Experiences of food access in hospital. A new questionnaire measure

Evaluating Patient Experience with Food in a Hospital-Wide Survey

Purpose: Patient dissatisfaction with hospital food is an important driver of poor food intake in hospitals. The objective of this study was to examine patient satisfaction with current menu offerings and explore patient preferences and values, in order to inform a patient-centred menu redesign.Methods: Between July and September 2021, a cross-sectional survey was distributed to inpatients receiving a lunch tray at Vancouver General Hospital, a large tertiary care centre in Vancouver, Canada. The survey was based on the Acute Care Hospital Foodservice Patient Satisfaction Questionnaire, with additional questions on food experience, factors impacting preferences for hospital meals, interest in plant-rich diets, and demographics.Results: The response rate was 5.5%, with 271 patients completing at least part of the survey. On a 5-point Likert scale, (5 - highest score; 1 - lowest score) satisfaction with food quality (mean = 3.09, p < 0.001) and the overall experience (mean = 3.54, p < 0.001) was lower than industry benchmark of 4, and qualitative feedback was generally negative. Open-ended responses indicated patients were interested in expanded cultural diversity in food provision, more fresh produce and better flavours, and were generally open to trying plant-rich foods.Conclusions: A number of opportunities for improvement were identified in this survey, which will inform an upcoming menu redesign in this institution.

Mealtimes matter: Measuring the hospital mealtime environment and care practices to identify opportunities for multidisciplinary improvement

AIMS

Hospital inpatients often eat poorly and report barriers related to mealtime care. This study aimed to measure and describe the mealtime environment and care practices across 16 acute wards in a tertiary hospital to identify opportunities for improvement.

METHODS

A prospective cross-sectional audit was undertaken over a two-month period in 2021. A structured audit tool was used at one breakfast, lunch and dinner on each ward to observe the mealtime environment (competing priorities, lighting, tray table clutter) and care practices (positioning, tray within reach, mealtime assistance). Data were analysed descriptively (%, count), with analyses by meal period and ward to identify variation in practices.

RESULTS

A total of 892 observations were completed. Competing priorities (59%), poor lighting (43%) and cluttered tray tables (41%) were common. Mealtime assistance was required by 300 patients (33.6%; 5.9% eating assistance, 27.7% set-up assistance) and was provided within 10 min for 203 (66.7%) patients. A total of 54 patients (18.0%) did not receive the required assistance. We observed 447 (50.2%) patients lying in bed at meal delivery, with 188 patients (21.1%) sitting in a chair. Competing priorities, poor lighting, poor patient positioning and delayed assistance were worse at breakfast. Mealtime environments and practices varied between wards.

CONCLUSION

This audit demonstrates opportunities to improve mealtimes in our hospital. Variation between wards and meal periods suggest that improvements need to be tailored to the ward-specific barriers and enablers. Dietitians are ideally placed to lead a collaborative approach alongside the wider multidisciplinary team to improve mealtime care and optimise intake.

Developing and validating a novel staff questionnaire to identify barriers and enablers to nutrition and mealtime care on hospital wards

AIMS

Improving hospital nutrition and mealtime care is complex and often requires multifaceted interventions and implementation strategies to change how staff, wards and systems operate. This study aimed to develop and validate a staff questionnaire to identify multilevel barriers and enablers to optimal nutrition and mealtime care on hospital wards, to inform and evaluate local quality improvement.

METHODS

Literature review, multidisciplinary focus groups and end-user testing informed questionnaire development and establishment of content and face validity. To determine the construct validity, the questionnaire was administered to ward staff working in five wards across two facilities (acute hospital, rehabilitation unit). Exploratory factor analysis was used to estimate the number of factors and to guide decisions about whether to retain or reject individual items. Scale reliability was assessed using Cronbach's alpha.

RESULTS

The questionnaire was completed by 138 staff, with most respondents being nurses (57%) and working in the acute care facility (76%). Exploratory factor analysis supported construct validity of four of the original seven subscales. The final questionnaire consisted of 17 items and 4 sub sub-scales related to (1) Personal Staff Role; (2) Food Service; (3) Organisational Support, and (4) Family Involvement; each sub-scale demonstrated good reliability with Cronbach's alpha values all >0.70.

