TECHNOLOGY & SCIENCE
BY – COL AM SHENDE, MHA- III SEM
ASSIGNMENT ON: MANAGEMENT OF DIETARY SERVICES IN THE HOSPITALS
Nutrition services are an integral aspect of patient care. The basic knowledge of nutrition should give health care professionals the ability to identify potential nutrition problems and realize when it is critical to refer patients to dietitians for comprehensive nutrition services. In the management of patients’ health care, nutrition screening, nutritional assessment, counselling and referrals are very essential. Today, cost containment pressures, healthcare management reorganizations, aging, demographic shifts, and services have changed the consulting role of dietetic professionals. Nutrition services must be provided by a sufficient number of qualified personnel under competent supervision. Nutrition services in hospitals are one of the most important hospital supportive services contributing to the recovery of health through scientifically prepared diets; educating the patients attending the hospitals for treatment regarding use and utility of different foods and balanced diets (Saroj, 1989).
In hospitals, good nutritional practice must encompass the diverse needs of individual patients. Local assessment of the dietary needs of each hospital population is fundamental for successful menu planning and appropriate food provision. For patients who are assessed to be ‘nutritionally vulnerable’, good nutrition means the provision of small, energy and nutrient-dense meals with frequent snacks to address the well recognised problems of poor appetite and risk of under-nutrition. However, there are also a significant proportion of patients who may be classified as ‘nutritionally well’ and whose nutritional needs do not differ from that of the general population. The accepted advice for these people is a healthy balanced diet that is characterised by low fat, salt and sugar foods and the inclusion of at least 5 portions of fruit and vegetables a day plus a higher proportion of starchy foods including high fibre foods. Hospitals should encourage promotion of healthy eating for those individuals, including staff and visitors who would benefit from a healthy balanced diet. This is the challenge, but one that can be met through clear communication and coordinated actions between all those involved in the food chain including input from the patients themselves. This will be central to the success of the wider nutritional care of patients (Walker and Higginson, 2000).
Nutrition services within health care systems have become increasingly important and significant. Scientific methods based on a standardized nutrition care process and consistent standardized language can guide nutrition practitioner’s clinical judgments, critical thinking process, and document information linking nutrition care to patient outcomes (Smith and Lewis, 2004). Unfortunately, this systematic approach is mostly absent in dietetic practice in hospitals in India, especially outside of metro cities. According to Gupta (1998), there are a number of functional responsibilities of the dietetic department such as selection and purchase of foods in a close working relationship with purchase department, receipt and storage of food items, preparation and distribution of food, maintenance of cleanliness and hygiene, dishwashing in a proper way, coordinating with the medical and nursing staff, sensing and influencing patients regarding the importance of food in the treatment process and so on. It is in this context that dietitians need an in depth knowledge of nutrition, in addition to the managerial ability, to organize his/her staff and their work so as to produce the best possible results, at the least possible costs.
Nutrition Services Environment. Ford and Fairchild (1990) have described some basic elements for nutrition services environment in hospitals. These are:
− A departmental statement of mission or purpose and a strategic plan for delivery of services congruent with the mission, that can be changed as needed in response to adjustments in either the internal environment or the external environment, or both.
− Nutritional standards of practice customized to meet the needs, resources and milieu of the department.
− Written, up-to-date policies and procedures to guide major responsibilities such as screening and nutritional status assessment, care planning, documentation, nutritional counselling, consultations and responsiveness to nutritional needs of patients.
− A method and tool for screening patients to identify efficiently those at nutritional risk and to set priorities for nutritional care services and a system of documentation that facilitates both communication and data retrieval.
− A method for determining patient acuity levels as a basis for setting clinical priorities and managing both time and resources.
− An observable and measurable system for tracking productivity, especially of professional staff members.
− Appropriate and effective staffing patterns and maximizing the potential of each dietetic team member.
− Criteria based performance standards to serve as the basis for competent practice, performance appraisal and professional development.
− An evaluation system to assess and monitor compliance with mandated regulations of government, healthcare agencies and commissions. An environment in which personnel are committed to the mission statement and strategic plan, kept informed, supported with recognition and reward systems and empowered to take responsibility for the quality of services provided.
Dietetic Department and Its Role. The dietetic department mainly serves the patient needs in terms of therapeutic diets, diet counselling and special feeds. The dietary service is one of the most supporting services of the hospital unlike any other support service. The objective of a diet service is to make provision for clean, hygienic and nutritious diet for the indoor patients as per their nutritional requirement. Dietary department of the hospital caters to the needs of all admitted patients by providing major meals including breakfast, lunch, evening tea and dinner, in the best possible hygienic conditions. The dietetic department does procurement, cooking and distribution of food under maximum supervision by the supervisory staff. The dietetic department provides meals to indoor patients in General wards as well as Paying wards. Procurement, storage and cooking is done in the main kitchen under the supervision of qualified Dietitians. The meals provided include Normal, Soft, Liquid, Salt restricted, Diabetic, Low Protein, Special diets and other Therapeutic diets. Diet being a therapy, diet counselling in this regard plays a major role in advising patients regarding diet in the presence of their attendants or individually, according to the patient’s nutritional assessment, food habit and therapeutic nutritional needs. Dietetic departments in hospitals also provide training by providing internship to postgraduate students in Dietetics. Anthropometric measurements and bio-chemical assessment are also done for patients to assess their nutritional status. The dietary service can be provided by in house provision or by out sourcing (Das, 2011).
In view of the importance of nutrition services for patients, DGHS (1989) has suggested recommendations for various staff required by a 2.1: Suggested hospital dietetic department.
PHYSICAL FACILITIES AND LAYOUT OF HOSPITAL NUTRITION SERVICES
A food service facility must be designed with both space and function in mind. To determine the best workspace for hospital nutrition services, physical arrangement, different areas of storage, preparation, service areas in the dining rooms and special support areas, must have special design features.
