Issue 20 / 10 June 2014

PATIENT nutrition is often an “afterthought” in the hospital environment and greater recognition of nutrition issues among doctors is needed, according to a leading Australian expert on human nutrition.

Professor Ian Caterson, Boden Professor of Human Nutrition at the University of Sydney, said many elderly people admitted to hospital had nutrition issues that were not considered in acute situations. Malnourishment could also be exacerbated during hospital treatment, he said.

“We fast [patients] for scans or procedures and then, if an emergency patient comes in, the [less urgent] patient gets bumped, so they spend some of their time in hospital not eating”, he said. “We have to think of ways around that.”

Professor Caterson was commenting on Canadian survey of 428 physicians that found while they believed that nutrition assessment should be performed when patients were admitted to hospital, most felt that this was not being done on a regular basis during hospitalisation and on discharge. (1)

“A multidisciplinary team is needed to address hospital malnutrition, and educational strategies that target physicians are needed to promote better detection and management throughout the hospital stay”, the researchers concluded.

Professor Caterson told MJA InSight education in nutrition was not given high priority in medical schools.

“While there is some [teaching of] nutrition in medical courses, it’s not high up. It tends to be recognising the issue in relation to diabetes or obesity, or calcium or cholesterol”, he said.

Professor Caterson agreed that a multidisciplinary approach to improving patient nutrition was needed. “It often happens that the clinical team don’t know about [a patient’s nutritional status] and the dietitian is not on the ward round”, he said. “The doctors have to recognise [nutrition care] and the allied health people have to let go of their turf a bit too and meet somewhere in the middle.”

Associate Professor Judy Bauer, director of the University of Queensland’s Centre for Dietetics Research (C-DIET-R), said there was a growing awareness of the need to detect and manage malnutrition in hospitalised patients.

“Definitely there is increased awareness but we are still a long way from managing nutrition well”, said Professor Bauer, citing a 2012 study conducted by C-DIET-R that found a third of acute care patients in public hospitals in Australia and New Zealand were malnourished. (2)

Professor Bauer said while some states were prioritising detection and management of malnutrition in hospitals, nutrition care was considered but not included in the 10 National Safety and Quality Health Service Standards released in 2012. (3)

“If we could achieve nutrition as one of the national standards, that would certainly increase the emphasis on nutrition care and the identification and treatment of malnutrition", she said, pointing to Canada and the European Union that had implemented nutrition taskforces to better target malnourishment in hospitals.

Professor Bauer said her centre’s research had found that even when gold standard systems for managing malnutrition — including protected meal times, nutrition screening on admission, dedicated dietitians in each unit and high quality food services — were in place, many patients still consumed only half of their nutritional requirements. (4)

“Although nutrition was on everybody’s radar, it was way down on their priority list”, she said.

A follow-up program that aimed to raise multidisciplinary team and patient awareness of nutrition, promote nutrition as a medicine and have the medical team prescribe nutrition supplements and encourage patients to eat, was far more successful in ensuring patients’ nutritional needs were met during their hospital stay. (5)

“Sometimes you believe all the critical elements for nutrition are are in placebut unless the multidisciplinary team all focus on nutrition and make it priority, then those strategies just won’t work”, Professor Bauer said.

She said doctors were crucial in promoting nutrition as an essential element in a patient’s recovery.

“In the acute care setting, if there’s a doctor who has a nutrition focus, it really does change the whole team’s emphasis on nutrition care.”

 

1. JPEN 2014; Online 2 June
2. Clinical Nutrition 2012; 31: 41-47
3. ACSQHC: Accreditation and the NSQHS Standards
4. Can J Physiol Pharmacol 2013; 91: 489–495
5. Clinical Nutrition 2013; Online 20 December

12 thoughts on “Hospital nutrition still neglected

  1. Sue Ieraci says:

    Thanks for the article. I have seen many examples of elderly people being kept fasted ”just in case”, or for tests that may not have been essential. In Emergency Departments, we often forget that the elderly may have waited some time for an ambulance, missing their regular meals, and then their comfort is forgotten in the quest for a diagnosis or rule-out. Physical comfort, including warmth, thirst and hunger, is an important part of well-being. SOmetimes we get more caught up in our own perception of diagnotic risk (risk of diagnostic error to ourselves) rather than real-world risk for the patient.