CONCLUSION

This novel and brief questionnaire shows good reliability and preliminary evidence of construct validity in this small sample. It provides a potentially useful instrument to identify barriers and enablers to nutrition and mealtime care from the staff perspective and inform where improvement efforts should be focused.

Opportunities for Patient Participation in Perioperative Malnutrition Care: A Qualitative Study

Introduction

In the perioperative period of hospitalization, barriers to food intake are common due to special nutritional needs, compromised nutritional status, and metabolic stress. Good nutritional care call for an interdisciplinary approach. And patients themselves may also play an essential role in managing nutritional care.

Objective

This study aimed to explore how patients with malnutrition experience nutritional care, their perspectives on patient participation, and their own role in malnutrition care in the perioperative period of hospitalization.

Methods

A qualitative study was conducted using an interpretive phenomenological approach. To follow patients' experiences, in-depth longitudinal interviews were undertaken before, during, and after hospitalization. Interview transcripts were analyzed thematically using open, axial, and selective coding and interpreted in an iterative process.

Results

Fifty-six interviews were undertaken with 26 patients with malnutrition scheduled for surgery and during the perioperative period of hospitalization. Four themes were identified: (1) unawareness and stigmata about being malnourished, (2) feasibility of optimal nutritional care, (3) needs and expectations for self-management, and (4) barriers and facilitators of taking own responsibilities in nutritional care.

Conclusion

Awareness and responsiveness to patients' perspectives, motivation, and compliance are prerequisites for patient participation in malnutrition care. This requires good communication between healthcare professionals and patients in all phases of hospitalization.

The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor’s ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

Older Adults' and Their Informal Caregivers' Experiences and Needs regarding Nutritional Care Provided in the Periods before, during and after Hospitalization: A Qualitative Study

To enhance prevention and treatment of malnutrition in older adults before, during and after hospitalization, deeper understanding of older adults' and informal caregivers' perspective on nutritional care is important. One-time in-depth interviews were conducted with 15 older adults who had been discharged from hospital, and seven informal caregivers. We explored their experiences and needs regarding nutritional care provided in the periods before, during and after hospitalization. Five themes emerged from the data: (1) dietary intake, (2) food service during hospitalization, (3) nutrition-related activities, (4) whose job it is to give nutritional care, and (5) competing care priorities. Further, several opinions about nutritional issues were identified. Older adults and informal caregivers did not always experience optimal nutritional care. When discussing nutritional care, they mainly focused on the in-hospital period. When providing nutritional care and developing guidelines, older adults' and informal caregivers' perspective on nutritional care should be incorporated. Here, the periods before, during and after hospitalization should be taken into account equally.

Patient-reported experiences of mealtime care and food access in acute and rehabilitation hospital settings: a cross-sectional survey

BACKGROUND

Nutrition and mealtime interventions can improve nutritional intake amongst hospital inpatients; however, patient-reported experience is rarely considered in their development and evaluation. The present study aimed to measure patient-reported food and mealtime experience to evaluate and inform continuous quality improvement of hospital nutrition care.

METHODS

A cross-sectional survey with inpatients in seven acute care and rehabilitation wards was conducted. A 27-item validated questionnaire measured five domains of patient experience: food choices, organisational barriers, feeling hungry, physical barriers to eating and food quality. Responses were summarised descriptively and compared between settings (acute versus rehabilitation), patient demographics (age, gender) and time in hospital.

RESULTS

Responses from 143 participants (mean age 67 years, 57% male, 28% rehabilitation, median 6 days into hospitalisation) showed that 10% or fewer respondents reported difficulties with food choices, feeling hungry or food quality. The most common difficulties were opening packets (36%), insufficient menu information provided (29%), being interrupted by staff when eating (28%), being disturbed when eating (27%), being in an uncomfortable position when eating (24%) and difficulty reaching food (21%). There were no significant differences in domain patterns by sex, age group or time in hospital. Organisational barriers were reported less frequently amongst rehabilitation participants compared to acute care (P = 0.01).

