Healthcare Research Paper on University College London Hospital

University College London Hospital

Introduction

The University College Hospital was founded in 1834 as the North London Hospital, which later changed its name to the university college hospital in 1837. As a teaching hospital, it is closely linked to the University College London (UCL) that was started in 1826. It is a part of the University College London Hospitals NHS Trust. It joined in 1994 and which runs six hospitals across London. Other Hospitals that comprise the NHS foundation include Royal National ENT Hospital, Royal London Hospital for Integrated Medicine, National Hospital for Neurology and Neurosurgery, Heart Hospital and Eastman Dental Hospitals.

The University College Hospital is currently divided into four departments, which include the Macmillan Cancer Centre, Hospital for Tropical Diseases, Elizabeth Garrett Anderson Wing, and the Institute of Sport Exercise and Health. The Hospital has state of the art equipments, which use innovative technologies (UCLH, 2014). The range of services offered by the hospital include: critical care, cancer care, clinical Hematology, Endocrinology, general medicine, general surgery, dermatology, neurology, gynecology, ophthalmology, pediatrics, rheumatology and urology.

In terms of facilities, the hospital boasts the largest critical care units in amongst the NHS hospitals and has a total of 12 operation theatres. With 665 in-patient beds in the hospital, it forms a major teaching hospital as well as a centre for research. The Accident and Emergency department in the Hospital receives and takes care of approximately 80,000 clients each year. The Dietetics department offers services such as the Head and Neck Oncology, Critical Care, cardiology and lipid lowering, bariatric surgery, neurosciences, diabetes, gastroenterology, pediatrics and adolescents, oncology, nutritional support, inborn metabolism errors and immunological and tropical diseases.

The specific clientele groups where dietetics department works include curative and palliative oncology patients who can be children or adults; curative and palliative hematology patients who can be either children or adults as well as adult head and neck patients. Moreover, intestinal failure patients, respiratory diseases patients, elderly care; patients suffering from acute and chronic gallstones, pancreatitis, and cholecystitis, IBD, infectious diseases, and stroke patients are catered for. The range of clientele means that the nutrition support department has to offer varying catering provisions in order to serve the entire client range.

The nutrition support services offered in the hospital form the focus of this paper. The most essential aspects of the nutrition support services that will be included in this paper are the factors considered within the hospital, the nutritional problems addressed at the hospital and the catering provisions that are used to address the various nutritional problems at the hospital.

Factors to Consider

Due to the wide range of clientele characteristics, various factors have to be considered during the modification of nutrition support services and hydration. The factors can be classified into three distinct categories. These are nutritional, social, and financial factors. The nutritional factors are the most critical in consideration since they play a major role in determining the effectiveness of the patient care process.

Nutritional Factors

Metabolic and Nutritional requirements – nutritional requirements in patients have to be considered especially in order to cater for the needs of patients suffering from nutritional problems such as malnutrition. In such cases, the patients should be given more of the nutrients they lack while balancing the provision of nutrients, which the patients have (mendonca et al, 2011). The objective of considering this factor is to avoid escalation of nutritional problems in clients through failure to provide required nutrients.

Gastro-intestinal functioning – the gastro-intestinal functioning in patients determines the types of foods that can be consumed by patients. For instance, patients who have undergone abdominal surgeries may require low fibre foods or less solid food as compared to other patients with normal gastro-intestinal functioning (Levy et al, 2006). Only foods matching the digestive capabilities of the different patients have to be serves to them.

Food allergies- this is another factor that has to be taken into serious consideration when modifying the nutritional provisions by the dietetics department. This is important since besides allergies to completely prepared foods, some patients may also be allergic to certain ingredients hence giving the need to avoid these ingredients during the preparation of specific foods (Steinman, 2010).

Oral Hygiene – the patients’ oral hygiene has to be considered since the nutritional value of foods consumed determines the ability of the patients to resist certain oral infections. For instance, the consumption of certain sugars aggravated the occurrence of periodontal diseases and hence results in tooth loss. Moreover, poor nutritional choices lead to faster progression of the periodontal disease, particularly in adults (ADA, 2010).

Social Factors

The social factors are related to interpersonal relationships between patients and their families, patients and health care providers as well as cultural expectations. The social factors are not directly related to dietetics but they have an influence on the ability of the patients to access and take advantage of catering provisions.

Mobility – the mobility of patients has to be considered prior to modification of nutritional support services and hydration. Nutritional services must be provided where the patients who need them can access them.

Compromised physiology – the patient’s physiology also plays an essential role in determining his/ her ability to access the nutritional services offered. This refers to shortcomings such as limitations in flexibility and physical impairments, memory impairment, and compromised brain oxygen among other shortcomings (Bohman et al, 2011). These compromises may make it difficult for patients to carry out nutritional activities such as eating on their own hence; they have to be considered during the planning of nutritional services.

