Protected Mealtimes - Guideline For

Publication: 26/03/2013  --
Last review: 31/05/2019  
Next review: 02/05/2022  
Clinical Guideline
CURRENT 
ID: 3280 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline For Protected Mealtimes

Summary of Guideline

The Leeds Teaching Hospitals NHS Trust is committed to providing high quality nutritional care to patients in its hospitals and recognises that protected mealtimes are an essential part of the delivery of safe and effective nutritional care which can improve health outcomes as well as the patient experience in line with the LTHT Food and Drink Strategy 2019. The purpose of this Protected Mealtime Guideline is to support the provision of optimal nutritional care and treatment for patients by ensuring that mealtimes are protected from unnecessary and avoidable interruptions, by providing an environment conducive to eating and by ensuring staff provide patients with support and assistance to eat and drink. The Protected Mealtime Guideline provides a framework for mealtimes (and the time shortly before and after it) that places the patient, and their nutritional care, at the centre of the mealtime experience. 

This Protected Mealtime Guideline protects mealtimes from unnecessary and avoidable interruptions. Wherever possible non-essential clinical and non-clinical activity (e.g. ward rounds, drug rounds, cleaning, therapy, ward staff breaks) should cease at mealtimes to provide an environment conducive to eating and ensure that the nutrition and hydration care of patients is not compromised. It is recognised that certain essential clinical tests may need to take place, on occasion, during mealtime and this will be a clinical decision. The protected mealtime guideline should never prevent emergency or critical care from taking place. For patients who are nil by mouth, X-rays or tests etc. may take place over mealtimes as this will not impact on their nutritional intake.

Wards will recognise that between the following times as a Protected Mealtime period:
Adult services:

  • Lunchtime: 12:30 - 1 pm 
  • Evening Meal: 5.30 - 6 pm

Children’s services

  • Lunchtime: 12:30 - 1 pm 
  • Evening Meal: 5:00 - 5:30 pm)

Signs (Appendix 1) displayed outside and/or inside the ward will be used to inform staff and relatives of the protected mealtime period.

From 30 minutes prior, during, and up to 15 minutes after each mealtime, the following measures should be in place on the ward to reduce patient interruptions and enable ward staff to prioritise nutritional care:

  • Patients, and their eating area, are prepared adequately before the meal takes place. All patients should be seated in a comfortable position for eating as far as possible, be encouraged and/or assisted to undertake hand hygiene and to use the toilet (if required) before their meal.
  • A named nursing mealtime co-ordinator links with the housekeeping team, and oversees the delivery of mealtime nutritional care (including the identification of other ward staffs’ roles for the mealtime) for the ward or clinical area.
  • A red tray will be used to identify those patients ‘at risk’ of malnutrition.  Ward staff will make food and fluid a priority for these patients during mealtimes by encouraging and assisting with eating, monitoring how much food is eaten by patients and completing food record charts for them.
  • Relatives, carers and visitors are made aware of the benefits of the ward’s protected mealtimes approach and may be invited to encourage or assist their friend or family member where appropriate.  
  • Food and drink is placed within easy reach of the patient, and patients are provided with prompting, encouragement or assistance to eat and drink, appropriate to their needs.
  • Interruptions e.g. ward rounds, drug rounds, assessments and/or interventions by healthcare staff, cleaning, documentation and therapy will only occur (during mealtimes) when clinically appropriate.
  • Department’s out-with the ward will avoid ringing wards during mealtimes where possible.

 

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Background

National estimates suggest that around 29% of adult patients admitted to hospitals in the UK are at risk of malnutrition, (Russell et al, 2014), with most of those affected at high risk. For many their hospital admission exacerbates the condition with many patients ‘at risk’ of malnutrition and dehydration during their stay (McWhirter et al 1994, BAPEN 2014).  If an individual is unable to achieve an adequate nutritional intake and becomes malnourished, they are more susceptible to disease. This can cause further deterioration, impairing their recovery. This vicious circle is demonstrated by the ‘Malnutrition Carousel’ (Stroud, 2012).

 

In the acute hospital setting a number of factors (e.g. disease-related malnutrition, side-effects of treatment, missed meals, nil by mouth for procedures) contribute to patients’ decreased nutritional intake, and subsequent malnutrition risk which in turn is linked with reduced quality of life, poorer health outcomes (e.g. increased infections, poor wound healing, mortality) and length of hospital stay (Stratton et al, 2003). In addition, certain groups of patients, in particular children and older adults, have specific dietary and/or eating/feeding preferences or requirements, that need to be met as part of their nutritional care to prevent malnutrition and to aid recovery.  The ‘Care and Compassion’ report from the NHS Ombudsman (2011) on care for older people in the NHS included many cases of people not receiving adequate food or water while in hospital.

The ward environment, presentation of food and the timing and content of meals are important elements in encouraging patients to eat well. The importance of mealtimes needs to be emphasised and ward based staff given the opportunity to focus on the nutritional care needs of patients at mealtimes. Positive and encouraging behaviour when handling and serving food provides invaluable support which is instrumental in persuading many unwell and anxious people to eat. This important input from foodservice staff should be complemented by the same positive attitude to the food and beverage services from nursing and other clinical staff (BDA, 2017).

