-rich meals per day, provided directly at the
bedside following proactive advice from a nutritional assistant, was evaluated as a
strategy to optimize protein and energy intake and prevent or treat malnutrition
during hospitalization. In a total of 311 patients in 4 different hospital wards, those
receiving this dietary service had an improved mean daily protein intake relative to
requirements and an improved mean daily energy intake when compared to patients
on the regular 3 meals per day service. Additionally, the new strategy also increased
patients satisfaction with the appearance and smell of meals (Dijxhoorn et al. 2018).
Another study followed a food quality control and improvement permanent process
in a Hospital for 9 years. Among the 1291 patients included, the consumption of 1
oral nutritional supplements daily increased the protein needs coverage from 80% to
115% (Thibault et al. 2011).
Sustainability, Environment, and Costing
In all foodservice settings there is increasing consumer demand for greater attention
to the nutritional quality and environmental impact of the food being offered. Recent
trends to greater use of cook-chill foodservices, and more portion packaged food and
disposable tray items (in order to reduce dishwashing) have not been made with
much awareness of the consequences for energy consumption or environmental
impact. These are factors that are likely to have increasing prominence, with a
demand for the use of more locally sourced food, recycling and improved energy
efciency. Organic menus have started to appear in the hospital sector and environ-
mental concerns may well have longer term impacts on the technologies employed
for meal production and delivery (Williams 2009).
Hospital foodservice systems can be responsible for up to 50% of all hospital
waste (Goonan et al. 2014). It has been suggested that some food waste is unavoid-
able to ensure patientsfood and nutrition needs are met. However, foodservice
systems can be more reactive and exible to minimize wasted food. Increasing
resource restrictions within the healthcare system are driving facilities to scrutinize
the costs of service delivery and investigate avenues for saving. The provision of
food to patients and associated levels of waste are often a priority focus in cost-
management strategies. Sources of food waste are varied and can include
foodservice model design (bulk cooking and rethermalizing, long lead time fore-
casting, and in-advance meal ordering), missed meals due to environmental factors
(hospital procedure and test scheduling), and individual patient factors (reduced
appetite and other impacts of clinical symptoms and treatments, such as nausea or
pain). Foodservice models that can reduce or eliminate these sources of waste are
considered optimal from this cost-management perspective (McCray et al. 2018;
Williams and Walton 2011).
22 V. A. do Rosario and K. Walton
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 hos-
pital, and there are also nancial 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: 665%),
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 difculty accessing food and complex ordering systems), and
environmental factors (such as inappropriate meal times, interruptions, and unpleas-
ant ward surroundings). Strategies to minimize waste include reduced portion sizes
with food fortication, bulk meal delivery system, feeding assistance, provision of
dining rooms, and protected meal times (Williams and Walton 2011).
A study reported that a multi-level approach is required to address the complex issue
of improved care processes and strategies to promote the nutrition care culture in
hospitals. Examples of strategies and processes at the organizational, staff and
patient levels have been provided to demonstrate that a change in culture to improve
patient-centered nutrition care is within reach. A structured implementation program
using implementation frameworks is needed to change organizational policies and
procedures, provide staff role delineation and training, as well as strategies to
reinforce this training and to empower patients and families. The framework
suggested by this study is presented below (Laur et al. 2015).
