Laboratory of Food Practices and Behavior – PrátiCA, Nutrition and Metabolism, Department of Internal Medicine, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, SP 14049-900, Brazil
Department of Nutrition, Federal University of Santa Catarina, Campus Universitário, Florianópolis, SC, 88040-900, Brazil
Faculty of Nutrition, PUC Campinas, Av. John Boyd Dunlop, s/n., Campinas, SP, 13060-904, Brazil
Department of Social Medicine, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
Abstract
Background
Food and nutritional care quality must be assessed and scored, so as to improve health institution efficacy. This study aimed to detect and compare actions related to food and nutritional care quality in public and private hospitals.
Methods
Investigation of the Hospital Food and Nutrition Service (HFNS) of 37 hospitals by means of structured interviews assessing two quality control corpora, namely nutritional care quality (NCQ) and hospital food service quality (FSQ). HFNS was also evaluated with respect to human resources per hospital bed and per produced meal.
Results
Comparison between public and private institutions revealed that there was a statistically significant difference between the number of hospital beds per HFNS staff member (p = 0.02) and per dietitian (p < 0.01). The mean compliance with NCQ criteria in public and private institutions was 51.8% and 41.6%, respectively. The percentage of public and private health institutions in conformity with FSQ criteria was 42.4% and 49.1%, respectively. Most of the actions comprising each corpus, NCQ and FSQ, varied considerably between the two types of institution. NCQ was positively influenced by hospital type (general) and presence of a clinical dietitian. FSQ was affected by institution size: large and medium-sized hospitals were significantly better than small ones.
Conclusions
Food and nutritional care in hospital is still incipient, and actions concerning both nutritional care and food service take place on an irregular basis. It is clear that the design of food and nutritional care in hospital indicators is mandatory, and that guidelines for the development of actions as well as qualification and assessment of nutritional care are urgent.
Background
Changes in population age distribution and lifestyle require that these institutions undergo modifications, in order to meet the current demands of society such as increased life expectancy and new disease profiles
Nutritional status in hospital inpatient has been the object of many studies
European research on food and nutritional care in hospital has recognized that it is necessary to define responsibilities, promote staff qualification, enable patients’ participation in nutritional decisions, and integrate the health care team into nutritional care
Food and nutritional care actions regarding both patient assistance and food quality must be well delineated and become an effective practice in health institutions. Different management sectors, namely the clinical and administrative areas, should be involved in the process, and actions should be recognized and evaluated by regulating agencies concerned with hospital quality control.
Standardization of nutritional care practice in the United States was implemented by the American Dietetic Association (ADA) in 1987. In 1993, the Clinical Nutrition Management executive committee selected professionals who later developed and assessed the standard nutritional practices that should be employed for management of the clinical nutritional area, which gave rise to a standard reference for this field
This study aimed to detect and compare actions relative to food and nutritional care quality in hospital in public and private hospitals.
Methods
Thirty-seven hospitals were investigated. Twenty-seven hospitals were located in municipalities of the state of São Paulo, more specifically Campinas and Ribeirão Preto, whereas ten hospitals were located in the city of Florianópolis, capital of the state of Santa Catarina. Both Campinas and Ribeirão Preto are important scientific-technological health centers with various services of nationwide recognition. The cities included in the present work are home to various public (federal and state) and private universities. Campinas, Ribeirão Preto, and Florianópolis have an estimated population of 1,039,297; 547,417; and 396,723 inhabitants, respectively.