CONCLUSIONS

This survey highlights areas of positive patient-reported experience with nutrition care and suggests that local improvement efforts should focus on physical assistance needs and organisational barriers, especially in acute care wards. The questionnaire may be useful for informing and evaluating systematic nutrition care improvements.

Approaches to patient satisfaction measurement of the healthcare food services: A systematic review

BACKGROUND & AIMS

Monitoring consumer's satisfaction is important in ensuring effective foodservice improvements and to provide a patient-centred foodservice experience. The aim of this study is to systematically review available patient foodservice satisfaction survey instruments developed and validated within the acute and long-term care settings.

METHODS

A literature search of four scientific databases was performed to identify relevant studies with 50 participants or greater. Study characteristics, such as identifying information, contexts, and descriptive data regarding the tool and its evaluation study, were extracted and synthesised. Quality appraisal of individual studies was undertaken to assess the risk of bias during data collection.

RESULTS

Majority of the survey instruments included utilised a quantitative research approach in the form of self- or interview-administered questionnaires. Tools within the long-term care settings were more likely to be administered via interviews using a shorter and even rating scale, potentially resulting in a higher degree of bias and reduced data sensitivity. Food quality was consistently shown to be the main predictor of the overall satisfaction in food services. Factors that are context-specific to the settings, opportunities to allow open-ended comments, and the involvement of patients' perspectives in instrument development were also critical in improving survey quality.

CONCLUSION

The available validated survey instruments are generally valid and of acceptable quality, enabling effective foodservice satisfaction measurement in the healthcare settings. Nonetheless, gaps have been identified in the literature with limited evidence available for foodservice satisfaction measurement within the paediatric settings, supporting the value of future research in this field.

Epidemiology of Hypoalbuminemia in Hospitalized Patients: A Clinical Matter or an Emerging Public Health Problem?

Serum albumin levels are strongly associated with the morbidity, prognosis, and mortality rates of patients with hypoalbuminemia, which is a frequent problem during hospitalization. An observational retrospective study was carried out to analyze changes in albumin levels in hospitalized patients at the “Fondazione Policlinico Tor Vergata—PTV” in 2018. The prevalence of preexisting hypoalbuminemia at the time of discharge from hospital was investigated using a sample of 9428 patients. Information was collected from the discharge files recorded in the central informatics system of the hospital. Analysis of albumin levels at admission and at discharge was conducted by classes of albuminemia and then stratified by age. At the time of admission, hypoalbuminemia was found to be present in more than half of the sample, with no sex differences. The serum albumin level tended to decrease with age, with pathologic levels appearing from 50 years and progressive worsening thereafter. The condition of marked and mild hypoalbuminemia was more prevalent in patients over 65 years of age. Our findings suggest that hypoalbuminemia should be considered a dangerous condition in itself and a serious public health problem. We aimed to emphasize the role of albumin as useful marker of the in-hospital malnutrition and frailty, to be integrated in the routinely assessment of patients for reconsidering ad hoc healthcare pathways after discharge from hospital, especially when dealing with fragile populations.

Effect of a Preoperative Home-Delivered, Protein-Rich Meal Service to Improve Protein Intake in Surgical Patients: A Randomized Controlled Trial

BACKGROUND

The preoperative period likely provides an important opportunity to improve postoperative recovery, as suggested by the finding that low nutrition status is a predictor of increased postoperative complications and longer length of stay (LOS). It was investigated whether a home-delivered, protein-rich meal service improves protein intake relative to requirements within 3 weeks prior to surgery compared to usual care (UC).

METHODS

This randomized controlled trial included adults (n = 126) with planned surgery performed at the orthopedics, urology, gynecology, or general surgery departments. The intervention group received 6 protein-rich dishes per day for 3 weeks, and the control group sustained their usual diet. Dietary intake, nutrition status, hand grip strength, physical performance, and quality of life were assessed at baseline and after 3 weeks. Patient satisfaction was reported after 3 weeks, and data on complications and LOS were reported 30 days after surgery.