Suggested Practices to Change the Culture of Nutrition Care
Organizational Level
Hospital management aware of the effect that nutritional status has on length of
stay, risk of readmission, and cost to the hospital, should make nutrition a priority
Use of knowledge translation/implementation frameworks to develop and imple-
ment policies/protocols for enhanced nutrition care
Frameworks in place to support changes in nutrition practices/culture
Hospital benchmarking and progress tracking for nutrition related goals
Effective communication systems (i.e., between wards and foodservices, and
between healthcare professionals)
Focus on all aspects of the nutrition care process including screening, referral,
assessment, intervention, and monitoring
Hospital Food Service 23
Interventions to promote intake (i.e., use of color-coded trays for patients requir-
ing feeding assistance or protected mealtimes)
Foodservices is able to respond quickly to diet changes and allow food access
outside of meal times (i.e., snack carts)
Staff Level
Clarication of staff roles and responsibilities in nutrition care
Staff education and training on how to perform these roles (i.e., nutrition
Auditing and feedback of nutrition care practices
Individual actions to promote nutrition (i.e., avoiding interruptions at mealtimes,
providing feeding assistance if needed)
Ensuring nutrition is considered in transitions in care (i.e., handovers, discharge
or transfer to other wards/areas)
Training of hospital volunteers to assist with specic tasks, when appropriate
Reminders in place for staff to ensure training is carried over into practice and
changes are sustained
Patient-Family Level
Encouraging patient and family participation in nutrition care (i.e., intake mon-
itoring, advocating for nutrition needs, making the dining area as pleasant as
Educating patients and families on the importance of nutrition during and post
Training families on meal setup and assistance for patients
Allow social interaction (i.e., opportunities for patients to eat while family is
Hospital foodservices present a challenging system, comprising a myriad of factors
ranging from administrative functions to high complex medical decisions. The
balance between costs, sustainability and foodservices provided should always be
centered in the improvement of patientshealth, recovery, and support. This chapter
addressed several topics in this eld, gathering practicable knowledge from different
parts of the world with diverse resources and populationscharacteristics. This
chapter serves as guide to the development, restructuring, and promotion of a
systematic approach to hospital foodservice.
24 V. A. do Rosario and K. Walton
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Hospital Food Service 27
... Also the nancial constraints of hospital and close economic boundaries of hospital catering, does not always permit the provision of food or service that matches the expectations of 2 patients . Meal consumption by inpatients has direct effect on nutritional status and satisfaction with the food service, along with other factors such as health status, medical conditions, appetite, the 3 eating environment and dentition . Furthermore, foodservice quality inuences patient satisfaction with hospital stay. ...
... It is widely recognized that food and other aspects of foodservice delivery are important elements in patient's hospital experience and that healthcare teams have a daily commitment to deliver appropriate food to patients. Provision of a foodservice that meets but also exceeds the expectations 3 of the patient is considered essential for a quality service . The quality for hospital foodservice depends on many different features like Hospital menus should be based primarily on clinical needs, as well as on patient's preferences. ...
... Moreover, the hospital environment and a positive attitude from the nursing and food service staff are considered in a quality approach to the complex problem of inadequate dietary intakes by many hospital patients. Accordingly, patient satisfaction with 3 hospital food service is multifactorial and can be difcult to assess . The hypothesis of this study is that food service plays greater role in patient's hospital experience. ...
Background: The goals of a hospital food service are to provide inpatients with nutritious meals that are benecial for their recovery and health. Foodservice quality inuences patient satisfaction with hospital stay. It is widely recognized that food and other aspects of food service delivery are important elements in patient's hospital experience and that healthcare teams have a daily commitment to deliver appropriate food to patients. Provision of a food service that meets but also exceeds the expectations of the patient is considered essential for a quality service. Accordingly, patient satisfaction with hospital foodservice is multifactorial and can be difcult to assess. The main aim was to “Study of patient Objective: satisfaction with hospital catering services in a Government tertiary care teaching hospital, Lucknow, Uttar Pradesh. In order to achieve this aim, the objective identied was to measure and assess patient satisfaction with the food and services in the hospital. Face to face interview Method: was conducted and the interview schedule was lled with data collected from Patients who were taking hospital diet. The patient's were Result: interviewed to assess their satisfaction with hospital service in relation to consumption of meals served in Breakfast, Lunch and Dinner and response of patients irt food served, Stewart and utensils through an interview schedule. It was also revealed by the study that most of the patients were consuming hospital meal but little improvement is needed in respect to food served.
... Hospital foodservice is considered one of the most complicated systems in hospitals. The many interrelated factors include menus that are based primarily on clinical needs and patients' preferences, as well as on variety, quality, aesthetics and the taste of the food [7,34]. A therapeutic diet is prescribed to meet a medical or special nutritional need; and can constitute a part, or even the main part of a clinical treatment. ...
... A therapeutic diet is prescribed to meet a medical or special nutritional need; and can constitute a part, or even the main part of a clinical treatment. Adherence to such diet may be essential for preventing immediate or longterm clinical damage [34]. Difficulties of the kitchen and the entities that link hospital food service to the medical departments (e.g., miscommunication between the medical departments to the kitchen staff due to other sectors involved in the relevant stages of patients' care within the hospital and mostly computerized procedures involved in this process, lacking guidance to kitchen staff, etc.) can impair implementation of the nutrition program. ...