Kitchen layout and other areas. The kitchen layout for hospital kitchens must be considered according to its functions. The kitchens should be designed in relation to the quantity of food needed for patients. The planning for an efficient layout is the assembly line, effective continuous workflow from receiving, storage, issuing, preparing, cooking and serving the food. In the receiving area, the outside door should be 6-foot single or regular double size to admit hand trucks, large cartons and any piece of large equipment. In a hospital nutrition service department, storage department requirements depend upon the form of food purchased. Dry storage rooms should be well ventilated. A desk and possibly a file should be provided for inventory records, requisition and order tests. Foods in prepared form, such as frozen foods require lower storage temperatures. In a hospital food service unit, vegetable preparation area should be set up in square or rectangular shape with equipment arranged on the sides and down the center with one end opened to the main kitchen. The cooking area is the hub or center of the kitchen and should be located adjacent to the vegetable preparation area, the pot and the pan-washing unit, the storage rooms and next to the serving units. This area should be located at one side or end of the room and as close to the serving unit as possible. The bakery and dessert area should be close to the service unit as the products from this unit are directly transported to the service unit. The serving area should be located near the cooking unit but out of main traffic lines. The pot and pan washing area must provide space and facilities for smooth flow of dishes through sorting, scraping, washing, rinsing, drying and removal from storage. The dishwashing area should be away from the dining rooms because of the noise. Employee rest rooms should be located near the dining area for convenience and security. Both garbage and trash must be collected and held for frequent removal and a central compact in which waste is compressed under heavy pressure to small volume may be used. Proper training should be provided to the personnel involved in the cleanliness, supplies, dish washing and maintenance of equipments. The food service equipment should be free from open seams, cracks, chipped places, exposed junctions and sharp corners. Standards of cleanliness and sanitation will be only as high as those established and enforced by the food service director (Palachio and Theis, 2012).
Suggested Space Requirement and Physical Facilities for a Hospital Dietetic Department by DGHS (1989) New Delhi. There are certain norms laid down by DGHS (1989), India, of space requirements for a hospital dietetic department. These are –
- 200 Beds or less – 1.86 sq.m. per bed (186 sq. m for 100 beds)
- 200-400 Beds – 1.67 sq. m. per bed (500 sq.m. for 300 beds)
- 500 Beds and above – 1.39 sq.m. per bed (700 sq.m.for 500 beds)
Storage space also has to be provided for:
– Dry stores-food materials and non-food items
– Cold storage-semi-perishables and perishables
– Cooking gas-outside the department
– Trolley parking-the extent of space needed will depend on the type of service, centralized or decentralized.
– Multiple tank dishwashing machines.
If staff dining facility and cafeteria for visitors are to be provided, there should be another kitchen with access to the dining room/cafeteria. The approximate space requirements for these, according to DGHS (1989) are given in Table 2.3 as follows:
The Dietetics Department should be rectangular in shape with rounded comers, well lit and well ventilated. The floors should be smooth and impervious, sloping to the drains. Windows and doors should be made fly proof. Ventilating hoods and adequate exhaust fans should be provided. Running hot and cold water should be available. The layout should be planned with adequate space for storage, preparation, washing area and office area. Employee facilities and garbage disposal should be provided outside the main unit.
The process of food production involves collecting ingredients, weighing and measuring them according to standard recipes, preparation techniques, cooking methods, dishing out for service and clearing up for the next production (Sethi, 2011). Hospital food has come into focus during the last decade due to reports of under nutrition and at the same time, food service has undergone significant changes.
In order to improve patient nutrition care in hospitals, integrating food production and patient nutrition is helpful in patient nutrition. In western countries, the system of food production has changed over a period of time. The job profile of employees in the kitchens has followed change in recent years. During the period 1995-2003, there has been less use of central plating with a higher use of buffets and satellite kitchens. The educational background of employees has also changed resulting in an increase in number of skilled employees (cooks, catering assistants) and fewer unskilled employees in the kitchens. Increased focus on nutritional status of patients has been observed from ward personnel with no connection to the kitchen. It is suggested that food ambassadors be responsible for the nutritional status of patients (Engelund et al, 2007).
Food production involves several aspects such as the hospital menu, purchase, receiving, storage and food costing.
Hospital menus. Menu is the basis for food production. Hospital menus may be designed to meet nutritional requirements. However, in practice, the planned food may not be eaten by individuals who are unwell or have a suppressed appetite, and hence, nutritional needs of such individual will not be met. Menu planning needs to take into consideration the patients dietary needs and other factors which affect food intake in order to provide a service which has choice, flexibility and meals that will be eaten. A multi-disciplinary group working together and planning a menu, needs to consider the special nutritional circumstances of hospital patients and allow each member to share specific knowledge and skills regarding the patient needs and hospital services (Thomas and Bishop, 2007).
Hospital menus must meet the nutritional requirements of diverse patient groups. To assist the patient in making a faster recovery and maintain a better standard of well being, the menu planner must strictly follow dietary regulations that have been set by the dietitian. Provision of a menu that meets the nutritional requirements outlined for hospital patients, must also be a menu that provides choices of dishes that tempt patients to eat, and which they will enjoy. Some guidelines for planning menus are as follows ¾ Use at least a three week cycle for menu planning. ¾ Ask the patients about their food habits and preferences and follow these as often as possible ¾ Serve fresh fruits and salads. ¾ Plan at least one cup of milk or a milk product a day ¾ Include sea food and fish at least twice a week for non vegetarian patients ¾ Serve soups and foods with high amount of water (such as salads, cucumbers, tomatoes, any kind of fruits) everyday to increase the fluid intake of patients. ¾ Serve 1.5 to 2 litre beverages, like water, fruit/herb tea everyday. ¾ Prefer cooking methods such as poaching, steaming, pressure cooking, roasting/sautéing, baking and broiling to prevent vitamin loss (Nestle, 2007).
A menu has to be more than a list of foods. It should contain foods that are of high nutritional value. Menu is a list of dishes planned for production in a catering operation. A menu forms the core of all other activities in a food service establishment. The success of a food service operation depends on the food service managers who plan the menus and how they do it (Sethi, 2011). Menu planning is important for food service institutions like hospitals. Good practices should be established through the development of national guidelines and standards for food provision in hospitals to meet the needs of all categories of patients including diets on medical indications, vegetarian, texture modified and energy and protein dense menus. A range of dishes enriched in energy and protein should be available in every hospital aimed at patients with disease-related undernutrition. The nutrient sufficiency of a menu should be documented at the planning stage itself. The Clinical Nutrition Service/Department, the Nutritional Steering Committee, or the Nutritional Support Team or an adequately qualified person, should be given the responsibility for ensuring that the menu reflects nutritional standards. A database on nutrient content of meals/menus and portion sizes should be established in each food service department to be made available for the purpose of assessing nutritional adequacy of menus and monitoring of food intake of patients. It is important to remember that a menu is a live document and as such should be reviewed and updated regularly in order to continue to meet the dietary needs of a potentially changing hospital population (Council of Europe, 2003a).