Compromised medical status – the medical status of patients determines the types of foods they can consume. Patients with lifestyle diseases such as diabetes may have restrictions in the types of food they can consume. It is therefore necessary for each patient’s medical history to be taken into consideration in order to plan effective for modifications in the nutritional services (A’Beckett et al, 2011).

Comorbidities – these often come about as a result of the presence of two or more chronic conditions or diseases in a patient. It is mostly prevalent in patients with conditions such as Chronic Obstructive Pulmonary Disorder (COPD) (Samet et al, 2004). The nutritional department must also consider the inherence of comorbidities in patients since this makes the nutritional demands of patients more serious thus requiring greater attention to detail since any mishap may aggravate the patient’s condition.

Dependency on others for access to nutritional services – This is applicable to patients who may not be capable of enjoying the catering provisions without assistance from others. The nutritional department has to take this group of patients into consideration since they may need to have special conditions set for the patient population. For instance, while other patients are not may not be allowed to have visitors during meal times, the patients with this condition always need someone to be there for them in order to offer the required assistance.

Ethnical and religious requirements – religions such as Islam have nutritional guidelines, which their members have to adhere to strictly. In the hospital, such religious and ethnical diet requirements are also taken into consideration in the modification of nutritional plans. It is appropriate for planning to cater for the needs of all patients regardless of their ethnic or religious backgrounds.

Impaired cognitive function – patients with cognitive impairment have been observed in various studies to be susceptible to malnutrition (Malara et al, 2014). It is therefore critical for the UCH dietetics department to determine the prevalence of cognitive impairment among the patients and to use this as a factor for deciding on the right modifications to diets. This also helps to detect malnutrition in patients before it escalates and subsequently to control it.

 Financial Factors

The major financial factor that has to be considered is the cost of nutritional service and hydration modification and the impacts of the cost on the hospital finances as well as on the patient’s finances. The costs of alternative foods should be comparable to the costs of main meals offered per person (Dong, 2015). For instance, in catering for the needs of diabetics it is imperative that foods offered, as alternatives should not cost more than the normal foods offered to the entire patient population.

Nutritional Problems at UCLH

Malnutrition/ under nutrition: malnutrition is one of the most prevalent nutritional problems in hospitals. As a problem, it is associated with several possible adverse outcomes such as muscle wasting, higher treatment costs, and longer durations of stay in hospitals and impaired healing of wounds (Barker et al 2011). It is essential that the dietetics department carry out frequent screenings for malnutrition among its patients. At the UCLH, screening for malnutrition is carried out through a rigorous process involving determination of the patient’s BMI consideration of various factors. Patients considered at risk include those who have experienced unintended weight loss of more than 15 percent of their body weight in about 3 – 6 months; those who have had low nutritional intake for more than 10 days and those with low level of phosphate, potassium, or magnesium before feeding.

Protein energy Malnutrition: PEM frequently presents in patients with chronic illnesses. It is caused by environmental, socioeconomic, and political factors (Grover, 2009). In patients with chronic illnesses, PEM is related to mortality and morbidity. Patients with COPD, chronic heart failure, rheumatoid arthritis and stroke are often vulnerable to PEM. This makes it one of the nutritional problems in UCLH since patients with these types of chronic disorders frequent the facility (Akner & Cederholm, 2001).

Disease related malnutrition: this is described in various ways depending on the context of presentation. In cases where there is malnutrition without inflammation, the condition is referred to as starvation related malnutrition. On the other hand, when the malnutrition presents with mild inflammation, it is described as disease related inflammation while malnutrition with severe or acute inflammation is defined as acute disease related or injury related malnutrition (Jensen et al, 2010). Disease related malnutrition presents in all health care facilities and has been classified as a worldwide problem. It results in immense economic costs in the health facilities as well as in national governments (Freijer et al, 2013). The dietetics department at UCLH therefore spends a lot in dealing with disease related malnutrition in patients.

Mal-absorption issues: mal-absorption in patients presents due to alterations in the gastro-intestinal capabilities of patients. In the health care sector, it is considered in most cases as an indication of serious intestinal failures i.e. the inability of the digestive system to digest or absorb nutrients effectively. Patients with intestinal failures are incapable of maintaining a sufficient fluid balance, nutritional status or mucosa integrity in the patient (Blaauw, 2011). Mal-absorption may also manifest through digestion impairment and excessive loss from the gut. In the case of digestion impairment, enzyme deficiencies and pancreatic insufficiency are often cited as the causes of mal-absorption (Flood et al, 2009).

