Food and Nutrition - Sydney South West Area Health Service

Policy DirectiveFood and NutritionDocument No:Functional Sub-Group:Summary:Approved by:SSW_PD2009_030Clinical GovernanceCorporate GovernancePolicy for acceptable food and nutrition standards that willassist in addressing issues associated with hospitalmalnutrition and ensure delivery of optimal nutritional carefor all patients.Director Corporate ServicesClinical Council (25/8/09)Publication (Issue) Date: September 2009Next Review Date: September 2012Replaces Existing Policy:Previous Review Dates:N/AN/ANote:Sydney South West Area Health Service (SSWAHS) was established on 1 January 2005 withthe amalgamation of the former Central Sydney Area Health Service (CSAHS) and the formerSouth Western Sydney Area Health Service (SWSAHS).In the interim period between 1 January 2005 and the release of single Area-wide SSWAHSpolicies (dated after 1 January 2005), the former CSAHS and SWSAHS policies wereapplicable as follows:-• SSWAHS Eastern Zone : CSAHS• SSWAHS Western Zone: SWSAHSCompliance with this policy directive is mandatory Page 1 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 2009FOOD AND NUTRITIONCONTENTS1. Background – Food and Nutrition in Health 32. Hospital Malnutrition – Incidence and consequence 33. Policy Statement 44. The Integrated Food and Nutrition System 55. Standards of Care 66. Definitions 137. References 13Compliance with this policy directive is mandatory page 2 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 2009FOOD AND NUTRITION1. Background – Food and Nutrition in HealthGood nutrition is important for everyone, but particularly for those who are ill or aresuffering from injury. The provision of good nutrition is an integral aspect of good clinicalcare and is associated with better patient outcomes. 1-3 For hospital patients, maintaininggood nutritional status or, for those who are malnourished, gaining nutritional repletion,relies on the ability of the hospital to provide foods which are both nourishing andacceptable to patients in terms of their cultural and psychosocial needs. In order toachieve the best outcomes for the patient other issues such as patient access to foodsand assistance with eating so that the food offered to the patient can be consumed, alsoneed to be addressed.Food is not only essential for physical health it is also integral to the individual’s sense ofself 4 and has strong psychological connotations associated with nurturing 5 . When aperson is admitted to hospital frequently, the only familiar thing and one of the few thingsthe patient feels qualified to evaluate, is the food. Familiar foods are important in highlystressful situations, such as being in hospital, as they represent comfort and security tothe individual 6 . Although hospital food services are constrained by limitations such assystems of food preparation and distribution; and the statutory requirements of providingsafe food to the patients; they have a duty of care to meet the nutritional requirementsand the psychosocial needs of each patient. All staff can contribute to making thehospital mealtime environment pleasant and can assist patients in accessing andenjoying their meals. Patients’ perceptions of hospital food quality have a strongcorrelation with their satisfaction with medical treatment and the hospital stay overall 7 .2. Hospital Malnutrition – Incidence & ConsequencesHospital malnutrition is a world-wide phenomenon which is multifactorial in its origin 2-3,8-12 . While many patients are malnourished on admission, patients’ nutritional status mayalso worsen during the course of admission 13 .Malnutrition in hospital may go undetected and, if untreated, cause a wide range ofadverse outcomes for the patient and for the health system.For the individual:• Apathy and depression• Dehydration• Delayed wound healing• Diarrhoea, constipation• Impaired metabolic profiles• Impaired mobility• Increased prevalence of both adverse drug reactions and drug interactions• Increased risk of pressure ulcers• Infection• Muscle wasting and weaknessCompliance with this policy directive is mandatory page 3 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 2009For the health system, malnutrition contributes to increased:• Clinical intervention• Complications• Costs• Lengths of stay• Rates of readmission• Staff time per patient• Use of antibiotics 1-3,8-132.1 The Risks Addressed by this Policy• Morbidity and mortality from malnutrition.• Increased length of stay and costs as a result of the complications associatedwith inadequate nutritional care.2.2 The Aims / Expected Outcomes of this Policy• All patients receive appropriate, safe and adequate nutritional care which isconsistent with their medical condition and with evidence-based best practiceguidelines.