Purchasing. Good food purchasing is the basis for preparing and serving meals. Purchasing is an essential function in any food service system. Realistically hospitals need to rethink their operations if they are to buy locally. Hughes (2006) points out those hospitals pursuing this policy need a kitchen so they can cook ingredients from scratch. They also require the flexibility to have a seasonal menu and to go with whatever produce is available (Sethi, 2011).
Receiving. The receiving area should be located near the delivery door and should be convenient to the storage areas. Purchases should be inspected for condition and checked against the invoice or delivery slip. The vendor’s delivery slip should only be signed after making sure that all received goods ordered are in proper condition (Palachio and Theis, 2012).
Food storage. After receiving, proper food storage is very important to prevent loss or waste. Dry, refrigerator and freezer storage should be adequate for food supplies. Proper ventilation, temperature and humidity controls are necessary for food quality (Palachio and Theis, 2012).
Storage practices. If foods are not properly stored after they have been received and checked, their quality is jeopardized (Palachio and Theis, 2012). Safely cooked foods can become cross contaminated through even the slightest contact with raw food. Therefore, it is imperative to avoid contact between raw foods and cooked foods (WHO, 1999), through proper storage. An investigation, including environmental sampling, was undertaken after four leukemic patients on the same hospital ward developed serious infections with Klebsiella aerogenes, capsular type K14. The source of this organism, common to all four patients, was found to be a food blender used for preparing milk-based drinks on the ward (Kiddy et al, 1987).
Food cost. Food is the most easily controlled item of expenditure and the one subject to greatest fluctuation in the food service budget. When assessing the cost of different food preparation systems, the patient’s satisfaction with the food served should be considered. The food budget should be valued as part of the budget spending on clinical support and treatment services. Hospital managers should take into account the potential cost of complications and prolonged hospital stay due to undernutrition, when assessing the cost of nutritional care and support.
Preparation. Since foods are so easily contaminated, any source used for food preparation must be kept absolutely clean (WHO, 1999). The preparation/process/cooking should be adequate to eliminate and reduce hazards which might have been introduced at the raw food level, to an acceptable level. The preparation/processing/cooking methods should ensure that the foods are not re-contaminated. The preparation/processing/cooking of vegetables and non-vegetarian products should be segregated. Food should not be overcooked or charred leading to chemical hazards. Whenever cooking or reheating of food is done, it should be hot all the way through. It is especially important to make sure that food is cooked thoroughly because there could be bacteria in the centre of the food. Re-use of cooking oil should be avoided (Food Safety and Standards Regulations, 2009).
Holding of Food. Cooked food should be consumed soon after cooking is finished. However, in most food service establishments, cooked foods need to be held for sometime before they can be served, since all customers/patients may not be served at the same time. Food needs to be prepared in advance; it should be held either hot above 60o C or cool below 5o C (WHO, 1999), to prevent growth of pathogens. Otherwise, time of holding should be limited.
FOOD SERVICE AND DELIVERY
Food service managers have a responsibility for making certain that after food is prepared it is safely delivered and served to patients. There are two major types of food delivery/service/systems. These are centralized and de-centralized.
Centralized delivery service system is commonly used in hospitals and health care facilities. In this service system, food items are portioned and plated and trays for individual patients are assembled in the central serving room.
Decentralized Delivery Service System is the one in which food items are sent hot and/ or cold to serving pantries or ward kitchens located throughout the facility, from where patients are served (Palachio and Theis, 2012).
The food service system in hospitals should be adjusted to the patients’ needs taking into consideration their physical and mental condition. This often requires different serving systems. All patients should have the possibility to choose their eating environment and to sit at a table when eating their main meals. The hospital eating environment should be improved with a focus on surroundings free from unpleasant smell/odours. Adequately trained personnel should be available to assist patients with mental/physical feeding difficulties and suitable modified equipment should be available when required to aid/facilitate independent feeding. Food service is a system in which meals are produced for hospital patients. The system includes the food service premises, the production and distribution technology, and human resources involved in management, production, distribution and serving. The supply of food to patients and staff is the responsibility of hospital support services (Barrie, 1996).
Food service in hospitals and nursing homes. Food and catering services in hospitals are all evidences of large scale food preparation and services. The development of these food services has closely followed the changes in the eating habits and needs of patients. With modernization, more and more patients are admitted to the hospitals thereby increasing meal service. While type of food services is varied and the number increasing every day, we need to focus on educating/training workforce and/or developing manpower for this emerging field. In the field, technical knowledge is necessary for this specialized area. Foodservices in nursing homes and hospitals reveal that there is lack of information about the nutritional quality of foods served. The nutrient content of foods prepared in large quantities lack data pertaining to nutrient content of foods served. The foodservice industry is growing rapidly with new technological innovations and management practices. However, little effort has been made toward knowing the nutrient quality of foods served by various foodservice operations, as in hospitals (Khan and Rao, 1983).
Trolley service and tray service in hospitals. Tray service is essential for providing appropriate nutrition care to patients and maintaining patient satisfaction. A monitoring system of tray assembly error rates was designed to evaluate patient tray accuracy and to identify types of assembly errors. The trays at various meal timings were assembled and two mornings, five noon, and five evening meals were assessed. They were also classified with respect to compliance to diet or contradictory to diet order. This was compared by meal, weekday vs. weekend, and first half of assembly period vs. second half. This study resulted in serving as the basis for quality control monitoring and as a motivational tool to stimulate improved performance by tray service employees (Dowling and Connor, 1988).
A study by Hartwell and Edwards (2003) was done to compare two hospital food service systems using parameters of food safety and consumer opinion. A hospital was selected where food delivery was due to change from a plated system to a cafeteria trolley system. Samples (50g) of dishes considered to be high-risk were collected for three consecutive days from breakfast, lunch and supper meals. The samples were taken from a pre-ordered tray (similar to that of a patient) in the plated system and from the trolley on the ward in the cafeteria system of meal delivery, approximately six months after its introduction. Consumer opinion cards were distributed and interviews were also conducted. Microbiologically, the quality of food items delivered by both systems was satisfactory. However, concern was raised with the plated system, not for hot foods cooling down but for chilled foods warming up and being sustained in ambient conditions. Overall patient satisfaction and experience was enhanced with the trolley system. Food was hotter and generally perceived to be of a better quality. Satisfaction with cold desserts was not dependent on the delivery system.