RESULTS

Protein intake relative to requirements significantly improved by 16%, and energy intake relative to requirements increased by 19% for the meal service, as compared with UC. The intervention group experienced significantly less stress with preparing meals and were more satisfied with the presentation of the meals than the control group. No significant effects of the intervention were detected on other secondary outcomes.

CONCLUSION

The home-delivered, protein-rich meal service was successfully implemented before surgery and improved protein and energy intake relative to requirements within 3 weeks while patient satisfaction maintained. The preoperative period serves as a window of opportunity to prepare patients before hospitalization.

Barriers to Oral Food Intake for Children Admitted to Hospital

Children are at risk for malnutrition in hospital, and a contributing factor may be poor oral intake. Barriers to intake have been studied in adults, but there is a lack of research in children. The purpose of this study was to identify the potential barriers to oral intake for children in hospital. Patients and families (n = 58) admitted to surgery and medicine units at the Stollery Children’s Hospital completed a survey on barriers to oral food intake. Barriers were classified into 6 domains and major barriers were those identified by at least 30% of the population. On average each patient was affected by 22% of the barriers. Within each domain, the proportion of patients identifying at least 1 barrier was as follows: organization (74%), hunger (67%), quality (60%), effects of illness (53%), choice (38%), and physical limitations (29%). Having food brought in from home due to hunger, not wanting what was ordered once it arrives, food quality, decreased appetite, sickness, fatigue, and pain were identified as major barriers. Children have unique barriers to oral food intake in hospital which have not been previously identified. Food service models should consider these barriers to better meet the needs of this population.

The Currently Available Literature on Inpatient Foodservices: Systematic Review and Critical Appraisal

BACKGROUND

An adequate hospital foodservice is important to optimize protein and energy intake and to maintain or improve a patient's nutritional status. Key elements that define an optimal foodservice have yet to be identified.

OBJECTIVES

To systematically describe the effects of published foodservice interventions on nutrition and clinical outcomes and determine which elements should be considered essential. Secondly, to describe the outcome measures used in these studies and evaluate their relevance and validity to guide future research.

METHODS

PubMed, Embase, the Cochrane Library, and the Web of Science databases were searched. Studies that included assessment of nutrition and/or clinical outcomes of hospital foodservice up to December 2017 were eligible. The details of the subject population, the type of intervention, and the effects on reported outcomes were extracted from each study.

RESULTS

In total, 33 studies that met inclusion criteria were identified, but only nine (27%) were rated as having sufficient methodologic quality. These nine studies concluded that various elements of a foodservice can be considered essential, including using volunteers to provide mealtime assistance, encouraging patients to choose protein-rich foods, adding protein-enriched items to the menu, replacing existing items with protein-enriched items, giving patients the ability to order food by telephone from a printed menu (room service concept), or a combination of these interventions. The interstudy heterogeneity was high for both outcome measures and methods.

CONCLUSIONS

Various foodservice interventions have the potential to improve outcome measures. Recommendations are made to facilitate future research.

Impact of Facilitated Behavior Change Strategies on Food Intake Monitoring and Body Weight Measurements in Acute Care: Case Examples From the More-2-Eat Study

BACKGROUND

Assessing and monitoring food intake and body weight of all hospital patients is considered part of "best practice" nutrition care. This study presents case examples describing the impact of behavior change strategies on embedding these 2 monitoring processes in hospitals.

METHODS

Four hospital medical units that participated in the More-2-Eat implementation study to improve nutrition care focused on improving food intake and/or weight monitoring practices. The percentage of admitted patients who received these care practices were tracked through chart audits over 18 months. Implementation progress and behavior change strategies were documented through interviews, focus groups, scorecards, and monthly telephone calls. Case examples are explored using mixed methods.