• Patients who are malnourished, or at risk of malnutrition, are identified andreferred for appropriate assessment and management.• Patients will continue to be monitored for risk of malnutrition throughout theiradmission so that any required intervention occurs as early as possible.• Patients and families receive education, as appropriate, with respect to anydietary modifications or nutritional interventions.3. Policy Statement1. Food and nutrition are recognised as an essential part of patient care and increating positive experiences in the health service 14 .2. Patients’ nutritional and dietary requirements are identified, documented andcommunicated in an effective and timely manner.3. Food and fluids provided meet the nutritional, clinical, therapeutic and psychosocialneeds of patients.4. Food service provision is customised to meet the requirements of particular clientgroups.5. Nutritional screening, assessment, care planning, documentation and monitoring ofnutritional status occur on admission and throughout the patients hospital stay.6. The mealtime environment is conducive to eating.7. Patients receive the assistance and encouragement they require when eating ordrinking.Compliance with this policy directive is mandatory page 4 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 20098. Staff, carers and volunteers who are involved in the delivery of food and/orassistance of patients at meal times receive appropriate education and training tosupport them in this function.9. Patients, carers and staff have the opportunity of providing feedback that informsthe development of policies and practices in the delivery of food and nutritionservices.10. Consideration is given to other factors including medications, drug/nutrientinteractions, fasting and end of life nutrition issues.4. The Integrated Food and Nutrition SystemThe diagram below summarises the connections between all key aspects of nutritionalcare. The complexity of this diagram reflects how integral the relationship betweenclinical and support services is to achieve best patient care.The patientReassessReassessConduct nutritionscreeningPatient deemed malnourishedor ‘at risk’ of malnutritionDevelop care planConduct full nutritionalassessmentFood &NutritionStandardsPrescribe appropriate dietProcure / prepare foodDelivery of patient mealOrganise nutritional supportOrganise assistance witheatingEducate and plandischargeFollow upCompliance with this policy directive is mandatory page 5 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 20095. Standards of Care5.1 Food and nutrition are recognised as an essential part of patient care and increating positive experiences in the health service.RationaleAn area-wide strategic and coordinated approach is necessary to ensure a highstandard of nutritional care is provided to patients in all facilities.Criteria• Executive and senior management staff of SSWAHS recognise that food andnutrition are an essential part of patient care.• Executive and senior management staff of SSWAHS support theimplementation of the ‘SSWAHS Food and Nutrition Policy’.• Executive and senior management staff of SSWAHS endorse the requirementof resource allocation and adequately trained staff that underpins theimplementation of the ‘SSWAHS Food and Nutrition Policy’.5.2 Patients’ nutritional and dietary requirements are identified, documented andcommunicated in an effective and timely manner.RationaleEffective and timely communication relating to the patient’s nutritional and dietaryrequirements, nutritional care plan and related management strategies is essentialto maintain patient safety. Systems and processes must be in place to ensure thatthis occurs.Criteria• Patients’ nutritional and dietary requirements are identified upon admissionand are communicated to Nutrition and Dietetics and Food Services as soonas possible.• Patients’ nutritional and dietary requirements are documented in such amanner that clinical and support staff have access to relevant information toenable them to deliver appropriate patient care.• Changes in patients’ nutritional and dietary requirements are identified andcommunicated to relevant staff as soon as possible.• All relevant data relating to the patients nutritional and dietary requirementsshould be documented and communicated through efficient systems,including specialised patient menu and dietary information systems, withoutloss of information.• The specialised patient menu and dietary information system should interfacewith other clinical information systems ensuring all relevant data is transferredautomatically without loss of essential information.Compliance with this policy directive is mandatory page 6 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 2009• Where appropriate, records of patient dietary information are maintained afterdischarge.