Room service food delivery system with patient’s caregivers. Patients who receive a service in which they eat with a caregiver have a greater caloric intake, protein intake, and/or degree of patient satisfaction than patients randomized to dine independently. However, in a study by Gurley et al, (1998), food was delivered via room service to caregivers of subjects randomized to dine with caregivers. Food intakes of each subject from food diaries, specifically with respect to kilocalories and grams of protein and patient satisfaction were assessed. Regarding patient satisfaction, there was no significant difference between the two groups. However, patients with tumors decreased their intake as the three days progressed, while patients with leukemia increased their intake as the days progressed. In the paediatric research hospital setting, parents dining with patients did not appear to increase caloric intake, protein intake, or patient satisfaction.
Hospital caterer. Currently a large number of hospitals in India are employing the services of professional caterers for production and service of meals in hospitals. The goal of any hospital caterer should be to provide food that meets nutritional requirements, satisfies the patient, improves morale and is microbiologically safe.
Hospital catering services. Hospital catering services are an essential component of nutritional care and should be flexible and responsive to patient needs. Hospital catering facilities have the same requirements as other catering establishments. Meals are prepared and transported to the wards to be served immediately. Throughout transportation and serving of food, its temperature must not fall below 65° C. Close liaison between clinical and catering staff is vital if patients are to receive what they need, when they need it and in a form in which they can eat (Kyle et al, 2005).
Contract food service. Guidelines and standards for out-sourcing hospital food service should be developed. Contracts should be sufficiently detailed and they should cover special diets on medical and personal indications, energy and protein dense menus and provision of snacks and/or meals at ward or near-ward level. They should also cover texture-modified menus for the management of dysphagia. The cost for adequate contract monitoring should be built into the contract. The Clinical Nutrition Service/Department, the Nutritional Steering Committee, the Nutritional Support Team or an adequately qualified person should be given the responsibility for ensuring that the contract reflects nutritional standards (Council of Europe, 2003a).
Meal Service to Patients. Patient meals are an integral part of treatment. Hence the provision and consumption of a balanced diet is essential to aid recovery. Meal service quality, food quality, staff/service issues and the physical environmental indicates an accurate, reliable measure of patients’ food service satisfaction. Assessment of meal service quality differentiates and collects detailed information about foodservice attributes and allows the application of systematic measures to improve foodservice quality. It also provides a tool for the continuous assessment of foodservice quality and measurement of changes in patients’ foodservice satisfaction (Capra et.al, 2005).
Patient menu choice is beneficial to improve the process of patient meal service. A study was done in a UK based hospital to see if menu choices improve patient’s satisfaction to meal service. It was seen that a fair percentage of patients (35%) did not select their menu options. However, menu selection optimized patient nutrient intake, improved patient satisfaction, and significantly reduced labor costs (Petnicki, 1998).
Inpatient and Outpatient Nutrition Services. Inpatient treatment is a type of treatment in which a patient is provided with 24 hour care at a hospital. Patients are educated on their modified diet prior to discharge. Outpatient treatments vary depending on the patient’s needs and the facility but they typically meet a couple of times every week for a few hours at a time. Unlike inpatient treatment, outpatient treatment does not often address medical conditions and nutritional needs. With inpatient treatment, everything is provided at one location. Outpatient treatment is desired by many people because of its flexibility (Casa Palmera, 2009).
Knowledge of patient satisfaction with services is important as nutrition professionals need tools to confidently assess the service provision and educational materials provided as part of that service. According to Scott-Smith and Greenhouse (2007), the nutrition services in the care of in-patients need an interdisciplinary team which can achieve the following goals:
− Establishing standardized systems at both facilitates inpatient and outpatient
− Improving patient care
− Improving work efficiency
− Limiting the number of health care provider contacts for each patient
− Reducing cost of care
Patients’ food perception. Patients’ perceptions of food service, food quality, service timeliness, service reliability, food temperature, attitude of the staff who deliver menus, attitude of the staff who serve meals, and customization, determine the patient satisfaction with nutrition services. Food quality was the best predictor of patient satisfaction with meals and foodservice, followed by customization and attitude of the staff who deliver menus. Individual characteristics like gender, age, education, perception of degree of control over health, and belief that food influences one’s health status and factors like normal or therapeutic diet, time spent at rest, and appetite influence patient satisfaction (Dube et al, 1994).
Monitoring patient’s meals. Monitoring of patients meals and food intake is helpful and important in improving quality of food services in hospitals. Monitoring should include specific characteristics like taste, appearance, colour, texture and temperature of the food served in the hospital. This increases the level of patient satisfaction with the food services for hospital managers and the food and nutrition departments. Also, this is helpful in monitoring the quality of food services in hospitals (Sahin et al, 2006).
Meal rounds: an essential aspect of quality nutrition services. A meal round by a dietitian is an essential aspect of quality nutrition services in long term care of hospital patients (Keller et al, 2006). Meal rounds can be a continuous quality improvement activity to readily identify nutrition risk factors that can influence weight change. The occurrence of weight change results from multi factorial processes, some of which can be considered nutrition risk factors. Feeding and eating difficulties are prevalent in patients, especially those with dementia. The proposed intervention of meal rounds can improve the quality nutrition services.
Nutrition counselling for in-patients in hospitals. Dietary counselling is vital for patients. Amongst the several responsibilities of dietitians in a hospital, important tasks to be performed by them include diet counselling by which patients are provided with diet charts with respect to their diseases. However, many patients do not make use of professional dietetic services like dietary counselling and education. There appears to be scope to improve uptake of dietetic services by patients, and to investigate further individual factors that affect access and usage (Robson et al, 2001).
Nutritional screening. Several steps are involved in the process of improving dietary intake in hospitals. These include screening of patients to identify those at nutritional risk, monitoring dietary intake, modifying the hospital diet as necessary according to the patients’ preferences, and ensuring that serving and ambience of mealtimes are focused on the patient with reduced appetite. By combining regimens ranging from a regular hospital diet to total parenteral nutrition, food can constitute about 60% of total nutrient intake in at risk patients. Furthermore, significant loss of body weight can be avoided in 90% of the patients and in those who cannot be weighed, if dietary intake is satisfactory in 95% of the patients (Kondrup, 2001).
