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 modiﬁcations 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 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 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
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
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
The meal experience is signiﬁcantly shaped by the individual living arrangements
in institutions and it has even been suggested that the word “meal”may 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)
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 (Dall’Oglio 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
medicine”meals, 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 Emperor’s Classic of Internal Medicine,
722–721 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 ofﬁce of the nurse, after she has taken care of the
patients’air, 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 beneﬁcial for their recovery and health, and also to give them an example of
healthy nutrition with menus tailored to patients’speciﬁc health conditions. When
meals are carefully planned and customized to meet patients’speciﬁc 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 inﬂuence patient satisfaction with hospital stay. It is widely
recognized that food and other aspects of foodservice delivery are important ele-
ments in patients’overall 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 (Dall’Oglio et al. 2015).
Deﬁning quality for hospital foodservice requires a balance of many different
features. Hospital menus should be based primarily on clinical needs, as well as on
patients’preferences. 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 identiﬁed 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 difﬁcult to assess (Dall’Oglio 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 efﬁciency 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 patients’voices 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 individuals’speciﬁc
nutritional needs is an essential goal. However necessary dietary modiﬁcations (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 deﬁned as a state in which deﬁciency, 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 identiﬁed
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 20–50% 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 ﬁeld 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 ﬁve 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 speciﬁc 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 sufﬁcient 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 1–15% in
community-living older adults, 25–60% in care facilities and 35–65% 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).
Insufﬁcient 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 deﬁned as a metabolic syndrome in
which inﬂammation 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 (difﬁculty swallowing),
gastrointestinal reﬂux, and constipation. Reduced gastric acid secretions increases
with aging, which inﬂuences 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 ﬂuid intake and increased
ﬂuid loss, consequently making them more susceptible to develop problems with
ﬂuid 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 ﬂuids 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
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 Insufﬁcient 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,
Vomiting, diarrhea, ﬁstulae, stomas, and colostomy
Chronic kidney, respiratory, gastrointestinal and liver diseases,
malignancies, HIV, AIDS, stroke, and surgeries
Eating environment Social isolation, bereavement, or other signiﬁcant life event
Hospital Food Service 7
There needs be some ﬂexibility 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 identiﬁed “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 ﬂexibility. 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 speciﬁed 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 vulnerable”patients; 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 signiﬁcant
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 ﬂagging 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)
Energy (kcal) 2250–2625 1800–2400 Daily
Protein (g) 60–75 56 Daily
Total fat (% food energy) Not speciﬁed 35 Averaged
over a week
Saturated fat (% food energy) Not speciﬁed 11 Averaged
over a week
Carbohydrate (% food energy) Not speciﬁed 50 Averaged
over a week
Non-milk extrinsic sugars
(NMES) (% food energy)
Not speciﬁed 10 Averaged
over a week
Fiber (g) Not speciﬁed 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 (riboﬂavin), 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 ﬁrst 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 ﬁfteen 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
(1–117) 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 Speciﬁc nutrient requirements for older adults >50 years
Nutrient Recommendation (daily)
Protein 1.0–1.3 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 difﬁcult 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.
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 ﬂavor 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
signiﬁcantly more likely to offer choices of portion size and optional sauces and
gravies with meat compared to cook-chill hospitals (Williams 2009).
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 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 ﬂexibility,
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, ﬂexibility, 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
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 food”and for “ﬂavor 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 patients’needs, not
those of medical, nursing, and other healthcare staff and should be managed as an
integral component of clinical care rather than a “hotel”function. 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,
Menu Planning and Recipe Development
Different foods provide different nutrients; some nutrients are only found in sufﬁ-
cient quantities if speciﬁc foods or food groups are included in adequate amounts in
the diet. Thus, in order to meet the nutrient standards speciﬁed 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 ﬁve food groups (and additional protein, fats, and
sugars where required), namely:
•Breads, other cereals, and potatoes
•Milk and dairy foods
•Meat, ﬁsh, 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 speciﬁed
Hospital Food Service 13
in the ﬁve food groups needs to remain ﬂexible 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; 3–4 week cycles are more
common in longer-care facilities (Williams 2009).
Menus are an important tool for the foodservice manager as they are the ﬁrst 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
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 ramiﬁcations 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 ﬁrst option, or alternately the last one
offered, which they may remember.
