Patient meals are not provided based on nutritional requirement of the patients, finds RAA
By Kinley Yonten
Not meeting specific nutritional needs of patients could deteriorate their condition and prolong hospital stay as well as their recovery, according to an audit report on performance audit of hospital food.
Patient meals were not provided based on nutritional requirements or disease conditions of the patients, according to the report. The RAA audited patient meals in six hospitals.
The RAA observed all in-patients are provided with regular meals regardless of clinical conditions. The food indenting process in the hospitals was found to be inefficient and uneconomical. It observed that all patients admitted were provided hospital meals irrespective of whether they want to eat or not.
“The food intake by patients was found to be suboptimal raising doubts on the acceptability of hospital meals. Suboptimal intake was caused mainly due to consumption of meals by the attendants, meals for patients brought from home, patients treated with food from hawkers and restaurants,” the report stated.
Patient meals with balanced diet are an essential part of hospital treatment that is crucial for patients’ fast recovery. Inpatient food service system should be flexible enough to provide a good choice of nutritious meals that can accommodate patients’ medical conditions, specific dietary requirements and preferences.
Even the guideline for inpatient food service system 2013 specifies different types of diets–regular, soft, therapeutic diets, and special supplements to be provided to inpatients based on their disease and nutritional requirements. Colour coded cards are then distributed to each patient depending on the type of diet.
However, RAA found that none of the hospitals provide therapeutic diets due to low acceptance of therapeutic diets since these diets have dietary restrictions such as low sodium, cholesterol and lower overall carbohydrate content.
“Effective menu planning can have a big impact on in-patient food services as menus determine foods to be purchased and prepared, kitchen staff and equipment needed, and finally the budget required,” noted RAA.
For this reason, hospitals menus are planned so that the food service system is efficient and cost effective. Further, menus should be planned by a wide range of professionals from nutrition, clinical, nursing and administration departments who bring their own expertise to the process.
Nutrient requirements of hospitalized patients will be higher than that of people who are not ill or malnourished and so, menus should be prepared accordingly to ensure that such needs are met. RAA stated that hospitals should plan menus by specifying nutrient criteria so as to maximise nutritive value of the meals provided.
“None of the hospitals had specific nutrient criteria while planning a menu,” the RAA team noted. There were no standards or guidelines for menu planning. Similarly, the RAA did not find any evidence that show the use of nutrition checklist for menu planning indicating absence of basis for preparing menus and as such, preparation of menus is left entirely up to the expertise of the dieticians. It was noted that nutrient criteria were not used because there are no nutrient reference values for Bhutan showing the nutritive value of Bhutanese foods. “Not having a basis for menu preparation could lead to difficulty in analysing the nutritional content of menus could impede assessment to ascertain whether nutritional requirements of the in-patients are being met from hospital meals,” the RAA team noted.
Only two out of six hospitals provided soft diet, blended food to those patients who need enteric or tube feeding but not catered to patients with low appetite, who cannot swallow, and have difficulty eating solid foods.
Menus have never been analysed for nutritional content, says the RAA report. “Hospital menus should be assessed for nutritional content by dieticians to ensure that patients are provided with nutritionally sound meals,” the RAA team noted.
However, dieticians were engaged in menu planning, none of the hospitals have conducted nutritional content analysis of their menus. Many dieticians claimed to use the Indian standards of nutritive value of foods as it is more or less similar to Bhutanese foods. Yet, menus have not even been assessed using the Indian standards to ensure that patients’ nutrient requirements are being met.
As a result, there is no validated information on whether patients are getting the required nutrients and limiting opportunities for improving the quality of inpatient meals.
From the menus collected from the hospitals, the RAA noted that all hospital menus follow a one week cycle menu but with repeated menus day in and out except on days when meat is provided. For example, CRRH Gelegphu follows a menu that repeats every day in that one week cycle. CRRH Gelegphu provides tea, egg and bread for breakfast every day of the week. Similar cases were noted in other hospital menus where rice, dhal, mixed vegetable curry for lunch and dinner seems to be the norm whenever meat is not served.
Repeated menu results in low food variety with hospitals providing the same food items frequently, RAA noted. Moreover, there was not much emphasis on providing variety of vegetables and fruits which are a rich source of macro- and micronutrients. Only three (MRRH, CRRH Gelegphu, and Trashigang District Hospital) out of six hospitals have provision for seasonal fruits in their menu. Although hospital menus do provide servings of vegetables during lunch and dinner, it was noted that most vegetables provided are potatoes. In fact, a long stay patient who is oxygen dependent in MRRH commented that she is “sick of potatoes”. There is a risk of patients getting food fatigue resulting in low food intake if any food item is repeated often in one cycle menu.
Providing regular meals for patients diagnosed with specific clinical conditions could result in not meeting the specific nutritional needs, which could further deteriorate their disease condition and prolong their recovery. As a result of not providing different types of diets, the colour coded card system was not followed in the hospitals.
All the patients were given the blue colour card on admission in most hospitals indicating regular diet. It was also noted that lack of resources in terms of financial and staffing were common causes of not providing diets based on nutritional needs or disease status of patients.
The CRRH Gelegphu expressed that they cannot implement all three types of diets because of man-power and equipment shortage at the moment but this system will be considered in the new hospital in the future. At the same time, the hospital also mentioned that they do provide soft diet like porridge and mashed rice with vegetables, pulses, and eggs to those patients who are not able to take solid foods. Moreover, amount of salt, cooking oil, spices are monitored in the kitchen in order to make the food nutritious and palatable.
The RAA agrees on the man-power and equipment shortages pointed out by the hospital. Nevertheless, instituting appropriate system to provide diets based on nutritional needs would make a greater difference in the improvement of patients overall health.
In order to improve inpatient food services, the Ministry of Health has developed a guideline for inpatient food service system in 2013 and appointed dieticians in hospitals as well as engaged them in menu planning, ensuring food safety, and cleanliness of kitchens, and quality control of patient meals. However, not undermining the initiatives of the Ministry, the RAA observed that patient meals were not provided based on nutritional conditions of the patients. The food indenting process was inefficient resulting in wastage of resources.
Moreover, the daily nutrient intakes as per Ration Scale do not generally meet the World Health Organisation (WHO) recommended daily requirement. Menu planning was found to be ineffective and mealtimes were not made conducive to encourage patients to increase food intakes.
Further, there was poor knowledge of food safety in practice. The RAA acknowledges the fact that health professionals have complex and competing clinical duties which often makes it difficult to carry out the role of greater nutritional care.
However, nutritional interventions are imperative as the benefits far outweigh the costs of interventions. The RAA observed that nutritional care often received lesser priority than clinical activities. The RAA stated that the criticality of clinical care; however, hospital management also need the clinical importance of nutrition and crucial role of healthy food in patient’s recovery and health. Thus, there is a need to change the hospital culture of giving less importance to nutrition than other clinical activities.