FOOD SANITATION AND HYGIENE IN THE KITCHEN
Inadequate sanitation is a major cause of disease world-wide and improving sanitation is known to have a significant beneficial impact on health, both in households and across communities. The word ‘sanitation’ also refers to the maintenance of hygienic conditions, through services such as garbage collection and waste water disposal (World Health Organization, 2012). Food sanitation and safety is a scientific discipline describing handling, preparation, and storage of food in ways that prevent food borne illnesses. This includes a number of routines that should be followed to avoid potentially severe health hazards (Satin, 2008).
In India, ‘Food Safety and Standards Authority of India’( FSSAI), established under the Food Safety and Standards Act, 2006, is the regulating body related to food safety and laying down of standards of food in India. In 2003, the WHO and FAO published the Codex Alimentarius which serves as a guideline to food safety (Codex Alimentarius, 2007). ISO 22000 is a standard developed by the International Organization for Standardization dealing with food safety. This is a general derivative of ISO 9000. The ISO 22000 International standard specifies the requirements for a food safety management system that involves interactive communication, system management, prerequisite programs, and HACCP principles. Routine cleaning of “contact” (hand, food and drinking water) sites and surfaces (such as toilet seats and flush handles, door and tap handles, work surfaces, bath and basin surfaces) in the kitchen, bathroom and toilet reduces the risk of spread of germs (Bremner et. al., 2008).
The five key principles of food hygiene, according to WHO (2010), are: –
– Prevent contaminating food with pathogens spreading from people, pets, and pests.
– Separate raw and cooked foods to prevent contaminating the cooked foods.
– Cook foods for the appropriate length of time and at the appropriate temperature to kill pathogens.
– Store food at the proper temperature.
– Use safe water and cooked materials.
Food Hazards. Food hazards can be due to biological or chemical contaminants or physical factors. • Among these, biological contaminants are the most important in the Indian context. Biological contaminants include protozoa, yeast, bacteria, moulds and viruses, which are included under invisible biological contaminants/hazards. Visible contaminants include weevils, caterpillars, flies, worms and cockroaches. • Chemical hazards: chemical hazards are toxic substances that may occur naturally or may be added during processing of food. It includes agricultural chemicals- pesticides, fertilizers and antibiotics, heavy metals such as lead, mercury, food additives and food allergens and cleaning compounds. • Physical hazards: physical hazards are hard or soft foreign objects in foods that can cause illness and injury. These include items like stones, metal pieces, tooth picks, bandages, staples, glass, fingernails, hair and wood (Swane et al, 2003).
Sanitary practices. Food borne diseases are easily preventable if food handlers receive extensive education and practice constant vigilance. If an employee starts work in a place that is clean and is kept clean all the time, he will soon acquire the same habits. So cleanliness should become a part of life (Kahrl, 1977). Effective use of sanitary procedures and their proper implementation is the only way of maintaining hygienic conditions, enabling food served to be safe and socially accepted (Roday, 1999). Most hospitals serve meals from breakfast to dinner. Sanitation of eating establishments is a challenging problem in food sanitation.
The following minimum standards have been suggested for food service establishments in India under the Model Public Health Act (1955), which gives the following recommendations:
– Location shall not be near any accumulation of filth or open drain, stable, manure pit and other sources of nuisances.
– Floors should be higher than the adjoining land, made with impervious material and easy to keep clean.
– For storage of uncooked foodstuffs, perishable and non-perishable articles should be kept separately, in rat-proof and vermin proof space. For perishable articles, temperature control should be adopted.
– For storage of cooked food, a separate room should be provided. For long storage, control of temperature is necessary.
– Rooms where meals are served shall not be less than 100sq.feet and shall provide accommodation for a maximum of 10 persons and walls upto 3 feet which should be smooth, impervious, easily washable and corners should be rounded. Lighting and ventilation should be ample. Natural lighting facilities aided with good circulation of air are necessary.
– Kitchen floor space should be a minimum of 60 sq. feet, window opening to be 25% of floor area; floor should be impervious, smooth and easy to keep clean.
– Doors and windows should be rat-proof, fly-proof and of the self-closing type. Ventilators should be 2% of the floor area, in addition to smoke pipes.
– Furniture should be reasonably strong and easy to keep clean and dry.
-Disposable of refuse: This should be collected in covered, impervious bins and disposed off twice a day.
-Water supply should be from an independent source, adequate, continuous and safe.
-Washing facilities should be provided, cleaning of utensils and crockery should be done in hot water and followed by disinfection.
Food safety in hospital kitchens. The World Health Organization (WHO) defines food safety as the conditions and measures that are necessary during production, processing, storage, distribution and preparation of food to ensure that it is safe, sound, and wholesome and fit for human consumption (WHO, 1984). Food safety remains a critical issue nowadays among professionals in the food service sector as well as consumers (Badrie et al, 2006; Scheule et al, 2001). This is basically due to outbreaks of food-borne diseases resulting in substantial costs to individuals and the economy (Egan et al, 2007; Kaferstein et al, 2003) and indeed the widespread and increasing incidence of food-borne diseases has severe social and economic impacts on the human population (Molins et al, 2001).
Food safety is more importantly a public health issue as it plays a noteworthy role in health development and consequently national economic development. Thus great endeavours should be made to improve it at all levels of the food chain. As part of the food chain, hospitals are required to give detailed attention to food hygiene in order to minimize food hazards, given that the patients represent of a vulnerable group of the society.
HOSPITAL ADMINISTRATORS IN NUTRITION SERVICES
Hospital food and nutrition administrators are challenged to consistently evaluate ways to reduce food costs and also maintain food quality. Hospital administrators manage hospitals, outpatient clinics, hospices, and drug-abuse treatment centers. In large hospitals, there may be several administrators, one for each department. In smaller facilities, they oversee the day-to-day operations of all departments. Administrators make sure hospitals operate efficiently and provide adequate medical care to patients of which nutrition care is an important part. Their responsibilities are numerous and sometimes require the assistance of the medical and support staff. They act as liaisons between governing boards, medical staff, and department heads and integrate the activities of all departments so they function as a whole. Administrators recruit, hire, and sometimes organize training for doctors, nurses, interns, and assistant administrators. Administrators plan budgets and set rates for health services. In research hospitals, administrators develop and expand programs and services for scientific research and preventive medicine. Administrators plan departmental activities, evaluate doctors and other hospital employees, create and maintain policies, help develop procedures for medical treatments, quality assurance, patient services including nutrition services for inpatients; and public relations activities They need to keep up with advances in medicine, computerized diagnostic and treatment equipment, data processing technology, government regulations including those related to nutrition care, health insurance changes, and financing options (The Princeton Review, 2012).
