Allison Miner TITLE: DURATION OF RECEIVING MEALS AFTER ORDER HAS BEEN PLACED IN A HOSPITAL SETTING AUTHOR(S): A.

Miner, B.S., Dietetic Intern, The Sage Colleges, Troy, NY LEARNING OUTCOME: Participants will understand the importance of patients receiving their meals quickly and how it can be improved at hospitals. ABSTRACT: Food plays a role in health outcomes especially among sick hospitalized patients; because increased intake may improve the quality of their health and healing time.1,3 The duration it takes for meals to make it from the kitchen to the patient may affect patient outcomes.1,3,7 The purpose of this study was to find out how long it took for an assisted patient to receive the meal after the order was placed with the ambassador. The ambassador is a food service associate that takes the orders of patients that are unable to call down to the call center and order their food themselves. Observations of the duration a meal spent on the tray line, time meal was placed on tray and time meal left the kitchen were recorded for one meal. Results from the observations revealed the average time a meal was on the tray line was twenty-eight minutes for breakfast. A second observational tool was developed to collect data on a 45-bed patient unit for breakfast and lunch, one and four days respectively. On the second observational tool the time the meal was ordered, the ticket time and the time the meal was delivered were collected. Observations were collected on 30 patients at lunch for day one, 32 patients at lunch for day two, 33 patients at breakfast and 35 patients for lunch on day 3, and 34 patients at lunch on day 4. On average this specific floor has anywhere from 14-28 patients requiring meal assistance. Results revealed that an assisted patient waits 71 minutes for their food. The longer it takes patients to receive meals will increase

Allison Miner hospital stay and result in higher costs to the hospital.3,7 Improvements such as, computers on wheals or hand held computer devices are recommended to decrease patient meal wait times and improve customer satisfaction. More research is needed to confirm if all patient floors experience the same long wait time and whether improvements to the assist process decrease meal wait time. Introduction The Sage Colleges International Review Board provided guidelines for this study and successfully reviewed the topic. The duration of receiving meals after an order has been placed is an ongoing problem in hospital settings.2 Long waiting periods for food not only decreases customer satisfaction but can also affect length of stay, cost for the hospital, and increase morbidity/mortality of the patient, depending on the level of sickness.2,3,4,5 Many factors of the meal can be affected when meals take longer than 45 minutes to get to the patient after it has been ordered, such as temperature of the food, desired meal times, positive attitudes, and is it what the patient ordered. Patients may not look at the situation as there are 200 hundred other patients ordering at the same time, or that it may be the cooks first day on the job by themselves. Patients want to eat food, get better, and go home healthy; isnt that the goal for all hospitalized patients? In many hospitals across the country, there is something called The Skeleton in the Hospital Closet which relates to malnutrition and it is happening every day.2,4 Malnutrition is a nutrition imbalance and can happen in people underweight and overweight.2 Under nutrition is more common among hospitalized patients because of the reduced food intake related to illness induced poor appetite, gastrointestinal symptoms, reduced ability to chew, swallow or nothing by mouth status (NPO) for diagnostic and therapeutic procedures.2,4 If a patient is in the hospital

Allison Miner for a long period of time dissatisfaction with menu cycles and therapeutic diets may occur which affects the patients health.2 Anywhere from 13% to 69% of hospitalized patients in the world suffer from malnutrition.2 Malnourished patients are usually forced to stay longer at the hospital, therefore costing the hospital up to 60% more than the initial price for that one patient.3 According to the United States Bureau, the average cost per day for the hospital is $1,853 and for the average stay is $10,043.6 The patients that suffer from malnutrition have many different reasons of why they are not getting the right food, which all relates back to foodservice. Many hospitals are utilizing the room service method which was introduced to hospitals in the 1930s to have a more institutional orientation.9 A quote from Alfred P. Sloan in the 1950s, the hospital in certain respects is a very specialized hotel, reassured him that he needed to put more funding towards training hospitals to use the hotel technique.9 However, having the technique is only the beginning. The more the employees are satisfied the better the service to the patients is going to be, which decreases malnutrition, enhances customer service, decreases hospital stays and costs to the hospital.1,5 Having good, happy employees is a key ingredient in great foodservice. How the food gets from point A to point B is also very important. A patient may receive the food, but if the food takes too long or it isnt the right temperature, chances are the food is not going to be eaten, and the food is unable to do its job of healing, and rather aids in malnutrition.7 Malnutrition has been hiding in the closets long enough, it is time to let it out and treat it properly. By allowing patients to receive the meal that was ordered in a reasonable time and at the proper temperature with a smile, can make all of the difference.