... The consequence is patients not receiving the optimal food for their needs, according to the medical and nutrition guidelines issued in the department, even if the correct nutritional instructions were recorded [35]. Food safety is a critical factor in the preparation and serving of food to hospitalized patients, who are more likely than the general population to be susceptible to foodborne illness, due to their decreased health status [7,34]. The provision and consumption of inappropriate food or fluids by patients who require a therapeutic diet can interfere with medical treatment, and under certain circumstances, pose a risk to immediate health; this is specifically true in the case of food allergic reactions [7]. ...
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Background Food allergy can result in life-threatening anaphylaxis and is considered an increasing public health burden. Hospitalized patients are dependent on the hospital menu to meet their nutritional needs; thus, errors in the meals provided can have a substantial impact on patients’ health outcomes. In Israel, no specific policy protocol exists to ensure food allergy safety in the setting of a hospital foodservice system. Objectives This paper has two aims: 1) to provide an in-depth review of food allergy as a major public health concern and 2) to report actions taken in a single large medical center, as an ongoing project that aimed to ensure patients’ safety, and which ended in developing policy on this matter. Results During the years 2017–2019, we initiated several interventions with the goal of achieving food allergy safety and ensuring quality of care for patients with food allergies at Hadassah Hebrew University Medical Center. These included integrating food management safety into the computerized foodservice system, highlighting labels on patients’ food trays, introducing safety checks into the process of food delivery to hospitalized patients; and ensuring the nutritional requirements of patients with allergy restrictions. Moreover, changes were made in specialized menus for patients with various types of food allergy, and specific procedures were implemented regarding enteral feeding, to prevent accidental allergen exposure. All the procedures were incorporated into a written protocol that applies to all hospital employees, and the staff received the relevant training. Conclusions Our experience suggests that methods for food allergy safety should be promoted, and that an established policy and suitable set of guidelines on this matter is required. This clearly mandates collaboration between the various sectors of the hospital, including management and the computer department; and the medical, nursing, dietetics and kitchen staffs. Furthermore, routine ongoing knowledge training programs for medical teams and kitchen staff are crucial for such implementational changes. In a technological world, computerized systems delivering food to hospitalized patients must be adapted such as to create a uniformly safe food environment of healthcare systems, and developing a suitable policy should be prioritized accordingly by hospitals across Israel, with collaboration and synergy between institutions management and the departments of nutrition and patient safety and risk management.
... Foodservice in hospitals refers to the provision of meals, snacks, and related services to patients, staff, and visitors in a hospital setting (do Rosario & Walton, 2020). It encompasses the planning, preparation, production, distribution, and service of food and beverages to meet the nutritional and dietary requirements of patients while adhering to food safety and sanitation standards. ...
Conference Paper
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Background: As the need for sustainable practices in healthcare settings becomes increasingly recognized, the use of biodegradable meal trays has gained attention as a potential solution to reduce the environmental impact of meal service in hospitals. This study aims to assess the feasibility, usability and cost of single-use biodegradable meal trays made from paddy straw. Methodology: A workflow was developed and compared between the current practice and the use of single-use meal trays based on investigator observations of the processes and approved after focused-group discussions. Staff handling the meal trays at various work processes were interviewed to capture their feedback and improvement suggestions. The components of direct cost analysis were identified based on previous literature. The resulting costs are compared between reusable and single-use biodegradable meal trays. Results: Compared to conventional meal tray, the use of biodegradable meal trays able to eliminate dishwashing and drying process and thus streamlined the work process. More than 120 minutes can be saved to complete meal serving activities when using biodegradable trays. It also has ergonomics advantage and reduced total cost up to RM 0.59 per patient over four meals in a day. It is estimated that 12.86% cost reduction can be achieved over 5-year period if biodegradable meal trays were use in hospital setting. Conclusion: Utilization of biodegradable meal trays in a hospital setting is feasible and has numerous advantages to the operating cost and staff involved.