RESULTS

Of the 4 units, 3 implemented food intake monitoring. One provided food service workers the opportunity to record food intake, with low intake discussed by an interdisciplinary team during bedside rounds (increased from 0% to 97%). Another went from 0% to 61% of patients monitored by introducing a new form ("environmental restructuring") reminding staff to ask patients about low intake. A third unit increased motivation to improve documentation of low intake and improved from 3% to 95%. Two units focused on regularity of body weight measurement. One unit encouraged a team approach and introduced 2 weigh days/week (improved from 14% to 63%), while another increased opportunity by having all patients weighed on Saturdays (improved from 11% to 49%).

CONCLUSION

Difficult-to-change nutrition care practices can be implemented using diverse and ongoing behavior change strategies, staff input, a champion, and an interdisciplinary team.

Perceptions and experiences of nutritional care following the overwhelming experience of lower extremity amputation: A qualitative study

INTRODUCTION

Good nutritional care of people following major lower extremity amputation is essential as poor nutritional status can lead to delayed wound healing. Working with patients to identify their perspectives on food, views on nutritional care and the need for dietary counselling enables the development of optimised nutritional care.

AIMS AND OBJECTIVES

To explore hospital patients' perspectives on food, dietary counselling and their experiences of nutritional care following lower extremity amputation.

DESIGN

A qualitative, explorative study design was employed.

METHOD

An inductive content analysis of semi-structured interviews with a purposive sample of 17 people over 50 years of age, who had recently undergone major lower extremity amputation, was undertaken. The study was reported according to the consolidated criteria for reporting qualitative research guideline.

FINDINGS

Three themes emerged: responsible for own dietary intake, diet based on preferences and experiences with dietary counselling and feeling overwhelmed. The participants expressed motivation to ensure their nutritional needs were met but described feeling emotionally overwhelmed by the experience of amputation. They appeared not to expect nursing staff to focus on nutritional issues as they expressed belief that they themselves were solely responsible for their dietary intake. They described being motivated to receive nutritional counselling but indicated advice should be compatible with their lifestyle and eating habits.

CONCLUSION

Lower extremity amputation can be an overwhelming experience which affects nutritional intake. People appear to consider themselves responsible for their nutritional care and describe not experiencing or expecting nursing staff to engage in this aspect of care. Dietary counselling by nurses who respect and incorporate patient preferences and experiences following amputation has the potential to enhance nutritional care.

RELEVANCE TO CLINICAL PRACTICE

This study illustrates that nurses caring for people who undergo lower extremity amputation need to recognise that nutritional care is an essential component of nursing and should focus on working in partnership with the patient.

Changing nutrition care practices in hospital: a thematic analysis of hospital staff perspectives

Background

Many patients are admitted to hospital and are already malnourished. Gaps in practice have identified that care processes for these patients can be improved. Hospital staff, including management, needs to work towards optimizing nutrition care in hospitals to improve the prevention, detection and treatment of malnutrition. The objective of this study was to understand how staff members perceived and described the necessary ingredients to support change efforts required to improve nutrition care in their hospital.

Methods

A qualitative study was conducted using purposive sampling techniques to recruit participants for focus groups (FG) (n = 11) and key informant interviews (n = 40) with a variety of hospital staff and management. Discussions based on a semi-structured schedule were conducted at five diverse hospitals from four provinces in Canada as part of the More-2-Eat implementation project. One researcher conducted 2-day site visits over a two-month period to complete all interviews and FGs. Interviews were transcribed verbatim while key points and quotes were taken from FGs. Transcripts were coded line-by-line with initial thematic analysis completed by the primary author. Other authors (n = 3) confirmed the themes by reviewing a subset of transcripts and the draft themes. Themes were then refined and further detailed. Member checking of site summaries was completed with site champions.

Results

Participants (n = 133) included nurses, physicians, food service workers, dietitians, and hospital management, among others. Discussion regarding ways to improve nutrition care in each specific site facilitated the thought process during FG and interviews. Five main themes were identified: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team.

Conclusions

Hospital staff need a reason to change their nutrition care practices and a significant change driver is perceived and experienced benefit to the patient. Participants described key ingredients to support successful change and specifically engaging the interdisciplinary team to effect sustainable improvements in nutrition care.