• The patient’s diet and any ongoing nutritional care plan should bedocumented on all transfer and discharge paperwork.5.3 Food and fluids provided meet the nutritional, clinical, therapeutic andpsycho-social needs of patients.RationaleFood not only provides the nutrients which are essential for survival and themaintenance of good health, but also satisfies a number of important social andpsychological needs. Individuals express their identity in their choices of food andthe manner in which the food is eaten 4 . In a hospital setting, food may also berequired to meet clinical and therapeutic requirements of the individual.Criteria• The menu provides for the nutritional and therapeutic dietary requirements ofeach individual patient, including patients with special requirements who areon complex dietary regimes or who have increased macro and / or micronutrientneeds.• A variety of foods are available to accommodate patients with specialrequirements and complex diets.• Menu items are sourced or developed giving consideration to meeting theneeds of patients with special requirements.• The menu has sufficient flexibility to allow for the individualised provision offood and fluids to meet each patient’s nutritional and psycho-social needs.• Adequate choice is provided for all patients in accordance with theirrequirements.• The menu provides foods that meet the diverse cultural and religious needsof the patient population.• Basic menu planning principles are observed with regard to colour, texture,flavour, popularity and variety both within the meal and across the menu.• Systems are put in place to manage high risk patient groups including thosewith dysphagia, allergies and those who are severely immuno-compromised.• All food provided by the hospital complies with relevant legislative standards,including those pertaining to food safety.• The diet ordering system is efficient and safe.• The meal delivery system is efficient and safe.• Meal times are spread out to cover most of the hours spent awake.Compliance with this policy directive is mandatory page 7 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 2009• Patients are given the opportunity of selecting their own food and fluids fromthe menu.• Patients are assisted with menu selection by a qualified member of staff suchas a dietitian assistant who ensures the patient selects a meal which iscomplete and nutritionally adequate.• Patients make their menu selections no more than one day ahead of the dayof service.• Relatives / carers can provide assistance to patients who are unable to maketheir own menu selections, by either making menu choices on the patient’sbehalf or informing staff of the patients’ food preferences5.4 Food service provision is customised to meet the requirements of particularclient groupsRationaleThe needs of various client groups may vary throughout the health care system.Food service provision should be flexible enough to accommodate the needs ofthese groups. It is also important to understand the needs of these patient groups,and to stay abreast of changes in the food habits or food preferences of thesegroups.Criteria• The service allows for the flexible delivery of food and nutrition toaccommodate the needs of particular patient groups.• Demographic data is collected and used to inform menu and servicedevelopment. Minimum demographic data collected should include, but is notlimited to: age, length of stay, religion and country of birth.5.5 Nutritional screening, assessment, care planning, documentation andmonitoring of nutritional status occur on admission and throughout thepatients hospital stay.RationaleMalnutrition screening identifies patients who are malnourished and those who areat risk of malnutrition. Nutritional assessment indicates the degree of malnutritionand helps determine appropriate actions. Early detection of malnutrition andimplementation of appropriate nutritional support reduces the risk of patients’nutritional status deteriorating while in hospital 13 .Criteria• On admission, factors that may prevent a patient from eating and / or drinkingadequately while in hospital are identified by nursing staff and communicatedto Nutrition and Dietetics as soon as possible• Screening for risk of malnutrition is undertaken by a designated staff memberusing a validated tool, both on admission and every 7 days throughoutadmission, or when patient circumstances change.Compliance with this policy directive is mandatory page 8 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 2009• Patients whose score identifies them as malnourished or at risk ofmalnutrition are referred to a dietitian for a full nutritional assessment.