Background: In health care service, patients' satisfaction depends on their cognitive and emotional reactions. This indicates a strong relationship exists between patients' satisfaction and health care service, especially foodservice. Foodservice quality is known to inuence patient satisfaction with hospital stay. Objective: The main aim was to study association between residence (rural/urban) and length of stay in hospital with reference to patient satisfaction in a government tertiary care teaching hospital. In order to achieve this aim, the objective identied was to measure and assess patient satisfaction with the food and services in the hospital. Method: Face to face interview was conducted of Patients who were taking hospital diet. Result: The patient's were interviewed to assess their satisfaction with hospital service in relation to understand the association between satisfaction level among respondents according to place of residence (rural/urban) and number of days in hospital stayed.
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Aim: This review explored peer-reviewed and grey literature to describe the types and characteristics of food or food-related waste management strategies used in hospital food service settings; their financial, environmental and staffing outcomes; and the barriers and enablers associated with their implementation. Methods: Six electronic databases, 17 Google Advanced searches, and 19 targeted websites were searched for peer-reviewed and grey literature. Literature reporting the financial, environmental, or staffing outcomes of food or food-related waste management strategies that reused, recovered energy from, or recycled waste instead of sending it to landfill were eligible. Document screening and review were completed in duplicate, and included peer-reviewed literature were assessed for quality using the Mixed Methods Appraisal Tool. Data were synthesised narratively. Results: Four peer-reviewed and 81 grey literature records reported 85 strategies. When grouped from most to least favourable according to the food recovery hierarchy they managed waste by: donating surplus food (n = 21); feeding animals (n = 2); industrial use (n = 11); composting (n = 34) and other (n = 17). These approaches had the capacity to reduce waste hauling fees (n = 14), reduce staff handling of waste (n = 3), and decrease the amount of waste sent to landfill (n = 85). Barriers included contamination of waste streams, while enablers included leadership and time-neutral changes. Conclusion: This review summarises the waste management strategies used by hospitals worldwide that divert food and food-related waste from landfill, their outcomes, and position in the food recovery hierarchy to enable hospital food services to implement appropriate practice and policy changes to decrease their environmental footprint.
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Hospital is a complex supply chain made up of multiple structures, stakeholders, operations, as well as information and material flows. Due to the Covid-19 pandemic, hospital overcomes several major challenges these last few months, which leads to consider its supply chain digitalization as a priority to improve healthcare and hospital services quality. Interesting in the specific service of hospital food, this article asks: How does digitalization support hygiene requirements in the hospital food supply chain? It describes the modelling and design of a hospital catering application, which aims to build a digital catering area in support to hygiene requirements.
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Background: Nutritional satisfaction is essential to the reduction of hospital costs given the faster recovery of patients. Food satisfaction may be influenced by self-operating or contractor food service management. Methods: This descriptive study was aimed to assess patient satisfaction with the dinner served in two hospitals of Tabriz, Iran by contractors and a self-operating system in 214 participants during April-May 2014. Data were collected using a researcher-made questionnaire with 20 items on demographic and food satisfaction data. Data analysis was performed in SPSS, and the intragroup and intergroup differences were evaluated and compared at the significant P-value of less than 0.05. Results: Overall food satisfaction was significantly higher in hospital A (contractor-supported food service) compared to hospital B (self-operating food service) (P<0.001). In addition, a negative correlation was observed between food satisfaction and the literacy level of the subjects. Having a companion also reduced the satisfaction score of the patients. Conclusion: Our findings could provide useful information for the legislation of new policies to increase the food satisfaction of inpatients and exploit its advantages, while contributing to the decision-making regarding the choice of financial support for hospital food services. Keywords: Food satisfaction, Self-operating food service, Contracting food service
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As humans age, the risk and severity of infections vary in line with immune competence according to how the immune system develops, matures, and declines. Several factors influence the immune system and its competence, including nutrition. A bidirectional relationship among nutrition, infection and immunity exists: changes in one component affect the others. For example, distinct immune features present during each life stage may affect the type, prevalence, and severity of infections, while poor nutrition can compromise immune function and increase infection risk. Various micronutrients are essential for immunocompetence, particularly vitamins A, C, D, E, B2, B6, and B12, folic acid, iron, selenium, and zinc. Micronutrient deficiencies are a recognized global public health issue, and poor nutritional status predisposes to certain infections. Immune function may be improved by restoring deficient micronutrients to recommended levels, thereby increasing resistance to infection and supporting faster recovery when infected. Diet alone may be insufficient and tailored micronutrient supplementation based on specific age-related needs necessary. This review looks at immune considerations specific to each life stage, the consequent risk of infection, micronutrient requirements and deficiencies exhibited over the life course, and the available evidence regarding the effects of micronutrient supplementation on immune function and infection.