DIETITIANS IN NUTRITION CARE
Dietitians supervise the preparation and service of food, develop modified diets, participate in research, and educate individuals and groups on good nutritional habits. The also provide medical nutritional intervention via safely prepared and food, serve and advise on flavoursome, attractive, and nutritious food for patients, groups and communities. Professional dietitians may also provide specialist services such as in diabetes, obesity, oncology, osteoporosis, paediatrics, renal disease and micronutrient research (WHO, 2010).
The role of dietitian has come a long way since the early 1900s. Their role is still unknown to a lot of people. Some think that dietitians, as their name implies, only give out diets to make individuals lose weight, whereas this is a small part of their role. The dietitian is the link between the patient and medical team or physician in assisting difficult decision making about nutrition care. Asian Society of Parenteral and Enteral Nutrition (ASPEN) state that the dietitian role in nutrition care has been recommended an adequate source and amount of balanced nutrients according to pre-established standards of care. A dilemma occurs when the disease state of the patient confound the adequacy of nutritional support, which has resulted in the patient’s malnourishment. The responsibilities spelt out for dietitians in hospitals are:-
– Planning food and nutrition programmes.
– Supervising meal preparations in hospitals.
– Recommending dietary modifications.
– Educating patients on diets that may help their condition.
– Working with other healthcare professionals to provide a multidisciplinary healthcare approach.
– Informing patients on the severity of illness and complications of treatments, inclusive of the benefits and burdens of feeding via different routes.
– Being active in the patients care, reporting on the nutritional status of the patient, as well as advising the physician and medicinal team, and
– Informing the legal decisions that may help determine the route of nutrition care for the patient, such as more aggressive or palliative care (Poonia, 2008).
In case of enteral feeding, dietitians are responsible for calculating nutrient and fluid needs, selecting formulae, determining the home feeding schedule, teaching the patient to prepare blenderized formulae, and teaching the patient to recognize formula intolerance. Dietitians should teach the patient to administer the formula, operate the pump, and flush the feeding tube. Dietitians have a larger role in hospitals which have a nutrition support team (Skipper and Rotman, 1990).
Dietary clerks. According to CBsalary (2011), Dietary clerks, are also known as “medical diet clerks” or “dietary workers.” They prepare dietary information for use by kitchen personnel in preparation of foods for hospital patients following standards established by a dietitian. They examine diet orders, prepare meal trays, maintain the storage area for food supplies, and ensure practice of sanitary procedures. They may operate computers to enter and retrieve data on patients’ caloric requirements and intake, or to track financial information. Dietary workers are typically trained on the job.
ROLE OF NURSES IN NUTRITION CARE
The nurse is the hub of all activities in a hospital, centered on the patient, who makes the patient get more individualised care. Archibald (2006) emphasized the importance of good nutritional intake for patients in hospital care. On busy wards, nutrition is often overlooked in favour of other aspects of care. Nurses’ increased knowledge about assessment of nutritional needs, nutritional care and personal capabilities, can improve patients’ experiences and outcome.
Nurses prepare the areas around patients beforehand, for example, bedside tables are cleared before the meal service. Nurses will ensure patients are positioned appropriately and safely for the meals. The importance of food in the care and treatment of hospital patients has been championed by the nursing profession for many years. Nonetheless it is still a neglected branch of nursing. The Salmon Report (1966) on senior nursing staff structure is widely believed to have diminished the importance of nutritional care as a key nursing role, so much so that the United Kingdom Central Council for Nursing (UKCC) now Nursing and Midwifery Council (NMC) wrote to all registered nurses reminding them of their responsibilities in this area (Wilson and Lecko, 2005).
ROLE OF DOCTORS IN NUTRITION CARE
Doctors are responsible for all medical treatment and prescribing appropriate treatment including nutritional treatment. In addition, they must provide some nutrition information to patients, in order to provide good care to patients. They can motivate patients to eat healthy and also guide for dietary change. This is especially so, as doctors are usually perceived as the best source of information, by patients.
However, the doctors need to refer to dietitians for actual delivery of nutrition care. In the case of more complicated patients, doctors should utilize the expertise of dietitians for optimal health and nutrition care of the patients (vanDillen et al, 2005).
Royal College of Physicians of London (2002) has given recommendations for doctors (which are relevant to the practice of every clinician). They include:-
– Nutritional assessment of all patients
– Preventive measures for when patients are seen to be at risk of becoming too thin or too fat
– Well organized treatment when under or overnutrition are sufficient to affect clinical outcome
– All doctors should be aware of nutritional problems and how to manage them. Every doctor should recognize that proper nutritional care is fundamental to good clinical practice
– A doctor should be responsible for ensuring that adequate information concerning nutritional status is documented in a patient’s clinical record, and that appropriate action has been taken to deal with any nutritional problem
– Nutritional screening of all patients should be an integral part of clinical practice. Screening is a rapid process that will identify patients who are over nourished or undernourished. If an abnormality is detected, further assessment and a specific management policy should follow
– Primary care, hospitals, nursing and residential homes should develop explicit protocols and standards to cover the whole process of nutritional management
-Hospitals should have a multidisciplinary nutrition steering group to establish policies for nutritional care. Doctors should be actively involved in this development. In addition, doctors should play an active role in a multidisciplinary support team for the care of patients with complicated under nutrition and patients requiring long-term tube feeds or parenteral nutrition
-Those responsible for clinical governance should identify nutrition as an important aspect of clinical practice that involves caterers and many health care disciplines. The inadequate provision of nutritional care has both medico-legal and ethical implications 9 The process and outcomes of nutritional care should be part of regular clinical audit 9 Medical undergraduate and continuing professional training programmes for doctors should include relevant aspects of clinical nutrition, along with consideration of the inter-relationships between under and overnutrition, and illness and health.
SANITATION AND HYGIENE IN THE KITCHEN
Food service establishments that prepare and provide food on a mass scale are important from the point of view of epidemiology of food borne diseases (Malhotra et al, 2007). Therefore, responsibility of the food service establishment is not only to serve attractive and nutritious food to patients, but also to ensure that it is wholesome and bacteriologically safe.