Enteral nutrition support individuals who have suffered from malnutrition and under nutrition previously often need enteral nutrition support such as tube feeding. It is the role of hospitals such as UCLH to provide nutritional support services to the patients who require this. Costs of caring for patients requiring enteral nutrition support are usually 50 percent higher than costs incurred in taking care of other patients (Stroud et al, 2003). Guidelines for clinical practice in offering enteral support to patients with critical illnesses provide that EN support should be started early enough to prevent the advancement of the illnesses, and to minimize the risks associated with illness (Heyland et al, 2003).

Some of the symptoms associated with nutritional problems in UCLH patients include diarrhea, GI function, abdominal distention, constipation, and vomiting/ nausea. These symptoms are usually signs of deeper causes and should be taken as the confirmation for need of further examination of patients.

Catering Provisions

Over 500 meals are provided in each service by the dietetics department at UCLH. The catering manager in collaboration with the dietician prepares the menus. The UCLH offers several distinct food options to the patients. These options include the healthy option, higher energy option, gluten free option, puree, vegetarian foods, soft foods, fork-mashable foods, low potassium, and medium or spicy foods. The vegetarian meals are suitable for patients requiring foods free of meat or fish. The neutropenic meals are unsuitable for patients requiring neutropenic foods, while the low potassium meals are suitable for people with renal impairments.

Besides the normal food options, UCLH also offers religious and ethnic diets. The foods provided in this category include Halal foods for the Muslims, Afro-Carribean diets, and kosher meals for the Jewish. In the provision of the menus, the hospital’s dietetics department uses several languages. These languages include English, Turkish, Bengali, Spanish, Arabic, Somali, and Cantonese. The importance of this variety in languages is that it enables the patients to have an understanding of what is offered by the hospital’s dietetics department without a language barrier.

In addition to the normal food options and the ethnic and religious diets, the UCLH dietetics department also offers alternative meals to the patients. The alternative meals are meant for patients with special diet meals such as diabetic patients, as well as those who have particular food allergies. Allergenic foods of 14 different types are offered by the hospital. It is the role of the dietetics department to train staff so that they can be aware of all ingredients used in the preparation of all foods and thus ensure that no allergenic ingredient is used for the preparation of hospital meals.

The catering department also provides for therapeutic diet needs. These diets are suited to approximately 15 percent of the patients in the hospital and are provided according to particular patient needs. The therapeutic diets are reviewed at UCLH after every two years. In the world, there are currently over 147 therapeutic diets that are used in hospitals (Williams et al, 2014). However, only a few of these are available in UCLH. These diets can be fat modified, fibre modified, allergy intolerance diets, drug interaction diets, and post procedure diets among others. Moreover, the hospital also provides menus for special preferences such as kids’ menu, special diets, and dysphagia.

The kitchen area is divided into the salads, snack, specific diets and assembly sections. In most of the cooking operations, the UCH catering department uses Steamplicity. This is a modern day pressure cooker, which is essentially a pressure release valve, which is used for the regulation of cooking temperatures resulting in faster cooking durations (Edwards & Hartwell, 2006). Foods such as fish may be prepared in about four minutes. Due to the present, need for food preparation. Steamplicity operates by steam build up within the cooker. At a certain level of steam, pressure is released and the microwave goes off. The impact of this is that all foods retain their original colour while being cooked. Since foods served are required to be between 70 and 75˚C, steamplicity enables the catering department to achieve this (Hickson et al., 2007). The kitchen maintains a three-day food supply. The foods in supply are stored under conditions in compliance with HACCP principles. Such conditions include temperatures of 1- 5 degrees in refrigerators and -18 degrees or below in the deep freezer.

Cooked chilled menus are also on offer from the main supplier i.e. Tillery Valley while the Vegan diets are only offered on the dietician’s recommendation. Tillery Valley changes the menu cycle once every year after reviews. During the regular reviews, activities carried out include plate wastage audit that is carried out every three months, annual beverage provisions audit, and quarterly tasting sessions. All patients are assisted during their meals times to eat their foods independently and those who cannot eat independently are helped. The nurses are capable of identifying patients who need help during meal times in order to avoid compromising their dignity.

At the hospital, meals are served at particular times of the day. Breakfast is served between 0700 and 0900 hours, lunch is between 1200hrs and 14hrs while the dinner is served between 1700 and 1900hrs. Snacks and drinks are served according to snack menu and with every meal respectively. During the meal times, packaged meals are preferred because they are less labour intensive; they result in higher food intake and less wastage and involve a flexible service mode. Packaged foods are also safer since they have records of the cook program numbers, product title, and storage information, the use by date and allergen data.