• Individual nutritional care plans are developed (with assistance from relativesand carers, where required), implemented and monitored for effectivenessand acceptability.• Outcomes of nutritional screening, assessment and care planning aredocumented in the health record.• Patients’ food trays are observed by a designated staff member before theyare removed, where applicable. When deemed appropriate, patients havetheir food intake recorded for an agreed period of time.• Patients who cannot consume adequate nutrition orally receive artificialnutrition support, giving consideration to end-of-life issues.• Patients on thickened fluids whose fluid intake is insufficient to prevent risk ofdehydration receive artificial nutrition support.• Patients who are Nil-By-Mouth for more than 3 days receive artificial nutritionsupport, giving consideration to end-of-life issues.• The discharge plan for malnourished patients includes information aboutnutritional status, special dietary requirements and arrangements for followup.5.6 The mealtime environment is conducive to eating.RationaleA relaxed and pleasant mealtime environment enhances patients’ enjoyment oftheir meals and can influence the amount of food and fluids they consume 15-16 .Preparing patients for a meal plays an important role in enhancing their ability toeat and enjoy their meals 15 .Hospital routines, clinical procedures and ward rounds can disrupt meal times andsignificantly reduce patients’ nutritional intake 17-18 .Criteria• Provision of a mealtime environment conducive to eating, and the provision offeeding assistance where required, are the primary focus of clinical staffduring mealtimes.• Interruption of patients’ meal times by ward/medication rounds, teaching anddiagnostic procedures is minimised.• Patients are prepared for eating prior to the meal delivery. This includespositioning, toileting, hand washing and clearing of over-bed trolleys.• All patients who are able are given the opportunity of sitting out of bed wheneating their main meals.Compliance with this policy directive is mandatory page 9 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 2009• Patients are treated with respect and dignity at all times when being preparedfor and receiving food and fluids.• Patients are given adequate time to consume the meal before the tray iscollected.5.7 Patients receive the assistance and encouragement they require when eatingor drinking.RationaleMany patients require some form of assistance with eating and drinking while inhospital. This ranges from opening of packages to fully assisted feeding. Ifassistance with eating and drinking is not provided, many patients’ nutritional statuswill be compromised.Offering assistance and encouragement to eat is an effective way of enhancingfood and nutrient intake.Criteria• Patients are offered encouragement in eating and drinking to maximise foodand nutrient intake.• Patients are provided with the appropriate modification to their meal to assistthem with accessing and/or eating the meal.• Development and assessment of new food products has ease of accessibilityfor patients as a criterion.• Independence with eating and drinking is promoted in a safe and supportiveway.• Patients are treated with respect and dignity at all times when being assistedwith eating and drinking.• Carers, relatives and volunteers can be involved in assisting patients to eatwhere this is deemed safe by the treating clinician and any necessary traininghas been provided.5.8 Staff, carers and volunteers who are involved in the delivery of food and/orassistance of patients at meal times receive appropriate education andtraining to support them in this function.5.9 Patients, carers and staff have the opportunity of providing feedback thatinforms the development of policies and practices in the delivery of food andnutrition services.RationaleStaff, patients and their carers can offer valuable feedback for improving food andnutrition services. Acting on this feedback will contribute to improving the patientexperience and reducing the risk of malnutrition in hospital.Compliance with this policy directive is mandatory page 10 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 2009Training of staff through continuing education programs improves theunderstanding of the link between good nutritional care and better patientoutcomes.Criteria• Patient satisfaction surveys are undertaken routinely (not less than annually)from a representative sample of patients and data collected is used to informmenu and service development.• Data collected includes, but is not limited to, satisfaction with temperature ofmeals, quality of food and fluids, menu variety, appearance of meals,assistance with accessing meals and staff courtesy.