Assessment of surface hygiene. Over 30 years ago, a food safety program was developed at Rutgers University USA in response to food borne disease outbreak (Montville and Schaffner, 2004). Data on the microbial quality of food service, kitchen surfaces and ready-to eat foods were collected over a period of 10 years in Rutgers University dining halls. Surface bacterial counts, total aerobic plate counts, and total fecal coliform counts were determined using standard methods. Analysis was performed on foods tested more than 50 times (primarily lunch meats and deli salads) and on surfaces tested more than 500 times (36 different surface types, including pastry brushes, cutting boards, and countertops). Coliforms were most commonly found in sea food salad (present in 61 samples) and least commonly found in coleslaw (present in only 7% of samples). Coliform counts (when present) were highest on average in shrimp salad. Average coliform counts in most products were typically between 1 and 2 log most probable number per gram. Fecal coliforms were not typically found in any deli salads or lunch meats.
An investigation, including environmental sampling, was undertaken by Kiddy et al, 1987 after four leukemic patients on the same hospital ward developed serious infections with Klebsiella aerogenes, capsular type K14. The source of this organism, common to all four patients, was found to be a food blender used for preparing milk-based drinks on the ward. Thus, randomized inspections of food service units in hospitals are an important tool in ensuring food safety.
Food distribution centres. Microbial quality of food depends on various aspects. The trolley/transportation being used to carry cooked/prepared food for serving should be dedicated for this purpose and should not carry anything else. Time required for transportation should be minimum to avoid microbial proliferation. Cooked food served hot should be kept at a temperature of atleast 60oC to prevent microbial growth. Cooked food to be served cold should be kept below 5oC to prevent growth of pathogens. All foods during transportation must be kept covered and in such a way as to limit pathogen growth or toxin formation by controlling time of transportation, exposure, temperature control and using safe water for cleaning (Food Safety and Standards Regulations, 2009).
Microbiology of water. Half of the world’s hospital beds are filled with people suffering from water related illnesses. Water should be stored hygienically in covered containers with taps for withdrawal. The water containers including water dispensers should be regularly emptied and cleaned and then dried by turning upside down at the end of the day’s work. Non potable water systems/containers should be identified and labelled. It should not connect with, or allow refluxing into potable water supply (Food Safety and Standards Regulations, 2009).
− Safe Drinking water in hospitals. As per (WHO, 2008), the purpose for which the water is to be used determines the criteria for water quality. The criteria for drinking water are usually not adequate for the medical uses of water. Drinking water should be safe for oral intake. Water is used in hospitals for many different uses. The water supply system should ensure the provision of safe water. The overhead storage tanks should be cleaned regularly and the quality of water should be sampled periodically to check for faecal contamination. Some microorganisms in the hospital have caused infection of wounds, respiratory tract and other areas where equipment such as endoscopes were rinsed with tap water after disinfection. Infection control teams should have written valid policies for water quality to minimize risk of infections due to water in hospitals. Where safe water is not available, water should be boiled for five minutes to render it safe. Alternatively, water purification units can also be used. The storage of water should be as hygienic as possible. Hands should not enter the storage container. Water should be dispensed from the storage container by an outlet fitted with a closure device or tap. Storage containers and water coolers should be cleaned regularly (WHO, 2002).
Proper waste disposal is necessary to minimize chance of contamination and to prevent the development of off odours (Bhat and Nageshwara, 1992). The Government of India has made sure that all persons who generate, collect, receive, store, transport, treat, dispose or handle medical waste in any form, are responsible for handling the medical waste without any adverse effect to human health and the environment (Indian Society of Hospital Waste Management, 2010). Waste disposal (organic and other) is critical to keep food and beverage safe at every point of the chain. Waste at no point should come in contact with the food directly or indirectly through flies or insects (Food Safety and Standard Authority of India, 2006).
General Waste includes general domestic type of waste from offices, public areas, stores, catering areas, comprising of newspapers, letters, documents, cardboard containers, metal cans, and floor sweepings and also includes kitchen waste. The bag or liner should be made of non-chlorinated plastics especially if it is to be incinerated. Alternatively, sturdy boxes with inner lining could be used, for example, cardboard boxes and latex lining or sturdy paper or draw sheet bags which are leak proof or having a lining of degradable wax or latex which may also prevent leakage effectively. General waste could be disposed off in ordinary cardboard boxes and kitchen wastes can be collected in sturdy containers without liners and later composted (Sharma and Mahajan, 2001).
Dishwashing is one of the most important tasks in food service establishment of hospitals. Unfortunately it is one aspect which is not given much consideration and is usually assigned to the lowest grade employees, who have little knowledge of sanitation. The three most important requirements for dishwashing besides running water are sinks, drain boards and detergent/washing agents (Roday, 1999).
Adequate equipment for cleaning and sterilizing utensils should be provided. Where a dish-washing machine is installed it should be worked efficiently and provide for thorough cleansing of utensils and for their sterilization. For hand washing of utensils, the minimal provision should be: − a sink or sinks (according to the size of the establishment) for the washing of utensils, with hot and cold water. − A separate sink or sinks for sterilizing, each furnished with its own supply or water which can be kept at a temperature of not less than 17°F, by steam injection or otherwise, with automatic devices for recording temperature. Sterilization in a steam chest if adequately carried out may be accepted as an alternative.
− In a small establishment, two-compartment sinks for washing and sterilizing respectively may be used instead of two separate sinks, provided that the necessary device is available for recording the temperature. Sterilization can be effected by simple steaming in a suitable vessel also.
Additional requirements for cleaning and sterilization of dishes and equipment include metal racks with handles to hold utensils for immersion in the sterilizing sink. There should be adequate shelves, hooks or racks to receive utensils for air drying. There should be reserves of glass, crockery and cutlery to ensure the prompt replacement of chipped, cracked or bent equipment. During rush hours, inadequately sterilized equipment should not be used. Detergents used in connection with utensil cleansing should be suitable for the conditions existing, and should be used in correct strength. The local authority is consulted as to the appropriate detergents to use.
CLEANLINESS OF INFRASTRUCTURE AND WORK PREMISES
DGHS (1989) has also given guidelines for infrastructure, work premises and usage of equipment, towards maintenance of cleanliness in the kitchen area. These are:
– Adequate and suitable covered receptacles of impervious material should be provided for refuse, food scraps and the like with a suitable and sufficient storage place for them outside all food-preparation rooms.