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The present systematic review critically examines the available scientific literature on risk factors for malnutrition in the older population (aged ≥65 y). A systematic search was conducted in MEDLINE, reviewing reference lists from 2000 until March 2015. The 2499 papers identified were subjected to inclusion criteria that evaluated the study quality according to items from validated guidelines. Only papers that provided information on a variable's effect on the development of malnutrition, which requires longitudinal data, were included. A total of 6 longitudinal studies met the inclusion criteria and were included in the systematic review. These studies reported the following significant risk factors for malnutrition: age (OR: 1.038; P = 0.045), frailty in institutionalized persons (β: 0.22; P = 0.036), excessive polypharmacy (β:20.62; P = 0.001), general health decline including physical function (OR: 1.793; P = 0.008), Parkinson disease (OR: 2.450; P = 0.047), constipation (OR: 2.490; P = 0.015), poor (OR: 3.30; P value not given) or moderate (β: 20.27; P = 0.016) self-reported health status, cognitive decline (OR: 1.844; P = 0.001), dementia (OR: 2.139; P = 0.001), eating dependencies (OR: 2.257; P = 0.001), loss of interest in life (β: 20.58; P = 0.017), poor appetite (β: 21.52; P = 0.000), basal oral dysphagia (OR: 2.72; P = 0.010), signs of impaired efficacy of swallowing (OR: 2.73; P = 0.015), and institutionalization (β: 21.89; P < 0.001). These risk factors for malnutrition in older adults may be considered by health care professionals when developing new integrated assessment instruments to identify older adults' risk of malnutrition and to support the development of preventive and treatment strategies.
Older adults are at increased risk of malnutrition, for a variety of physiological and psychological reasons. This has implications for health, quality of life, independence and economic circumstances. Improvements in nutrition are known to bring tangible benefits to older people and many age-related diseases and conditions can be prevented, modulated or ameliorated by good nutrition. However, practical and realistic approaches are required to optimize diet and food intake in older adults. One area where improvements can be made relates to appetite. Encouraging older adults to prepare meals can increase appetite and food intake, and providing opportunities for older adults to eat a wide variety of foods, in company, is a simple strategy to increase food intake. The protein requirement of older adults is subject to controversy and although considered the most satiating macronutrient, it appears that protein does not elicit as great a satiating effect in older adults as it does in younger individuals. This indicates that there is potential to increase protein intake without impacting on overall energy intake. Other areas where simple practical improvements can be made include both packaging of foods that are easy to prepare and the education of older adults on the safe storage and preparation of food. Research into improving the diets and nutritional status of older adults has indicated that many of the strategies can be easily and cost-effectively undertaken.
Background & aims Improvement of hospital meal services is a strategy to optimize protein and energy intake and prevent or treat malnutrition during hospitalization. FoodforCare (FfC) is a new concept comprising 6-protein-rich meals per day, provided directly at the bedside following proactive advice from a nutritional assistant. Our aim is to investigate whether this new concept, FfC, improves dietary intake and patient satisfaction, compared to the traditional 3-meals a day service (TMS). Methods We performed a quasi experimental study at medical (Gastroenterology) and surgical (Gynecology, Urology, Orthopedics) wards. Patients were offered TMS (July 2015–May 2016; n = 326) or FfC meal service (after stepwise introduction per ward from January 2016–December 2016; n = 311). Primary outcome was the mean percentage of protein and energy intake relative to requirements, between patients receiving TMS and those receiving FfC, on the first and fourth day of full oral intake. Patient satisfaction comprised rating of the experienced quality of the meals and the meal service by means of a validated questionnaire. Results Patient characteristics were similar between groups, with the exception that the FfC group contained more oncology patients (p = 0.028). FfC improved mean daily protein intake (in g/day) relative to requirements (1.2 g/kg/day) at day 1 (mean % ±SD: 79 ± 33 vs. 59 ± 28; p < 0.05) and day 4 (73 ± 38 vs. 59 ± 29; p < 0.05). Mean daily energy intake (in kcal/day) relative to requirements improved at day 1 (88 ± 34 vs. 70 ± 30; p < 0.05) and day 4 (84 ± 40 vs. 73 ± 31; p = 0.05). On a scale of 1–10, patient satisfaction remained unchanged, in terms of food quality (7.7 ± 1.5 vs. 7.4 ± 1.4; p = 0.09) and meal service (7.8 ± 1.3 vs. 7.7 ± 1.1; p = 0.29). The FfC group was more satisfied with the appearance and smell of the meals (both p < 0.05). Conclusions Implementation of this novel meal service substantially improved protein and energy intake while maintaining, and to some extent, improving patient satisfaction. Registration no NCT03195283.