A review found that modiﬁcations 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 ﬁndings show that the use of an
electronic menu management system can create efﬁciencies 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).
A therapeutic diet is modiﬁed from a “normal”diet 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 reﬂect local population needs and healthcare organizations need to
develop their own protocol for the requirement and provision of therapeutic diets for
•There must be a hospital protocol for the provision of all therapeutic diets.
•Patients must be given choice for all food and ﬂuid options suitable for their diets,
including therapeutic and/or texture modiﬁed 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
•Where relevant, foodservice service contracts must be sufﬁciently 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 speciﬁcations, 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
speciﬁc requirements, such as texture-modiﬁed diets, allergy and intolerance diets,
diabetic diets, diet–drug interaction diets, macronutrient modiﬁed diets (fat, protein,
and carbohydrates), ﬁber-modiﬁed diets, ﬂuid 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 ﬁnd it difﬁcult to eat sufﬁcient 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
The requirement for texture modiﬁed or modiﬁed consistency food and ﬂuid,
usually results from difﬁculties 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 person’s ability to
adapt and compensate for an inadequate swallow is further reduced by less saliva
or chewing difﬁculties, 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 ﬂuid of an inappropriate consistency increases the risk of food
or ﬂuid 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).
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
signiﬁcant risks to patients if allergen-free diets are not provided when required.
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 deﬁciencies 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 patients’dietary needs should be catered for in the
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 patients’diets when exclusion of
speciﬁc foods is required due to an allergy or food intolerance.
Hospital Food Service 17
Where an allergenic ingredient or its derivative is not clearly identiﬁed in the
name of the food (e.g., malt vinegar), the allergenic ingredient should always be
clearly identiﬁed 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 ﬁnished product, even in an altered
form. This includes carryover additives, additives used as processing aids, solvents,
and media for additives or ﬂavoring and any other substance used as a processing
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 beneﬁt from this type of diet by
reducing symptoms such as bloating and low-grade inﬂammation.
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
patients’cultural and religious food needs, there are some patient groups with
alternative needs. A patient’s 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, ﬁbers, 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 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 stafﬁng 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 speciﬁc 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 scientiﬁcally 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
signiﬁcantly 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 signiﬁcantly 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 difﬁculty 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 difﬁculty 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 identiﬁed
were lack of choice due to special diet, boredom arising from the length of stay, a
lack of feeding assistance, limited variety, and inadequate ﬂexibility of food service
(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 “ﬁddly”packaging (i.e.,
packaging that appears to require dexterity to access the contents) and decreased
hand strength are shown to inﬂuence 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 signiﬁcant proportion of staff are also unable to open these packages.
This study also identiﬁed 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 difﬁculties 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 fortiﬁcation, 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 well”patients, 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-
ble”patients, 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
patient’s 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
efﬁciency. 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 patients’food and nutrition needs are met. However, foodservice
systems can be more reactive and ﬂexible 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 ﬁnancial and environmental costs. Plate waste is typically
measured by weighing food or by visual estimation of the amount of food remaining
on the plate, with results presented as the percentage by weight of the served food, or
by calculating the protein, energy or monetary value of the waste. Results from 32
studies in hospitals show a median plate waste of 30% by weight (range: 6–65%),
much higher than in other foodservice settings. Levels are lower in hospitals using a
bulk food delivery system compared to plated meal delivery. Reasons for these high
levels can relate to the clinical condition of patients, food and menu issues (such as
poor food quality, inappropriate portion sizes, and limited menu choice), service
issues (including difﬁculty accessing food and complex ordering systems), and
environmental factors (such as inappropriate meal times, interruptions, and unpleas-
ant ward surroundings). Strategies to minimize waste include reduced portion sizes
with food fortiﬁcation, bulk meal delivery system, feeding assistance, provision of
dining rooms, and protected meal times (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
•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)
•Clariﬁcation 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 speciﬁc tasks, when appropriate
•Reminders in place for staff to ensure training is carried over into practice and
changes are sustained
•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 patients’health, recovery, and support. This chapter
addressed several topics in this ﬁeld, gathering practicable knowledge from different
parts of the world with diverse resources and populations’characteristics. 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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