Trial registration

Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.

Need for the Integrated Nutrition Pathway for Acute Care (INPAC): gaps in current nutrition care in five Canadian hospitals

BACKGROUND

Malnutrition is common in hospitalized patients and is associated with increased mortality, length of stay, and risk of re-admission. The consensus based Integrated Nutrition Pathway for Acute Care (INPAC) was developed and validated to enhance patients' nutrition care and improve clinical outcomes. As part of the More-2-Eat project (M2E), five hospitals implemented INPAC activities (e.g. screening) in a single medical unit. The purpose of this paper is to demonstrate the care gaps with respect to INPAC activities on these five units prior to implementation. Results were used as part of a needs assessment on each unit, demonstrating where nutrition care could be improved and tailoring of implementation was required.

METHODS

Cross-sectional data was collected by site research associates (RAs) using a standardized audit form once per week for 4 weeks. The audit contents were based on the INPAC algorithm. All medical charts of patients on the study unit on the day of the audit were reviewed to track routine nutrition care activities (e.g. screening). Data was descriptively displayed with REDCap™ and analyzed using R Studio software.

RESULTS

Less than half of patients (249/700, 36%) were screened for malnutrition at admission. Of those screened, 36% (89/246) were at risk for malnutrition yet 36% (32/89) of these patients did not receive a dietitian assessment. Also, 21% (33/157) of patients who were not screened at risk were assessed. At least one barrier to food intake was noted in 85% of patient medical charts, with pain, constipation, nausea or vomiting being the most common. Many of these barriers were addressed through INPAC standard nutrition care strategies that removed the barrier (e.g. 41% were provided medication for nausea). Advanced nutrition care strategies to improve intake were less frequently recorded (39% of patients).

CONCLUSION

These results highlight the current state of nutrition care and areas for improvement regarding INPAC activities, including nutrition screening, assessment, and standard and advanced nutrition care strategies to promote food intake. The results also provided baseline data to support buy-in for INPAC implementation in each M2E study unit.

TRIAL REGISTRATION

Retrospectively registered ClinTrials.gov Identifier: NCT02800304, June 7, 2016.

Are energy and protein requirements met in hospital?

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.

Quality Nutrition Care: Measuring Hospital Staff's Knowledge, Attitudes, and Practices

Understanding the knowledge, attitudes, and practices (KAP) of hospital staff is needed to improve care activities that support the detection/prevention/treatment of malnutrition, yet quality measures are lacking. The purpose was to develop (study 1) and assess the administration and discriminative potential (study 2) of using such a KAP measure in acute care. In study 1, a 27-question KAP questionnaire was developed, face validated (n = 5), and tested for reliability (n = 35). Kappa and Intraclass Correlation (ICC) were determined. In study 2, the questionnaire was sent to staff at five diverse hospitals (n = 189). Administration challenges were noted and analyses completed to determine differences across sites, professions, and years of practice. Study 1 results demonstrate that the knowledge/attitude (KA) and the practice (P) subscales are reliable (KA: ICC = 0.69 95% CI 0.45-0.84, F = 5.54, p < 0.0001; P: ICC = 0.84 95% CI 0.68-0.92, F = 11.12, p < 0.0001). Completion rate of individual questions in study 2 was high and suggestions to improve administration were identified. The KAP mean score was 93.6/128 (range 51-124) with higher scores indicating more knowledge, better attitudes and positive practices. Profession and years of practice were associated with KAP scores. The KAP questionnaire is a valid and reliable measure that can be used in needs assessments to inform improvements to nutrition care in hospital.