Background: Room service is a foodservice model that has been increasingly implemented across health care facilities in an effort to improve patient satisfaction and reduce food waste. In 2013, Mater Private Hospital Brisbane, Australia, was the first hospital in Australia to implement room service, with the aim of improving patient nutrition care and reducing costs. Objective: The aim of this study was to comprehensively evaluate the nutritional intake, plate waste, patient satisfaction, and patient meal costs of room service compared to a traditional foodservice model. Design: A retrospective analysis of quality-assurance data audits was undertaken to assess patient nutritional intake between a facility utilizing a traditional foodservice model and a facility utilizing room service and in a pre-post study design to assess plate waste, patient satisfaction, and patient meal costs before and after the room service implementation. Participants: Audit data were collected for eligible adult inpatients in Mater Private Hospital Brisbane and Mater Hospital Brisbane, Australia, between July 2012 and May 2015. Main outcome measures: The primary outcome measures were nutritional intake, plate waste, patient satisfaction, and patient meal costs. Statistical analyses performed: Independent samples t-tests and χ(2) analyses were conducted between pre and post data for continuous data and categorical data, respectively. Pearson χ(2) analysis of count data for sex and reasons for plate waste for data with counts more than five was used to determine asymptotic (two-sided) significance and n-1 χ(2) used for the plate waste analysis. Significance was assessed at P<0.05. Results: This study reported an increased nutritional intake, improved patient satisfaction, and reduced plate waste and patient meal costs with room service compared to a traditional foodservice model. Comparison of nutritional intake between a traditional foodservice model (n=85) and room service (n=63) showed statistically significant increases with room service in both energy (1,306 kcal/day vs 1,588 kcal/day; P=0.005) and protein (52 g/day vs 66 g/day, P=0.003) intake, as well as energy and protein intake as a percentage of requirements (63% vs 75%; P=0.024 and 65% vs 85%; P=0.011, respectively). Total mean plate waste decreased from 29% (traditional foodservice model) to 12% (room service) (P<0.001). Patient satisfaction ratings indicated improvement with room service across all Press Ganey meal scores: 68th to 86th percentile overall; 64th to 95th percentile for "quality of food"; and 60th to 99th percentile for "flavor of food." Evaluated during comparable times of the year, patient meal costs decreased by 15% with room service. Conclusions: A patient-centered foodservice model, such as room service, can improve patient nutritional intake and enhance patient satisfaction in a budget constrained health care environment.
Background: Malnutrition is a problem within hospitals, which impacts upon clinical outcomes. The present audit assesses whether a hospital menu meets the energy and protein standards recommended by the British Dietetic Association's (BDA) Nutrition and Hydration Digest and determines the contribution of oral nutrition supplements (ONS) and additional snacks. Methods: Patients in a UK South West hospital were categorised as 'nutritionally well' or 'nutritionally vulnerable' in accordance with their Malnutrition Universal Screening Tool score. Energy and protein content of food selected from the menu ('menu choice'), menu food consumed ('hospital intake') and total food consumed including snacks ('overall intake') were calculated and compared with the standards. Results: In total, 93 patients were included. For 'nutritionally well' patients (n = 81), energy and protein standards were met by 11.1% and 33.3% ('menu choice'); 7.4% and 22.2% ('hospital intake'); and 14.8% and 28.4% ('overall intake'). For 'nutritionally vulnerable' patients (n = 12), energy and protein standards were met by 0% and 8.3% ('menu choice'); 0% and 8.3% ('hospital intake'); and 8.3% and 16.7% ('overall intake'). Ten percent of patients consumed ONS. Patients who consumed hospital snacks (34%) were more likely to meet the nutrient standards (P ≤ 0.001). Conclusions: The present audit demonstrated that most patients are not meeting the nutrient standards recommended by the BDA Nutrition and Hydration Digest. Recommendations include the provision of energy/protein-dense snacks, as well as menu, offering ONS where clinically indicated, in addition to training for staff. A food services dietitian is ideally placed to lead this, forming a vital link between patients, caterers and clinical teams.