All food-handling practices are guided by food safety principles as outlined by the Hazard Analysis and Critical Control Points (HACCP).

Hazard Control and Critical Control Points

The HACCP is an international standard for the maintenance of consumer safety and for the protection of the consumers. All food related businesses are required to comply with the guidelines provided by the HACCP in order to maintain food safety. In the UCLH, the HACCP is the most applicable guideline for ensuring food safety and the protection of consumers. The standard is based on 7 principles which include: Hazard identification and risk assessment, identification of critical control points, establishment of critical limits, implementation of continuous monitoring, implementation of corrective measures, verification of validation, and documentation and record keeping (Britton et al, 2009). The HACCP system has found wide application worldwide and various methods of compliance have been developed in various countries. for instance in the UK, the Safer Food Business Pack has been developed by the Food Standards Agency to aid businesses in complying with the requirements of HACCP (FSA, 2009). This clearly shows how important they are to the maintenance of food safety.

Conclusion

The most prevalent problem in the catering department is malnutrition among the patients. Dieticians should carry out anamnesis and frequent screening in order to cover all nutritional factors. Frequent screening enables identification of emerging problems and their control before exacerbation (Savage & Scott, 2005). Therapeutic menus should also be designed to enable patients to choose meals freely depending on their medical status. This can enable the hospital to address nutritional problems in an easier way through the cooperation of the patients (Flood et al., 2009). Other solutions to the problems that are workable by the dietician include planning of tasting sessions, development of innovative ideas for menu improvement, and menu coding. Tasting sessions enable the dietician to monitor changes in tasting capabilities among patients while menu coding aids in ease of identification of menu provisions by the patients (CMUH, 2013).

 

References

A’Beckett, K., Baytieh, L., Carr-Thompson, A., Fox, V., MacLennan, P., Marriott, J. et al  (2011). Clinical practice guidelines: Nutrition burn patient management.  Agency for Clinical Interventions.

Akner, G., & Cederholm, T. (2001). Treatment of Protein Energy Malnutrition in Chronic non-malignant disorders. American Journal of Clinical Nutrition, 74(6), 6-24

American Dental Association ADA (2010). “Food Choices can affect your Oral Health”. Retrieeved from http://www.colgate.com/app/CP/US/EN/OC/Information/Articles/ADA/2009/article/ADA-04-Food-Choices-Affect-Your-Oral-Health.cvsp

Barker, L., Gout, B. & Crowe, T. (2011). Hospital Malnutrition: Prevalence, Identification and Impact on Patients and the Healthcare System. International Journal of Environmental Research Public Health, 8(2), 514 – 527.

Blauuw, R. (2011). Malabsorption: Causes, consequences, diagnosis and treatment. South African Journal of Clinical Nutrition, 24 (3), 125-127.

Bohman, L.E., Heuer, G.G., Macyszyn, L., Maloney-Wilenskey, E., Frangos, S., LeRoux, P.D. et al (2011). Medical management of compromised brain oxygen in patients with severe traumatic brain injury. Neurocrit Care, 14(3), 361-369.

Britton, D., Heimowitz, P., Pasko, S., Patterson, M. & Thomson, J. (2009). HACCP Hazard Analysis and Critical Control Point Planning to Prevent the Spread of Invasive Species. USFWS-NCTC.

Central Manchester University Hospital CMUH (2013). Dieticians, nutrition screening and nutrition support. Retrieved from https://www.cmft.nhs.uk/media/588906/cmft_spoke_2013%20march%20copy.pdf

Dong, G. (2015). Performing well in financial management and quality of care: evidence from hospital process measures for treatment of cardiovascular disease. BMC Health Services Research, 15(45).

Edwards, J. S. A., & Hartwell, H. J. (2006). Hospital food service: a comparative analysis of systems and introducing the Steamplicity concept. Journal of Human Nutrition and dietetics, 19(6), 421-430.

Flood, P., Keogh, S., O’Grady, A, McKiernan, M., Feehan, S., Barnes, E. et al (2009). Food and nutritional care in hospitals: Guidelines for preventing under nutrition in Acute Hospitals. Department of Health and Children.

Food Standards Agency FSA 2009, The Food Safety Act 1990 – A guide for food businesses. Retrieved from http://www.food.gov.uk/sites/default/files/multimedia/pdfs/fsactguide.pdf

Freijer, K., Tan, S., Koopmanschap, M., Meijers, J., Halfens, R. & Nuitjen, M. (2013). The economic costs of disease related malnutrition. Clinical Nutrition, 32, 136- 141.

Grover, Z. & Ee, L.G. (2009). Protein Energy Malnutrition. Pediatr Clin North Am, 56(5), 1055-1068.