• Where appropriate, patient satisfaction surveys or methodologies can beadapted to reflect the patient group or type of service being measured.• Staff are aware of the role of food and nutrition in maximising patients’ clinicaloutcomes and quality of life.• Staff involved in the clinical nutritional care of patients are appropriatelyqualified and have knowledge of key aspects of nutritional care includingscreening, assessment, therapeutic diets, food safety, assistance with eating,feeding techniques and monitoring food intake.• Staff involved in the clinical nutritional care of patients are aware of thedifferent treatment regimes that may compromise nutritional status includingmedications that reduce appetite and lead to weight loss.• Staff are aware that nutritional status may be compromised in patients whopresent as overweight or obese.5.10 Consideration is given to other influencing factors including medications,drug/nutrient interactions, fasting and end of life nutrition issues.MedicationsMedications should be administered in a form which is safe to patients.Medications administered as tablets or capsules can pose physical risks to patientswho are being tube fed or who have swallowing difficulties.• Patients on tube feeds should receive oral medications in liquid form anddelivered appropriately.• Patients with dysphagia should receive oral medication in compliance with thepolicy ‘Sydney South West Area Health Service - Identification andManagement of Adults with Suspected Swallowing Difficulties (oropharyngealdysphagia) SSW_PD2008_20’.Drug / nutrient interactions, which can occur in many different ways whichimpact on the patient’s nutrition, should be acknowledged and managedappropriately.Compliance with this policy directive is mandatory page 11 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 2009Medications can affect a patient’s nutrition in a variety of ways. As well as alteringfood intake by either stimulating or depressing the appetite medications can causeadverse reactions such as hypoglycaemia, nausea, constipation, diarrhoea and drymouth 19 . The patient’s nutrient requirements can also be altered by the medicationeither changing the metabolism or excretion of nutrients. Absorption of nutrientscan be altered by either direct inhibition or by changing the pH of thegastrointestinal tract.Polypharmacy may decrease the patient’s ability to eat, especially if the patient iselderly 19 .• Staff should be aware that the patients’ nutrition could be affected by themedications they receive.• Staff should be aware of drug/nutrient interactions of specific medications.• The menu should have the ability to provide additional foods to meet patients’increased nutrient requirements resulting from drug/nutrient interactions.• Food should be available outside of meal and midmeal times to treat patientswith hypoglycaemia.FastingFasting is managed to limit the impact on patients’ nutritional status.Fasting is required prior to surgery and some procedures and tests. However,prolonged fasting has a negative impact on the patient’s overall food intake andcan contribute to a decline in the patient’s nutritional status.• Fasting time pre- and post procedure should be kept to a minimum tominimise the number of meals the patient misses.• Early breakfasts should be provided for patients scheduled for late morningprocedures which require fasting.• The evidence for fasting prior to particular procedures should be examinedand policy and practice changed accordingly.End of Life CareDiscussion involving health personnel, patient and family should occur re end of lifeissues prior to instituting a nutritional care plan. The nutritional goals at the end oflife are:• Respect the patient’s wishes• Maximise patient comfort and eating enjoyment• Promote positive feeding• Provide support to reduce caregivers concerns 20Compliance with this policy directive is mandatory page 12 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 20096. DefinitionsHospital malnutritionRefers to protein/energy malnutrition due to insufficient food, unbalanced diet ordefective assimilation.Nil By Mouth (NBM)The patient receives no food or drink per oro.Nutrition screeningThe process of identifying characteristics known to be associated with malnutrition. Itspurpose is to detect patients who are malnourished and those at risk of becomingmalnourished who will have an improved nutritional outcome when given nutritionalsupport.Nutritional assessmentThe process of assessing the degree of malnourishment in nutritionally compromisedpatients.Nutritional supportThe provision of nutrients to make up the shortfall between the patient’s nutrientrequirements and their nutrient consumption. Supplementary nutrition can be given inthe form of additional