Background: Inadequate dietary intake is a common problem amongst older acute-care patients and has been identified as an independent risk factor for in-hospital mortality. This study aimed to explore whether food and mealtime experiences contribute to inadequate dietary intake in older people during hospitalisation. Methods: This was a qualitative phenomenological study, data for which were collected using semi-structured interviews over a three-week period. During this time, 26 patients aged 65 years or more, admitted to medical and surgical wards in a tertiary acute-care hospital, were asked to participate if they were observed to eat less than half of the meal offered at lunch. Participants provided their perspectives on food and mealtimes in hospital. Responses were recorded as hand-written notes, which were agreed with the interviewee, and analysed thematically using the framework method. Results: Twenty-five older people were interviewed across six wards. Two main themes, 'validating circumstances' and 'hospital systems', were identified. Each theme had several sub-themes. The sub-themes within validating circumstances included 'expectations in hospital', 'prioritising medical treatment', 'being inactive', and 'feeling down'. Those within 'hospital systems' were 'accommodating inconvenience', 'inflexible systems', and 'motivating encouragement'. Conclusion: Inadequate dietary intake by older hospital patients is complex and influenced by a range of barriers. Multilevel and multidisciplinary interventions based on a shared understanding of food and nutrition as an important component of hospital care are essential to improve dietary intake and reduce the risk of adverse clinical outcomes. Improving awareness of the importance of food for recovery amongst hospitalised older people and healthcare staff is a priority.
Purpose: Most patients in developed countries solely depend on the hospital menu to order their food. The provision of menu choices to patients differs between facilities. The purpose of this paper is to determine which strategies that provide menu choices to patients are effective in improving clinical and non-clinical outcomes in hospital. Design/methodology/approach: Five databases were searched to identify relevant publications. Prospective research published in English with the menu as the primary intervention was included. Study eligibility was determined and risk of bias assessed. Outcome data were combined narratively due to absence of homogeneous study design and outcomes. Findings: Of the 2,201 records screened, six studies met inclusion criteria. Standardised menu formatting and the spoken menu system were found to improve meal tray accuracy. The spoken menu and computerised interactive menu selector system enhanced aspects of patient satisfaction without cost increases. Descriptive menus may increase food consumption. Branding food items was not well supported by patients. One study rated positively for study quality with the remaining five studies receiving neutral quality ratings. Research limitations/implications: The small number of studies conducted on each intervention and the quality of the evidence made it difficult to establish a solid evidence base around providing menu choices to patients. Further research is needed on menu ordering systems, including spoken and visual menus, to determine their impact on outcomes in hospital. Originality/value: This review is first to examine the effectiveness of menu interventions in hospital. Hospital foodservice departments should consider these findings when reviewing local systems.
This study examined an initiative in which e-menus and touch screen technology were piloted in a large UK hospital, with the aim of improving food service and satisfaction. Current practice often means that patients may receive the wrong meals, resulting in dissatisfaction and plate waste. An alternative approach is for patients to use electronic menus (e-menus) to make their order, using touch screen technology on the TVs, which in many hospitals are provided at every bedside. A pre-test, post-test questionnaire, which elicited scaled responses and written comments (n= 90) was administered to a comparable group of patients. Results from both types of data suggested that most patients used e-menus effectively, although for older patients, it was more challenging. However the biggest difference in the effectiveness of the new technology was between the wards, which also showed substantial differences in service standards. It is concluded that e-menus are an effective way of imparting information about the food, and that they tend to produce greater satisfaction in recipients. However, the results suggest that more training of foodservice staff will be required in order to make the most of initiatives of this kind.