Factors associated with nutritional decline in hospitalised medical and surgical patients admitted for 7 d or more: a prospective cohort study

This prospective cohort study was conducted in eighteen Canadian hospitals with the aim of examining factors associated with nutritional decline in medical and surgical patients. Nutritional decline was defined based on subjective global assessment (SGA) performed at admission and discharge. Data were collected on demographics, medical information, food intake and patients' satisfaction with nutrition care and meals during hospitalisation; 424 long-stay (≥7 d) patients were included; 38% of them had surgery; 51% were malnourished at admission (SGA B or C); 37% had in-hospital changes in SGA; 19·6% deteriorated (14·6% from SGA A to B/C and 5% from SGA B to C); 17·4% improved (10·6% from SGA B to A, 6·8% from SGA C to B/A); and 63·0 % patients were stable (34·4% were SGA A, 21·3% SGA B, 7·3% SGA C). One SGA C patient had weight loss ≥5%, likely due to fluid loss and was designated as stable. A subset of 364 patients with admission SGA A and B was included in the multiple logistic regression models to determine factors associated with nutritional decline. After controlling for SGA at admission and the presence of a surgical procedure, lower admission BMI, cancer, two or more diagnostic categories, new in-hospital infection, reduced food intake, dissatisfaction with food quality and illness affecting food intake were factors significantly associated with nutritional decline in medical patients. For surgical patients, only male sex was associated with nutritional decline. Factors associated with nutritional decline are different in medical and surgical patients. Identifying these factors may assist nutritional care.

Should we implement mealtime assistance in the hospital setting? A systematic literature review with meta-analyses

AIMS AND OBJECTIVES

This review aimed to determine the effect of mealtime assistance provided to hospitalised patients (≥65 years) by nurses, trained staff or volunteers on nutritional and anthropometric outcomes.

BACKGROUND

Malnutrition is a critical issue in hospitals with a reported prevalence of 20-50%. Nutritional supplementation has been associated with increased weight gain, improved function and decreased mortality; however, other system approaches including mealtime assistance may also contribute to improving nutritional intake.

DESIGN

A systematic literature review.

METHODS

Six electronic databases (CINAHL Plus, Cochrane Library, ProQuest Nursing and Allied Health Source, Scopus, PsycINFO and MEDLINE) were searched from their inception to August 2014. Inclusion criteria were hospitalised patients ≥65 years, provided mealtime assistance by nurses, volunteers or trained staff. Studies were examined for quality and risk of bias. Outcome data were combined narratively and by meta-analyses.

RESULTS

From 5458 publications, five studies met the inclusion criteria. Studies were rated neutral and positive according to the Academy of Nutrition and Dietetics Quality Checklist. Adherence to study protocols was not always reported. Meta-analyses demonstrated significantly greater daily energy and protein intake where mealtime assistance was provided. Anthropometric outcomes generally did not differ significantly with mealtime assistance. Observation and sampling bias were noted in several studies.

CONCLUSIONS

There is evidence that mealtime assistance increases daily energy and protein intake in hospitalised patients (≥65 years). More robust research is needed to elucidate whether this strategy may be an effective means of addressing the high prevalence of malnutrition in hospitals.

RELEVANCE TO CLINICAL PRACTICE

The evidence identified suggests that mealtime assistance provided to hospitalised older patients (≥65 years) leads to a statistically significant increase in energy and protein intake. For many patients, this increase in both energy and protein intake will be clinically significant, reducing the gap between requirements and actual intake.

A systematic review of hospital foodservice patient satisfaction studies

The quality of hospital foodservice is one of the most relevant items of health care quality perceived by patients and by their families. Patient satisfaction is considered a way of measuring the quality of services provided. The purpose of this study was to retrieve and review the literature describing patient satisfaction with hospital foodservices. The systematic review was conducted on three electronic archives, PubMed, Excerpta Medica Database, and the Cumulative Index to Nursing and Allied Health Literature (1988 through 2012), to search for any articles reporting patient satisfaction with hospital foodservices. A total of 319 studies were identified. After removing duplicates, 149 abstracts were reviewed, particular attention being given to the presence of a description of the tool used. Thirty-one articles were selected and the full texts were reviewed. Half the studies (n=15) were performed in North America. Patient satisfaction scores were generally high, with some variation among hospitals and different modes of food delivery that was investigated through intervention studies. Qualitative studies were also reported (ethnographic-anthropologic methods with interviews and focus groups). Quantitative tools were represented by questionnaires, some of which relied on previous literature and only a few were validated with factorial analysis and/or Cronbach's α for internal consistency. Most analyses were conducted assuming a parametric distribution of results, an issue not primarily tested. More studies on the quality of hospital foodservice have been carried out in North America than in Europe. Also, a variety of tools, most of which have not been validated, have been used by the different investigating facilities.