  2. Graham Row says:

    At last someone has discovered the elephant in the room. I strongly agree with Sue Ieraci’s observations. Patient nutrition is a long way down the list of priorities. The food service leaves the tray,  The elderly, frail, anorexic patient receives no encouragement or assistance to eat the food thereon.  I can’t count the number of times I have helped a patient sit up, ripped off the sometimes very resilient lids on the portion controlled food containers, found and unwrapped the eating utensils and cut up the food to manageable bits.  Sadly the supervision, assistance and observation of patient nutrition seems not to be a nursing priority any more.  Some patients particularly the elderly receiving dietary “education” to avoid salt,saturated fat, sugar, potassium, etc.  become afraid to eat anything, or the hospital special diet appropriate to their condition is so foreign or unappetising that it is rejected.  In my experience, the vast majority of acute hospital inpatients who are able to eat will respond positively to strong reassurance that it is both safe and beneficial in the short term to eat what they prefer and feel they can tolerate.  Special diets are important and can be introduced when the patient’s appetite has returned.

  3. Sue Ieraci says:

    Spot on, ex-Doc! The time of pain, discomfort, nausea and anxiety is not the best time to cut out salt, fat and sugar – it may be when one needs them the most! In the very elderly, towards the end of life, it’s too late for  preventive health measures – let them eat what they enjoy!

  4. Amber kelaart says:

    A point prevelence study funded by the Department of Health (n=1693) looked at malnutrition in adult oncology patients across 15 Victorian Health services. Results demonstrated malnutrition occurred in 57% of inpatients & 25% of ambulatory patients. The study demonstrated that malnourished patients stayed in hospital five days longer than the well-nourished group, were more likely to experience infective complications & 25% of malnourished patients required admission. Apart from having significant negative effects on patient physical & QOL outcomes, malnutrition is extremely costly to the healthcare system. Interventions around awareness raising, early identification and management are short change in comparison to the costs that organisations need to cover for this group.         

    Multi-disciplinary clinicians working in oncology were surveyed & indicated they have a good understanding of factors impacting nutrition and strongly agreed with malnutrition screening. Only 74% of clinicians reported malnutrition screening was routine in their units & reported low levels of nutrition care embedded into ward practices including nutrition is discussed for all patients on ward rounds, nutrition is considered in discharge planning & including nutrition information in the medical discharge summary. Health services with strong nutrition governance practices (including policy, a multidisciplinary nutrition committee & regular auditing), malnutrition education/awareness processes for multidisciplinary clinicians, nourishing food service systems that are reactive to patients needs as well as appropriate dietetic resourcing are needed to combat this significant issue.

  5. Sue Ieraci says:

    Is it time for hospital diets to drop long-term aims (low salt, fat and sugar) for short-term aims (improved appetite)? Hospital should not be seen as a normal lifestyle.

  6. University of Adelaide says:

    I think there are a couple of important issues at play here. First, a large proportion of patients are malnourished on admission to hospital. There’s not a lot that hospital staff can do about malnourishment on admission, apart from working hard to ensure that during their hospital stay, these patients’ nutritional status improves. Secondly, nutrition in hospital patients and ensuring that patients can eat what is provided to them seems to have slipped between professional cracks; whereas in the past it was seen as a nursing fundamental of care, it is less so now. So, we recently tested an intervention that was designed to prevent nutritional decline in hospital patients. Acknowledging that the problem is multi-disciplinary, we focussed on three professions where we thought we could get ‘buy in’ (kitchen staff, nursing and dietetics), and developed a three-pronged intervention comprising malnutrition screening, feeding assistance and enhanced use of nutritional supplements. In addition to trying to change practice and policies, we also measured patient outcome (changes in body weight) during the admission. Aside from challenges around accurately measuring body weight in hospital patients, we found that while it was possible to change practice, nutritional decline is more intractable and is difficult to arrest, particularly in the short lengths of stay (less than a week), which are typical in Aust hospitals now.
    The paper was recently published: Schultz, T. J., A. Kitson, et al. (2014). “Does a multidisciplinary nutritional intervention prevent nutritional decline in hospital patients? A stepped wedge randomised cluster trial.” e-SPEN Journal 9: e84-e90.

