Impact of protected mealtimes on mealtime environment and nutrient intake in hospital patients

Abstract

Background: Malnutrition is reported in 13–40% of hospital patients and is associated with poor clinical outcomes and high healthcare costs (Elia et al., 2005). Despite the lack of high quality evidence, recent government strategies have focussed on the provision of adequate nutritional care to alleviate malnutrition. Protected mealtimes (PM) are one of the Council of Europe's 10 key characteristics of good nutritional care in hospitals (Council of Europe Alliance, 2003). The aim of this observational ‘before versus after’ service evaluation was to compare mealtime environment and nutrient intake pre and post PM implementation in an acute hospital trust. Methods: Data was collected over a 3 week period at both baseline (2008) and following PM implementation approximately 1 year later (2009). PM was implemented by posting guidelines on the Trust intranet and issuing wards with a PM sign and information posters. A mealtime questionnaire was completed individually by two observers (dietetic and nursing) for 10 randomly selected patients on all wards across two hospitals. The questionnaire covered 19 PM objectives, as described by the Royal College of Nursing. All patients screened as high risk for malnutrition and not receiving artificial nutrition were considered for participation of a weighed food intake evaluation, which was completed separately to the mealtime questionnaire. Characteristics that may influence food intake were recorded for each patient (e.g. gender, disease category etc.) and were similar in the pre-PM and PM analysis. The researcher weighed wastage at one lunch time meal and nutrient intake was calculated based upon average serving size. Categorical data was analysed using the Chi-squared test and continuous data was analysed using the Mann Whitney-U test (SPSS version 15). Results: Questionnaires were analysed for 253 and 237 individual patients on 40 and 34 wards pre-PM and post-PM respectively. Of the 19 PM objectives measured, there were significant improvements in only three: number of patients on food and/or fluid charts (32.1% versus 42.7%, P = 0.021), patients offered opportunity to clean hands prior to eating (30.0% versus 40.1%, P = 0.029) and clean and clear tables during mealtimes (54.3% versus 63.9%, P = 0.039). There was no significant difference in the proportion of patients experiencing mealtime interruptions (68.3% versus 74.8%, P = 0.143). For the nutrient intake analysis, 39 at pre-PM and 60 patients at post PM had their meal waste measured and group there were no significant differences in group characteristics. There was no significant difference in energy or protein served to each group. There was no significant difference in energy intake (260 kcal versus 200 kcal P = 0.246), however the PM group consumed significantly less protein (7.5 g versus 14 g, P = 0.039). Discussion: This study showed that small improvements were made in the PM environment on the wards. This improvement did not include the important criterion of reducing mealtime interruptions. The observed improvements in cleanliness of environment and nutritional monitoring were insufficient to increase nutritional intake. The reason for a lower protein intake is unclear. The lack of differences following implementation may be attributed to the implementation not incorporating several critical success factors such as highlighting and addressing specific barriers to change and disseminating a PM policy via multidisciplinary structured education (National Patient Safety Agency 2006). Limitations that may have confounded the results include inter-rater variability in mealtime observations, questionnaire quality limiting response rate which may have been improved through piloting and menu changes which could have impacted on food intake. Conclusion: These findings highlight the need for an evidence based PM implementation method which produces measurable improvements in all PM objectives and so enabling a reliable measure of the impact of PM on nutritional and clinical outcomes.