– There should be proper receptacles constructed of impervious material for all foods broken down from bulk. All except those for vegetables should have covers.
– There should be a cool larder of adequate size for the storage of foods particularly those of a perishable nature.
– The surface of tables and benches should be impervious to liquids and without open cracks.
– There should be separate and adequate storage for all utensils and, in particular, covered racks for crockery, trays for cutlery and suitable shelving for saucepans and small cooking vessels.
– There should be a separate sink or sinks for vegetable preparation.
– Ventilated hoods, or adequate alternative means for the removal of steam, fumes, intense heat from grillers should be provided, wherever required.
Work Premises and Method of Work. Besides personal hygiene, DGHS has also laid down norms for working premises and method of work to ensure hygiene and sanitation.
– The premises and fixtures should be constructed and fitted such that all parts of both premises and fixtures are capable of being readily cleaned
– Premises: The premises should be large enough for orderly sequence of work without undue crossing of traffic line
– Cooking equipment: The cooking equipment should be so placed that wall areas adjacent thereto and the equipment itself are readily accessible for cleaning
– Floors: The floors should be free from cracks, without open joints, impervious, non-slip and capable of being easily washed down. They should slope evenly towards the drainage outlet
– Walls: The walls should be substantial, durable, smooth, impervious, washable and of a light colour such as white tiles Terraso or polished Kotah
– Ceilings: The ceilings should be dust proof and free from cracks
– Repair: All premises should be maintained in sound repair and every precaution taken against infestation from vermin
– Drainage: Gullies outside and in close proximity should be trapped. All yards should have impervious and even surfaces and should be properly drained
– Water supply: An adequate supply of wholesome water piped to taps over sinks, lavatory/basins and other appropriate fixed receptacles should be provided
– Hot water: Apparatus to provide hot water up to at least 170°F for all requisite purposes should be installed
– Lighting: All parts of the premises used for food preparation should be adequately lit, preferably both by natural light and by artificial light.
– Ventilation: Adequate ventilation should be provided. Here a system of artificial ventilation is not installed but an adequate flow of fresh air should be maintained
– Cloak room: Clean and adequate cloak-room accommodation should be provided for the staff, distinct from but preferably adjacent to the food-preparation rooms
– Sanitary conveniences: There should be a sufficient number of sanitary conveniences to meet the needs of the staff. It should be well lit, ventilated and kept clean
– Washing facilities: There should be a sufficient number of wash-basins in immediate proximity to the sanitary conveniences, and elsewhere as may be necessary, to meet the needs of the staff. In addition, a wash-basin should be fixed in the kitchen itself, or immediately adjacent thereto. Kitchen sinks should not be used for hand washing. All wash-basins should be well lit, with hot and cold water laid on, and should be kept clean. Soap, nail brushes and towels should be provided.
These steps facilitate maintenance of good hygiene and sanitation in the kitchen area and also offer some protection against infestation from rodents and flies.
Vermin and Flies For pest control. DGHS (1989) has laid down guidelines. These are :-
Rats and Mice: Infestation by rats and mice is dangerous as they can spread infection to man. All practicable steps should be taken to eliminate this source of infection. It is essential: (a) to maintain the premises in good repair and to stop all ascertainable means of rodent access (b) to ensure that all food scraps are promptly removed and the premises maintained at a high level of cleanliness (c) to provide impervious receptacles with tightly fitting covers for the storage of all foods attractive to rodent (d) To consult and seek the help of the local authority if rats or mice are found in substantial numbers.
Flies, cockroaches and other insects: The number of flies on the premises can be materially reduced by the rapid and efficient disposal of all food scraps and by using flyproof covers for food to the fullest possible extent. Manure or refuse piles or other materials serving for fly breeding near to the catering establishment should be reported to the local authority. The presence of cockroaches and other insects in numbers is often evidence of faulty fixing of plant and of inadequate hygienic practices. Thorough cleanliness and the provision of proper food containers are important preventive measures. The local authority should be consulted if the presence of these pests continues. When insecticides are used, great care should be taken to prevent the contamination of food, equipment and utensils.
Anyone who has gone without food for one or two days will know the discomfort it gives. In European hospitals it is common that patients go without food for several days. It has been amply demonstrated that this starvation has human, functional, clinical and financial implications. The money spent treating nutrition-related complications is enormous as is the monetary value of hospital food wasted.
Despite the significant number of hospitalised patients affected, disease-related undernutrition is rarely recognised or treated, meaning that only few of those who need nutritional support receives it. There is a general lack of awareness of the untoward consequences of disease-related undernutrition among not only health care professionals but also hospital managers despite the potential savings resulting from better nutritional care.
A major cause of the failure in nutritional care of hospitalised patients can be linked to lack of appropriate education and training. Also, there is disagreement between different health care professionals as to whom, is responsible for the nutritional treatment of the patients. Meals are rarely pleasant social occasions, all patients are considered equal with respect to food needs and furthermore have little control over food choice, methods of preparation and times of eating. The provision of meals is regarded as a hotel service, rather than as an essential part of treatment for many patients.
However, all patients have the right to expect that their nutritional needs will be fulfilled during hospitalisation. Patients in good nutritional status are sound indicators of the quality of care provided. Also adequate energy intake is a prerequisite for an optimal effect of medical and surgical treatments. The costs of identifying nutritionally at-risk patients are low. So is the use of energy and protein dense menus for nutritional support. Finally, early and adequate nutritional support is associated with cost-benefit. Most patients, relatives and hospital managers are not aware of this. To secure their active involvement and engagement, such information has to be made public.
The average length of stay in hospitals has been steadily decreasing and is now between 5 and 10 days. Besides, the majority of patients are undernourished already at admission. Therefore, the monitoring and follow-up of the patient has to continue all the way through the hospital stay and out in the community. Hence:
- Organised contact between the hospital and the primary health care sector should be established.
- Medical and nursing admission, discharge and outpatient records should contain information about each patient’s nutritional status, physical and mental abilities, in relation to food intake.
- The nutritional risk of all patients should be routinely assessed prior to admission.
- The patient (and relatives) should be informed of the importance of good nutrition throughout the disease process to attain a successful treatment.
- The involvement of relatives in the nutritional care and support of patients should be welcomed.
In recent years national initiatives to enhance understanding and promote good practice in nutritional care and support are gathering momentum. Such initiatives should be expanded.