  7. Michele Meltzer says:

       Having unfortunately spent too much time in a big Sydney teaching hospital sitting with an ill family member, I was decidedly unimpressed with the food turning up on her dinner tray at meal times. A typical meal might be a 8 x 8 cm square of soggy macaroni cheese, and some grey soggy looking matter which may or may not once have been broccoli. On other occasions, a slice of roast was so dry and tough that it seemed to have the consistency of a doormat, and vegetables were presented as an unidentifable lump of mixed items.

      When I asked about this, I was told that an area health service prepares all of its meals in one centralised kitchen for the whole sector, then snap freezes it, ships it out by truck to all the constituent hospitals, where it is thawed, and then kept in warming trays while distributed to the wards. I believe that there is quite a small budget for a main meal – maybe $3 or $4 or so?

      Recently in a private hospital that cooks its food on site, I was most impressed to see beans which were actually green, carrots which were actually orange, and meat tender enough for a sick person to chew.

      Do our microbiologists have anything to say about snap freezing, thawing, and then keeping food in a warming tray? Do our nutritionists have anything to say about the nutritional value of grey soggy broccoli? Do our patient reps have anything to say about such unappetising offerings?  Australia is an affluent country – surely we can do better!!

  8. Sue Ieraci says:

    “Anonymous” is right – the so-called “cook-chill” process is very common in public hospitals – the chilled food is transported cold, then re-heated at the receiving site (on the plate). The justifications are a combination of efficiency/cost savings and food spoilage safety – the method is actually shown to minimise microbiological contamination, though clearly at the cost of palatability. The mass-production cook-chill process caters to the lowest common denominator – food is generally cooked without salt, sugar, spices or condiments. This is bad enough for older Anglo-Australians, but how do people from other food cultures ever cope if they don’t have family to bring them palatable food? FOr readers with a strong stomach, the preparation guidelines are here:  http://www.foodauthority.nsw.gov.au/_Documents/industry_pdf/guidelines_v

  9. Graham Row says:

    Sue, I am by no means an apologist for airline food, especially that served to passengers in “chicken coop” class.  The “cook-chill” system seems to work well for airlines and in my experience the end-product out performs hospitals with centralised food services.  I am sure it is a question of budgets.  Catering at my private hospital was supervised by an excellent five star restaurant trained chef.  I remember his constant battles with dietitians over issues such as butter in the mashed potatoes or (horrors) salt added to food.  It seems to me that one needs to break a few “healthy diet” guidelines to achieve the primary purpose of hospital food: to get it past the patient’s back teeth and not return.

  10. Michele Meltzer says:

    Thanks for that interesting document Sue. I notice that the document does not anywhere mention such factors as palability, taste, tenderness to chewing, appealing appearance, or cultural preference.  I am always worried when I see a patient putting on weight in hospital – it makes me wonder what on earth they are eating at home. 

    Does anyone know the current public hospital budget for a main meal? The $3 I mentioned was a few years ago. 

  11. Sue Ieraci says:

    Budget for food was about $10 per person across three meals (per day) at the time of the Garling review in 2009.

  12. Kylie Fardell says:

    This may be contentious, but another issue is patients being made ‘nil by mouth’ or being put on pureed food/thickened fluid because of aspiration risk.  We do need to balance quality of life versus this risk.  In my experience, very few patients comply with use of thickened fluids on discharge (understandably – I wouldn’t!) and after discussion of the risks in hospital many patients and their families opt to accept risks and eat food or normal texture.  

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