The Protected Mealtimes Initiative (PMI) was an initiative of the National Better Hospital Food Programme, supported by NHS Estates, Hospital Caterers Association and Royal College of Nursing (the latter two providing a policy template in 2004). The purpose of the PMI is to allow patients to eat their meals without unnecessary interruption, and to enable nursing staff to provide assistance to those patients unable to eat independently. (Protected Mealtimes Review - Findings and recommendations report, NPSA, 2007). The initiative has the support of many national organisations, including, as follows:

National Patient Safety Agency (2007): “The patient experience is critical, involving all elements of care, and one important aspect of this is ensuring that protected meal times are nationally implemented”.

British Dietetic Association, (2012):Missing meals, or experiencing interruptions during the mealtimes, can compromise a patient’s nutritional intake, which could have a negative impact on their health and wellbeing.  Health professionals need to work together to ensure that patients have a calm, uninterrupted period of time to eat”. 

  Royal College of Physicians (2002): “Doctors can help to promote more satisfactory nutrition for patients by making sure that as far as possible the service and consumption of meals is not interrupted by ward rounds or routine tasks which could take place at other times and procedures, such as x-rays, are scheduled to ensure, whenever possible, that patients do not miss meals.  Nutritional care depends on teamwork between health care workers in different disciplines, the scope and contribution of whose work should be recognised”.

   BAPEN (Allison) (1999): “Interruption of patients’ meal times by ward rounds and procedures should be minimised and each ward should have a clear policy in this respect.  The environment at meal times should be made as conducive to eating as possible.” 

In 2006 Age Concern’s (now Age UK) ‘Hungry to be Heard’ campaign responded to evidence that many older people were malnourished in hospital and identified seven steps to end malnutrition in hospitals,  which included the introduction of protected mealtimes. Recommendations from Age UK (2011), based on further regional research, include that Trusts should put in place strategies to increase effectiveness of protected mealtimes and to cover all mealtimes.

In 2006, a multi professional group at Leeds Teaching Hospitals NHS Trust produced a ‘Protected Mealtimes Policy’. In 2012, it was recommended, and agreed by the Nutritional Care Steering Committee, that the policy be updated and take the form of a guideline.

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Management

  • In order to maximise the benefits to patients of the mealtime experience, ward staff are required to prepare themselves, the environment and their patients during the 30 minutes prior to the service of food
  • Patients should be able to eat their food in a relaxed environment, at their own pace and rest afterwards. Thus, during the Protected Mealtime period all none essential ward based activities (where clinically appropriate) should stop.
  • Ward-housekeeping and ward teams will serve food and give assistance and support to patients, respectively.
  • Patients’ clinical needs are a priority and protected mealtimes will not prevent treatments, procedures or transfers from being carried out where deemed a clinical priority
  • Where there are unavoidable interruptions to patient mealtimes such as scheduled investigations these will be anticipated and alternative meal/food arrangements made to ensure that the nutrition and hydration care of the patient is not compromised.
  • Where a patient misses a meal due to unforeseen circumstances, the nursing team will ensure an alternative is provided. A ‘Missed Meal Menu’ is available for this purpose.
  • If, under exceptional circumstances, a meal is not provided then this will be documented in the patient’s record.
  • Staff from departments out with the ward should avoid ringing the ward at mealtimes where possible
  • Senior Sisters/Charge Nurses are responsible for implementing the protected mealtimes guidelines in their clinical areas and should adopt the following principles/standards  in all clinical areas where patients receive food:
    • A nursing ‘mealtime coordinator’ will be allocated at the start of each shift
    • 30 minutes prior to meal service time the coordinator will allocate roles (to support the below) to the ward team
    • Ward staff will encourage, and where required, assist patients to undertake hand hygiene prior to the service of food
    • Ward staff will check, where required, that dentures are in place and the patient’s mouth in the optimum condition in order to eat
    • Ward staff will provide patients with assistance to use the toilet, where required prior to the service of food
    • Bed tables and eating areas will be cleared (prior to the service of food) of items not conducive to mealtimes e.g. urine bottles and used dressings
    • Each table will be clean and suitably prepared prior to the service of food and beverages, with appropriate place mats, cutlery, crockery and condiments
    • Consideration will be given to where patients (including provision and encouragement for communal eating) sit to eat their meals, supporting the social aspects of mealtimes whilst respecting the preferences, religious or cultural views of the individual
    • Patients will be made comfortable prior to the service of meals and will be in an appropriate position for eating where possible.
    • Patients requiring assistance (prompting, encouragement, feeding) with eating will be identified by the nursing team prior to the service of meals.
    • Appropriate feeding aids e.g. rimmed plates, adapted cutlery handles will be provided, if required, to support independence as far as possible
    • Clear signage will be used to inform staff and visitors of the Protected Mealtime periods
    • Food will be served within a comfortable reach
    • Drinks will be available, within easy reach and in the appropriate drinking vessel
    • Assistance, such as removing packaging or with eating and drinking, will be provided to patients, as required
    • Patients, their relatives, carers and visitors will be made aware of the benefits of the wards protected mealtimes approach and asked not to make telephone enquiries during the meal time period. They should be referred to the LTHT internet site for further information Information about visiting during protected mealtimes. http://www.leedsth.nhs.uk/patients-visitors/patient-and-visitor-information/visiting-times/ The presence of carers or family members at mealtimes should reflect the principles of Johns Campaign http://www.goldstandardsframework.org.uk/john-s-campaign-dementia and be negotiated in individual conversations in the best interests of the patient.
    • Interruptions to mealtimes  e.g. from ward rounds, drug rounds, cleaning, documentation and therapy will only occur (during mealtimes) when urgent/clinically unavoidable
    • Staff directly involved with patients at meal times will avoid answering the telephone at mealtimes. 
    • In line with the LTHT Guideline for the Oral Nutritional Support of Adults (2019), a red tray will be used to identify those patients ‘at risk’ of malnutrition. Ward staff will make food and fluid a priority for these patients during mealtimes by encouraging and assisting with meals, monitoring how much food is eaten by patients and completing food record charts for them.
    • Collaborative working and clear communication, specifically handover of dietary requirements and concerns, between catering/facilities staff and ward teams should be embedded and evident.
  •  