In the states of São Paulo and Santa Catarina there are 2.29 (0.58 public and 1.71 private) and 2.66 (0.67 public and 1.99 private) hospital beds/ 1,000 inhabitants, respectively. The metropolitan region of Florianópolis holds a larger concentration (72.7%) of public beds (2.61 of the 3.59 hospital beds/1,000 inhabitants are public), while the metropolitan region of Campinas has a larger proportion (74.6%) of private beds (1.47 of the 1.97 hospital beds/1,000 inhabitants are private)
The following inclusion criteria were considered: hospitals located in the studied municipalities, regardless of the type – general, specialized, public, private, small (up to 50 beds), medium-sized (between 51 and 150 beds), or large (more than 150 beds) – that agreed to take part in the research. Psychiatric hospitals, day hospitals, nursing homes, and shelters were not included. Hospitals that did not have a dietitian responsible for the Hospital Food and Nutrition Service (HFNS) were excluded because this is compulsory according to the Brazilian law and hospitals that refused to participate in the study were not included, either. Although the healthcare team is responsible for nutritional screening and other actions, the piece of this investigation was to evaluate the dietitians actions of the hospitals food and nutritional services. An informed consent for the participation in the research was obtained from both the interviewee and a representative of the participating institution. The project was approved by the Research Ethics Committee of Faculdade de Medicina de Ribeirão Preto, University of São Paulo.
Data was collected by means of a structured interview, using a questionnaire designated Instrument for Evaluation of Food and Nutritional Care in Hospital – IEFNCH
Activities carried out by the HFNS were divided into two corpora of criteria, one relative to nutritional care quality (NCQ) and another concerning quality of the actions related to hospital food service (FSQ). Descriptive statistics was accomplished for the NCQ and FSQ criteria in terms of the legal nature and location of the institution. Differences in the criteria between public and private hospitals were considered substantial, moderate, and small when they were equal to 30%, less than 30 to 15%, and less than 15%, respectively (Table
The criteria were subdivided into 8 groups of actions, designated NCQ and FSQ indicators (4 groups of actions for each corpus). These indicators, consisting of between 3 and 6 criteria, were measured as a percentage of existence of that group of actions in a certain institution. Each indicator thus corresponded to 25% of the total NCQ and FSQ value. Food and Nutritional Care Quality in Hospital (FNCQH) was determined as the mean percentage that each institution complied with the NCQ and FSQ indicators, and comparisons in terms of the legal nature, type (general or specialized), size, and location of the hospital as well as the presence of a clinical dietitian were made. It was considered “clinical dietitian” the professional who works in the infirmary with the patient’s nutritional care. The existence of actions was assessed; however, the extent of their coverage was not evaluated.
Descriptive statistical data analysis was also performed, and ANOVA models were employed for comparison of NCQ and FSQ among the studied institutions. Such model assumes that the residues obtained from the difference between values predicted by the model and the observed values have normal distribution with average 0 and constant variance. In situations in which this assumption was not confirmed, transformed-response variables were utilized
Results
Sixty-seven point six percent of the sample consisted of private hospitals, including philanthropic institutions (10 hospitals), whilst 32.4% were public hospitals, 18.9% of which were university hospitals and 13,5% were government institutions. In Florianópolis the majority of the sample was comprised of public hospitals (70,0%), whereas the cities of the state of São Paulo had a larger number of private institutions (81.5%) (Table
As for HFNS human resources ratio, the average number of hospital beds per HFNS staff member and per dietitian was 3.81 (SD 1.98) and 68.04 (SD 43.26), respectively. Both indicators had a large coefficient of variation (Cv) (52.01% and 63.58%, respectively). Concerning meal production per staff member and per dietitian, the average number of produced meals was 20.55 (SD 14.61 and Cv 71.08%) and 320.65 (SD 173.67 and Cv 54.16%), respectively. There were a significant statistical difference between public and private hospitals to the number of hospital beds per HFNS staff member (p = 0.02) and per dietitian (p < 0.01) (Table
Evaluation of the presence of actions related to criteria of the NCQ corpus revealed that the difference between public and private hospitals varied between 1.7% and 50.7%, and that the average of this difference were 17.4% (SD 14.9%). The actions with the most differences (≥30%) between public and private institutions were presence of routine visits to patients, evaluation of nutritional status, and existence of mechanisms for patients to require changes to the diet (Table
In all the studied cities, actions related to inpatient dietary coverage were rarely present in public and private hospitals (between 12% and 35% of the institutions developed these actions). A slightly better situation was found in terms of actions concerning assessment and nutritional status monitoring, which existed in 33.3% to 66.7% of the public hospitals. Nutritional guidance at discharge was one of the actions that were most present in both public and private institutions. As for the remaining actions, they occurred in approximately a third of the private hospitals.