Allison Miner Materials and Methods The National Institute of Health (NIH) Protecting Human Subject Research Participants course was completed before the study took place (Appendix 1) along with the International Review Board Informed Consent form being signed by the facility (Appendix 2). A scheduled meeting with the Food Service Manager in charge of patient meals guaranteed the information that was planned to be observed went to the right person that could make changes. A thoroughly thought out idea was brought to the managers attention that could be changed for the better. A good portion of time was spent in the facility before changes were suggested to assure positive feedback. To find out how long it took patients to receive meals after being ordered all aspects had to be observed, which included, the call center where phone calls came in and ambassadors dropped off the meal tickets, the tray line, and the ambassadors job of taking orders and delivering trays. First the tray line was observed. Time was spent watching the tray line during breakfast. An employee received a ticket from the printer and is the starter of the tray line, after the tray went through this process the ticket time from the tray was recorded on a piece of paper, along with the floor that it was being delivered to; since this study was floor specific all other floors information besides the pilot floor were discarded. After the tray had made it through the cold and hot production part of the line, the tray was placed in a cart, which was passed on to the ambassador. Anywhere from two to twenty trays would leave the kitchen at the same time. A close eye was kept on which trays would go into the cart. The time the cart left the kitchen was recorded on the paper. After the observation was completed, a data chart needed to be made, to keep the information easy to understand.

Allison Miner After the tray line was observed, the ambassadors job would have to be observed. This job was observed for three 12 hour shifts for a total of 36 hours. After permission was received from the food service manager, staff relief was needed to obtain the crucial data. Meal tickets were used to collect this data (Appendix 3). Originally the only times that were observed were the order of the meal and the time the meal was delivered, but collecting this data one day, the results showed that the correct data was not being collected. The next observation day, the ticket time was added to the collection times. The times from the meal being ordered to the ticket time is what can essentially be changed, which is why this change made sense. The pilot floor that was being observed consisted of two wings, twenty beds on the east wing, and 25 beds on the south wing, for a total of 45 beds. After collecting data using the meal tickets two days in a row, the data was decided to be collected a different way. When the ambassador received the meals on the floor in the cart, the meal ticket would still be in the call center waiting to be picked up, but the ambassador rarely had time to run down to collect them, some data was lost in the first couple of days, which is why breakfast was only collected on one day. Before each meal, a patient list was printed out, letting the ambassador know the patients name, room number, diet and any notes from the nurses, which usually let them know if a patient was an assist or not. This piece of paper stayed with the ambassador for the duration of the meal. This made collecting the data much easier, because the ambassador always had the information on hand. After the ambassador went into a room and got the meal to be ordered the time would be recorded on the observational tool. When the ambassador received a cart filled with trays, one tray would be recorded at a time to be efficient for the patients. The ticket time was observed and written down, and then the tray was delivered and the time of delivery was recorded. This

