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Chairman and Editor: Dr SP Allison

Summary and Recommendations

The Problem
Forty percent of adult hospital patients and 15% of children are malnourished on admission, half of these severely so. The majority who depend on hospital food for all their nutrition, continue to lose weight while in hospital, reflecting the inadequacy of current feeding policies. Between 30 and 50% of hospital food is wasted and average food intakes are less than 75% of that recommended, particularly among the elderly. This impairs clinical outcome and wastes resources.

Cost of Waste
The monetary value of hospital food wasted annually in England alone can be calculated at £45 million. If labour and overheads are included, this cost rises to £144 million. There is also a hidden cost of the extra morbidity associated with malnutrition.

Evidence Base
Recent studies, reviewed in this report, provide strong evidence that measures such as improved staff training, nutritional screening and assessment, and monitoring, combined with better catering practices, can result in most patients' nutritional requirements being met. Fortified meals, between meal snacks and adequate ward staffing have all been shown to contribute to achieving this goal, which leads to better clinical outcome, less waste, shorter hospital stay and a more cost-effective service.

Quality Standards
High standards of nutritional care including hospital food provision should be one of the Quality Standards required of Health Authorities, purchasing groups and Trusts. These authorities should have their own explicit, written nutritional standards and guidelines based on official national standards. Appropriate funding must be made available to attain these standards. Good feeding should also be part of Clinical Governance.

Audit and Accreditation
Achievement of these standards should be monitored and be the subject of regular audit, as well as part of the Audit Commission's assessment, Hospital Accreditation schemes, and Commission for Health Improvement inspections.

Catering Officers
This report is not a criticism of catering officers in the Health Service, who are working under difficult conditions. Most of the shortcomings highlighted are outside the power of catering officers to change and necessitate a combined team effort from all disciplines in the Health Service.

Cost of Food
Better catering and feeding may be slightly more costly, but we consider that this is justified in the interests of the quality of care and a better clinical outcome.

Which Budget?
Consideration should be given to transferring the catering and nutritional care service from the hotel/facilities budget to the clinical support and treatment service budget. Consideration should also be given to a new Nutrition Directorate with overall responsibility for all aspects of nutritional care.

Management of the Service
The Nutrition Directorate should be supervised by a Nutrition Steering Committee responsible for overseeing all aspects of nutrition, including hospital food, oral supplements and artificial nutrition, since these overlap and are interdependent. The committee should have the power, not only of making recommendations, but of implementing change. It should consist of a core group including the chief dietitian, the chief catering officer, a manager from the finance or business section of the hospital, a senior clinician with a special interest in nutrition, a senior nurse, who may be the nutrition nurse specialist, and a pharmacist. Other members may be recruited as appropriate.

Contracting Out
In contracting out or in the development of in-house catering services, the Steering Committee must be involved in contractual arrangements from the beginning. They should be responsible for evaluating the experience of other centres and seeking expert advice. They should also direct subsequent monitoring and audit of the service.

Role of Dietitian
The chief dietitian should have executive not just advisory input into catering services.

Role of Nurses and Other Staff
The primary responsibility for the nutritional care of in-patients rests with the nurses in charge of the ward. Food should be served by nurses,  supported where necessary by other grades of staff trained for this purpose, e.g. ward hostesses, diet technicians/helpers, care assistants, etc. Assistance  with eating must be provided, and special utensils provided where necessary.  Plate or tray collection should be supervised by nursing staff, to enable patients'  food intake to be monitored.

Responsibility of Doctors
Doctors should acknowledge a responsibility for patient nutrition as an important  part of overall management. This falls within the definition of their 'duty of care'.

Nutritional Screening of Patients
Nutritional risk screening should be an integral part of the nursing and medical  admission process. Screening should be linked to a nutritional care plan in  those found to be at risk. All patients should be monitored during their hospital  stay to identify any changes in risk category.

Menus should be designed to meet the needs of particular patient groups, e.g.  the elderly, children and ethnic minorities. Adequate choice should be available to meet these needs. A range of meals specially fortified in energy and protein  should also be available in every hospital, and snacks and nourishing drinks should be kept on the ward and routinely offered between meals. The timing of meals should be reviewed and made more relevant to patients' customary meal patterns.

Nutritional Requirements
Patients' food intake should meet minimum total energy (30-35 kcal/kg/day),  protein (1 g/kg/day) and micronutrient requirements, as described in the body of  this report. In many cases, none of these are currently being met.

Food Preparation and Serving
All methods of food preparation, e.g. in-house cook-serve or bought in cook- chill (with ward kitchen regeneration) have proved successful, but each is highly dependent on the method of distribution and serving. With proper management,  a bulk trolley bedside service best serves patients' needs and is the method recommended by this working party.

Near Ward Kitchens
Consideration should be given to the use of a few near ward kitchens, strategically sited to serve the needs of particularly vulnerable patients, identified as having nutritional needs, not readily met by a centralised catering service.

Interference with Meals
Interruption of patients' meal times by ward rounds and procedures should be  minimised, and each ward should have a clear policy in this respect. The  environment at meal times should be made as conducive to eating as possible.

Proprietary Oral Supplements
Proprietary oral supplements and artificial nutrition techniques should not be a  substitute for the adequate provision of normal food. Where clinically indicated,  however, they can be extremely effective means of achieving nutritional goals  and improving clinical outcome.

Effect of Drugs
The use of drugs with side effects of anorexia, nausea and gastrointestinal  symptoms should be minimised by careful review of drug charts, particularly in  the case of elderly patients.

Monitoring and Audit
Regular monitoring and audit of nutritional care should be undertaken at the  point of consumption, to measure patient satisfaction, nutritional content of the  menu and food intake and wastage. Other measures such as weight change  during  hospital admission, length of stay and clinical outcome criteria may also  be assessed in relation to the adequacy of patients' nutritional intake.

Education and Training
Fundamental to the success of any catering or nutritional care policy is a  programme of education and training for all staff, who should feel a sense of ownership of and responsibility for the service. There should be clear channels of communication by which all staff can influence policy and contribute to improved standards of care.

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