When it comes to municipalities, hospitals in Florianópolis stood out particularly for entry of nutritional care information in the medical record and existence of a printed form specially designed for nutritional care.
As for actions related to integration of the health care team into nutritional care activities, over 70% of the HFNS of public and private hospitals participated in events held outside the institution, evidencing engagement of the service with nutritional issues. On the other hand, actions related to insertion of the dietitian into the health care team were more frequent in public hospitals; for instance, routine visits to inpatients and requirement for nutritional care interconsultation with the HFNS took place in public institutions more often.
Information about the diet energy supply, present in approximately half of the hospitals, and the choice of nutritional supplement offered by the HFNS, which occurred in approximately one third of the institutions, indicated that HFNS actions supporting dietotherapy must be implemented and valued, since they are essential for efficient delivery of inpatient nutritional care.
Evaluation of the criteria of the FSQ corpus revealed that the difference between public and private hospitals in terms of the presence of actions related to meal production was 17.3% (SD 13.5%) on average, varying between 1.0% and 39.3%. A higher number of private hospitals had a good practice manual, a diet manual, an instrument for staff evaluation, and a periodic training programme (Table
Management control actions were strongly influenced by the legal nature of the institution, many of which reflected in the differences found between public and private hospitals. Among the actions that were detected in most of the institutions, HFNS participation in other hospital administrave spheres and cost control can be mentioned. In contrast, less than a third of the hospitals conducted evaluation regarding user satisfaction. It is noteworthy that less than half of the institutions had a standard diet prescription form (nutritional contents of food preparations furnished by the Service). There was a larger difference between public and private hospitals with respect to the meal production qualification actions. In the same way, it is important to note that few public institutions carried out staff qualification actions.
The mean percentage of compliance with the NCQ criteria in private and public hospitals was 41.6% (SD 19.8) and 51.8% (SD 16.1), respectively, and the median was 39.2% and 53.0%, respectively. As for FSQ criteria, compliance values were 49.1% (SD 20.7), median of 46.7% and 42.4% (SD 16.6), median of 42.7%, respectively.
Among the variables analyzed in Table
Discussion
HFNS human resources, measured in terms of number of hospital beds and produced meals, are heterogeneous and characterized by a wide coefficient of variation, thus suggesting that there are no preset parameters for human resources ratio in this area.
The relation number of staff members per hospital bed, an indicator of hospital human resources in Brazil, varies between 1.0 and 7.2, while in public institutions this indicator varies from 4.0 to 9.0
Viabilization of nutritional care through evaluation of nutritional status and establishment of actions that suit their clinical and nutritional status along the duration of hospital stay depend on the relation number of hospital beds per dietitian
More heterogeneous conditions were detected for the productivity indicator (number of produced meals per staff member). The number of meals produced for other segments such as hospital staff members and visitors may distort the aims of the HFNS and redirect human resources from the nutritional care sector to meal production. An increase in administrative demands may also deteriorate inpatient nutritional care actions
Comparison between public and private health institutions in terms of NCQ criteria reveals that there are more actions related to nutritional care in public hospitals (routine visits to patients, evaluation of nutritional status, mechanisms for patients to require changes to the diet, entry of nutritional care information in the medical record, among others). Such actions may avoid or detect nutritional problems that can be handled during the hospital stay, thereby preventing nutritional aggravations
Some actions are lacking in both public and private institutions, with a difference smaller than 15% between them. Such lack of NCQ actions denotes little technical qualification for very important actions. Only half of the hospitals provide information about energy supply, whereas only a third has appropriate forms for registration of nutritional care, participation of the dietitian in meal distribution, and production of nutritional supplements by the HFNS. The legally prescribed nutritional support team
Differences in FSQ criteria demonstrate that there is greater concern about staff evaluation and standardized procedures such as good practice and diet manuals in private institutions. Slight differences emerge when most of the NCQ and FSQ criteria are compared between public and private hospitals and among municipalities, which highlights the need for establishing general quality standards for an HFNS.