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Appendix 1

(Available at: http://lthweb.leedsth.nhs.uk/sites/nutrition-and-dietetics/welcome-to-nutrition-and-dietetics/adult-oral-nutritional-support/adult-oral-nutritional-support)

 

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Provenance

Record: 3280
Objective:

Aims

  • To promote an environment and culture that recognises the central importance of meal times in providing a nutritious diet for our patients, as an integral part of their care and treatment
  • To provide consistent individualised high quality care in provision of nutrition at mealtimes for patients of Leeds Teaching Hospitals NHS Trust
  • To improve the “mealtime experience” for patients by enabling them to eat their meals without non-urgent interruption in an environment conducive to eating
  • To provide as a minimum protected mealtimes for two meals per day; both the lunchtime and evening meals.

Objectives 

  • To focus ward housekeeping and ward teams on the service and provision of food and drink for patients
  • To create a quiet and relaxed atmosphere in which patients are given time and support to enjoy meals
  • To limit ward activity, both clinical and non clinical (e.g. ward rounds, diagnostic tests and observations, patient ward moves) to those that are ‘essential’ to undertake during the protected mealtime periods
  • To ensure patient mealtimes are free from avoidable and unnecessary interruptions
  • To ensure patients are adequately prepared for and supported during mealtimes
  • To recognise and support the social aspects of eating
  • To provide an environment that is welcoming, clean and tidy for eating.
  • To improve the nutrition and hydration care of patients by supporting them at mealtimes with the consumption of food and drink
Clinical condition:

All

Target patient group: All Inpatients (Adults and Paediatrics)
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Adapted from:

Evidence base

  • Age Concern (2006) Hungry to be Heard: The scandal of malnourished older people in hospital.
  • Allison, SA, (1999) Hospital Food as a Treatment, British Association of Enteral and Parenteral Nutrition.
  • British Dietetic Association, August 2012, ‘The care of nutritionally vulnerable adults in community and all health and care settings’, Policy Statement.
  • British Dietetic Association (2017) The Nutrition and Hydration Digest (2nd Edition) Improving outcomes through food and beverage services.
  • Hospital Caterers Association and Royal College of Nursing (2004) Sample Protected Mealtimes Policy.
  • McWhirter JP, Pennington CR, (1994) Incidence and recognition of malnutrition in hospitals. BMJ; 308: 945-8.
  • NHS England (2013) Patient-led assessments of the care environment (PLACE).
  • NHS Ombudsman (2011) Report on care for older people in the NHS ‘Care and Compassion’.
  • Royal College of Physicians, (2002), Nutrition and Patients: A Doctor's Responsibility. A Report of a working Party of the Royal College of Physicians. London.
  • Russell CA, Elia M. Malnutrition screening surveys in hospitals in the UK, 2007-2011. A report based on the amalgamated data from the four Nutrition Screening Week surveys undertaken by BAPEN in 2007, 2008, 2010 and 2011. Redditch, UK; 2014. Available from: .

  • Stratton RJ, Green CJ, Elia M. (2003) Disease-related malnutrition: An evidence based approach to treatment. Oxford: CABI Publishing.

 

  • Stroud M (2012) Malnutrition Carousel, Malnutrition Task Force/British Association of Enteral and Parenteral Nutrition. http://www.malnutritiontaskforce.org.uk/wp-content/uploads/2014/07/Dr-Mike-Stroud.pptx.
  • The Leeds Teaching Hospitals NHS Trust (2019) Food and Drink Strategy 2019 - 2021
  • The Leeds Teaching Hospitals NHS Trust, (2019) Guidelines for the Oral Nutritional Support of Adults. detail.aspx?ID=1391

 

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

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