[Predictors of patient satisfaction with the food services in a public hospital in Madrid]

OBJECTIVE

To describe patients satisfaction with the food services during hospitalisation, and to determine the predictors.

METHODOLOGY

A cross-sectional study was conducted in the "Clínico San Carlos" Hospital, between May and September 2010. A self-completion questionnaire was given to patients with both regular and therapeutic diets after their hospital discharge. We included socio-demographic variables, overall satisfaction, and satisfaction regarding different aspects and types of food. Descriptive and multivariable analyses were performed, with the overall satisfaction with food as the dependent variable using binary logistic regression.

RESULTS

A total of 549 questionnaires were returned (rate 29%), of which 60.7% received a therapeutic diet. 55.4% were men, and the median age was 68 years. Three-quarters (75%) were satisfied or very satisfied. Statistically significant variables associated with patient satisfaction with the food services received were the meal's taste and temperature, as well as being satisfied with the fish and soups on the menu.

CONCLUSIONS

Despite the high level of satisfaction with food services, there is scope for improvement. We have identified some of the aspects on which action would be more beneficial.

Designing a national clinical audit of nutritional care in health and social care settings: consideration and future directions

The aim of this review paper is to consider how the principles of clinical audit could be applied to the development of an audit of nutritional care in hospitals and care homes, based on criteria derived from the Essence of Care: Food and Drink. A literature review identified fifteen key papers that included guidance or standards for nutritional care in hospitals or care homes. These were used to supplement the ten factors suggested by the Essence of Care to develop a set of potential audit criteria covering all aspects of the nutritional care pathway including the identification of risk of malnutrition, implementation of nutritional care plans, referral to healthcare professionals for further nutritional assessment and nutritional support strategies. A series of audit tools have been developed, including an organisational level audit tool, a staff questionnaire, a patients' and residents' records audit tool and a patients' and residents' experiences questionnaire. Further issues to consider in designing a national nutritional audit include the potential role of direct observation of care, the use of trained auditors and the scope for including the results of pre-existing local audits. In conclusion, a national audit would need to encompass a very large number of health and care organisations of widely varying sizes and types and a diverse range of people.

Higher food intake and appreciation with a new food delivery system in a Belgian hospital. Meals on Wheels, a bedside meal approach: a prospective cohort trial

AIM

A new system of meal distribution called Meals on Wheels, allowing food ordering at mealtime and providing guidance by trained nutritional assistants, might show benefit in offering nutritional support. This study investigates whether Meals on Wheels improves total food intake per day and yielded improved appreciation of food quality and increased access to food and mealtimes.

METHODS

In a prospective cohort trial where control and intervention groups were taken from all patients hospitalized at the respiratory disease department, age, sex, BMI, admission weight, height, reason for admission and discharge weight were noted, as was food intake, supplements, waste per meal and daily total. For food appreciation the questionnaire developed by Naithani et al. was used. The study included 83 patients in the control group and 106 patients in the Meals on Wheels group.

RESULTS

Mean total daily food intake was 236 g higher in patients in the Meals on Wheels than in controls. There was higher intake of oral nutritional supplements in the Meals on Wheels group compared to controls, resulting in significantly less oral nutritional supplements wasted. There was also significantly less waste in the Meals on Wheels group. For food access and appreciation, patients appreciated Meals on Wheels more than the old system in terms of choice, hunger, food quality and organization.

CONCLUSIONS

Meals on Wheels resulted in higher food intake during each meal, less waste and better use of oral nutritional supplements. Patients appreciated Meals on Wheels more than the old system in terms of choice, hunger, food quality and organization.