snacks, enteral feeds or TPN (Total Parental Nutrition).Artificial nutrition supportAdministration of specially formulated liquid nutrients through a tube directly into the gut(enteral nutrition) or into a vein (parental nutrition).Same meal serviceThe meal that is about to be served or is in the process of being served.Next meal serviceThe meal that will be served after the conclusion of any current meal being served or thenext meal to be served if no meal is currently being served.7. References1. Smith ES, Smith AE. High-quality nutritional interventions reduce costs. HealthcareFinancial Management 1997; August: 65-69.2. Chima CS, Barco K, Dewitt MLA, Maeda M, Teran JC, Mullen KD. Relationship ofnutritional status to length of stay, hospital costs, and discharge status of patientshospitalised in the medicine service. Journal of the American Dietetic Association1997; 97 (9): 975-978.3. Middleton MH, Nazarenko G, Nivison-Smith I, Smerdely P. Prevalence ofmalnutrition and 12-month incident of mortality in two Sydney teaching hospitals.Internal Medicine Journal 2001; 31(8): 455-461.4. Fischler C. Food, self and identity. Social Science Information 1988; 27(2): 275-2925. Lupton D. Food, the Body and the Self. 1996; Sage, London.Compliance with this policy directive is mandatory page 13 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 20096. Bell D & Valentine G. Consuming Geographies, We Are What We Eat. 1997;Routledge, London.7. Maller O, Dubose CN & Cardello AV. Consumer opinions of hospital food andfoodservice. American Journal of Nutrition and Dietetics 1980; 76(3): 236-242.8. Bistrian B, Blackburn GL, Vitale J, Cochran D, Naylor J. Prevalence of malnutritionin general medical patients. Journal of the American Medical Association 1976; 235(15): 1567-1570.9. Naylor CJ, Williams PG, Bullock JR. Analysis of the nutritional screening survey ofall inpatients at Royal Prince Alfred Hospital. Masters thesis University of Sydney1996.10. Labadarios D. Malnutrition in hospitals often unrecognised and invariablyneglected. South African Journal of Clinical Nutrition 1998; 88 (1): 73-74.11. Holmes S. Malnutrition in hospital: an indictment of the quality of care? BritishJournal of Health Care Management 2004; 10 (3): 82-85.12. Huq F, Ravens JA, Lamb S. The prevalence of malnutrition among adult inpatientsat Royal Prince Alfred Hospital between 1996 and 2005: a nutritional assessmentsurvey. Masters thesis University of Wollongong 2005.13. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital.The British Medical Journal 1994; 308 (6934): 945-948.14. NSW Department of Health. A new direction for NSW. State Health Plan Towards2010. February 2007.15. de Raeve L. To feed or to nourish? Thoughts on the moral significance of food.Nursing Ethics 1994; 1(4):237-241.16. de Castro JM & de Castro ES. Spontaneous meal patterns of humans: Influence ofthe presence of other people. American Journal of Clinical Nutrition 1989;50(2):237-247.17. Davidson A, Corbett N & Bartlett S. Interruptions at mealtimes: An observationalaudit. 2004; University Hospital, Coventry and Warwickshire, unpublished report.18. Zerubavel E. Patterns of Time in Hospital Life: A Sociological Perspective. 1979;The University of Chicago Press, Chicago.19. Coleman Y. Drug-Nutrient Interactions. 2000; Nutrition Consultants Australia.20. Ravens JA. Ethical issues in withdrawing nutrition support. Australian Journal ofNutrition and Dietetics 1997; 54(2): 79-81.Related Policies• Sydney South West Area Health Service - Identification and Management of Adultswith Suspected Swallowing Difficulties (oropharyngeal dysphagia)SSW_PD2008_20.Compliance with this policy directive is mandatory page 14 of 15

Sydney South West Area Health ServicePolicy No: SSW_PD2009_030Date Issued: September 2009• Sydney South West Area Health Service – The Minimum Standard for the NursingSupport of Adult Patient Oral Nutrition (draft 2009).• Much of this document has been informed by the ‘Nutritional Care Policy(PO2008_002)’ developed by the NSCCAHS Clinical Governance Unit and wegratefully acknowledge their contribution.Policy Author(s):Policy Reviewers:Dr Jenny Ravens, Director Nutrition & Dietetics, Eastern Sector, SSWAHSMs Suzanne Kennewell, Manager Technical Support, Food Services, SSWAHSMs Maria Kokkinakos, Director Food Services, SSWAHSMs Lesley Miller, Director Nutrition & Dietetics, Western Sector, SSWAHSDepartment of Nutrition & Dietetics, SSWAHSDepartment of Food Services, SSWAHSDepartment of Speech Pathology, SSWAHSCentre for Applied Nursing Research, SSWAHSDirectors Nursing & Midwifery Services, SSWAHSChair of New Ways of Caring Implementation Team and Clinical Director,Cardiovascular Services, SSWAHSCompliance with this policy directive is mandatory page 15 of 15