Among the FSQ actions, up to a third of the hospitals have duty shift in the area of meal production, carry out staff evaluation, and conduct formal evaluation of the HFNS regarding user satisfaction. There are actions that call for closer attention, since they take place in less than a third of the hospitals. For instance, despite being present in most of the public hospitals and in half of the private institutions, supervision of patient nutrition in the ward would very much facilitate establishment of mechanisms for patients to require changes to the diet if patient food ingestion was directly observed. Unfortunately, this contact between the dietitian and the patient has been overlooked
Request of nutritional care by physicians and other professionals by means of interconsultations demonstrates recognition of this type of action by the multiprofessional team. Nevertheless, this takes place in less than a third of private institutions. In public hospitals, the situation is slightly better, though below the desired frequency. Similar results indicating that food and nutritional care is still incipient in health institutions have also been reported by De Seta et al.
Herein, the legal nature of the institution did not influence the food and nutritional care quality, in spite of the larger number of dietitian present in public hospitals. Evaluation of HFNS human resources ratio did not necessarily imply in better quality, since it also depends on professional qualifications and skills. Nevertheless, hospitals with clinical dietitians had substantially better NCQ, and 80% of the 15 institutions that hired a dietitian were public. The presence of a specialized professional in this area may make all the difference in terms of nutritional care quality not only because of qualification, but also because of the existence of institutional policies valuing these actions. However, it is noteworthy that an array of conditions should also exist, so that this type of care can be improved
The more complex structure of general hospitals favors NCQ. A higher demand due to the diverse nutritional problems that may arise in general institutions may contribute to this result. Although there are no significant differences in relation to FSQ, data for general (49.8%) and specialized (34.5%) hospitals suggest that more complex units are more qualified in this area. Results concerning hospital size can be analyzed in the same light. Larger hospitals have higher FSQ. Additionally, size does not significantly influence NCQ, but scores rise with increasing hospital size. Furthermore, university hospitals may influence hospital nutritional care positively, once they are placed among general institutions. It should be borne in mind that five of the seven university hospitals included in this work are large.
The significant difference between the NCQ scores of hospitals located in two cities of the same state (both cities proportionally having the same number of university hospitals) and the lack of any difference as compared to institutions located in Florianópolis, where public hospitals are the majority, suggest that other factors operate when service qualification is being analyzed. Even if no differences among these municipalities exist in terms of staff qualification, differences regarding professional skills may be present.
Conclusion
Food and nutritional care quality in hospital must be evaluated and qualified for improved efficacy of health institutions. The legal nature and size of hospitals may interfere in the examined segments, human resources score, NCQ, and FSQ. However, results from the present analysis lead to the conclusion that nutritional care is still incipient, and that actions concerning patient care and food service take place on an irregular basis in hospitals. This study allowed for attainment of a qualitative panorama of these actions and human resources indicators concerning hospital food and nutrition services.
The fact that coverage of the assessed actions was not verified is a limitation of the present work, which might have generated biased data. For instance, it is possible that some hospital units have excellent nutritional care teams while the care delivered to inpatients of some wards is deficient. The other limitation of the study was the frequency that these actions were developed. Both are important aspects that can influence in the quality of care. Some criteria influenced by the legal nature of the hospital may have given rise to some distortions.
Put together, our results show the performance of the actions developed by the HFNS. Although we cannot measure the coverage and the frequency of the actions, this study made a profile of the food and nutritional care in hospitals, an important step in guidelines for nutritional care in hospitals.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
RWDG was the mentor of the work, was involved in the protocol and study design, data collecting and analysis, carried out the statistical analysis and wrote the manuscript. AS and RPCP participated in the planning of work, discussion and data collection in Florianópolis. VALM participated in the planning of work, discussion and data collection in Campinas. EZM made the statistical analysis and corrected the manuscript. All authors read and approved the final manuscript.
Acknowledgments
This study was supported by FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo) and FAEPA HCFMRP-USP.