Allison Miner process repeated until all of the trays were delivered. Usually by the time one cart was empty, another cart would appear on the floor for the process to start again. Observations were collected on 30 patients at lunch for day one, 32 patients at lunch for day two, 33 patients at breakfast and 35 patients for lunch on day 3, and 34 patients at lunch on day 4. On average this specific floor has anywhere from 14-28 patients requiring meal assistance. This job is not always easy, sometimes assisted patients are not awake, or do not want to have breakfast yet, so they decline at first. The most difficult part of being an ambassador is remembering to get that patients order while running around frantically, delivering meals. Randomly throughout the shift the ambassador would call down to the call center if they had a full cart to deliver and did not have time to deliver the meal ticket themselves, these times were also collected if it was for a meal assisted patient and recorded on the observational tool. Dinner was not a meal that was collected because the ambassador would collect the meal order anywhere from one to two hours before the meals were allowed to be entered into the computer. The assisted patients were always told that the meal would be arriving between the hours of 5 PM and 6 PM. After each day of collecting data it was documented into the computer and the documents were thrown out in the confidential trash can so it could be disposed of properly. A PERT chart is available to view on Appendix 4.

Allison Miner Results For the tray line, the data showed that a tray could spend anywhere from 12 to 47 minutes in the kitchen before leaving to go to its next destination of the patients floor with an average of 28 minutes of waiting. A chart of this information can be found at Appendix 5. This data can change day by day, depending on who is at the starter position, who is on the tray line and who is cooking the hot meals. After the meals leave the kitchen they head to the patients floor where the meals are distributed. The time between the meal being ordered and the ticket time was anywhere from 4 to 63 minutes with an average of 30 minutes. The ticket time to delivery time was anywhere from 18 to 58 minutes with an average of 41 minutes. The total wait period was anywhere from 37 to 116 minutes with an average of 71 minutes. One outlier was documented, which was a call down order from the ambassador, which was one minute between the ordered time and the meal ticket time, 23 minutes before the meal was delivered for a total of 24 minutes of waiting. This information can be found at Appendix 6. With this information provided, patients are definitely suffering from malnutrition, because the food was not received when it was expected. This could potentially be costing the hospital thousands of dollars, depending on how long the patient stays.1,2,3,4,5,6,7 Allowing ambassadors to do the ordering from the floor will eliminate the time of the meal being ordered to the ticket time, which would allow the patients to receive meals within an hour of ordering, which will increase the amount of food they are eating, increase recovery time and decrease their length of stay and cost to the hospital.

Allison Miner Discussion and Recommendations During this study, the facility used is aware of the situation at hand and was missing the hard facts. This hospital uses a cook-serve system in the kitchen which is the most popular in the United States.1 Certain gestures can allow patients to feel at home and consume the meals provided, which is as simple as a friendly person taking the order and delivering the meal in a timely fashion.2,4,7 Many factors can affect the quickness of when the meal arrives, such as the employees working the tray line. The more efficient and accurate the quicker the meals can get out of the kitchen. The chef cooking the hot meals for the patients is also a key factor to getting meals out of the kitchen quickly. This takes experience, however, sometimes there is an option of having two cooks on the hot food line, and this would make production faster and get the meals moving out of the kitchen and to the patients rooms. Another person affecting the outcome is the ambassador. As long as the ambassador can move quickly outside the patients room and deliver the meal without being frantic, and making sure the quality of care, setting up the tray, possibly cutting the food and placing the tray in front of them is a huge help. In some hospitals up to 40% of the patient food is wasted.8 Some other things affecting this waste is extra aid, temperature of the food, and the others that have been mentioned several times.2,4,6,7,8 If patients cannot open the items, cut or season the food, chances are it will not get eaten. After a meal is delivered a patient can wait up to an additional 43 minutes to eat the food.8 With the information provided, that would mean that some patients could potentially be waiting 159 minutes to eat the food. That is 21 minutes shy of 3 hours, which is unacceptable. Luckily, with room service, the ambassadors can open items, cut food, place meals near the patients, and get the nurse right away to adjust the bed to make it easier for the patient to eat the meal.

Allison Miner There are other options for patients to receive the meal quicker, such as computers on wheels on every wing. A lot of hospitals have extra computers not being used, why not turn them into computers on wheels for the ambassadors to use. It may take a lot of work to get a login for every computer only for the ambassadors to use for the network the hospital uses for the nutrition guidelines, however it may be worth it in the price that is being saved. The ambassadors would be able to go to the computer after every patient and enter the meal that was ordered, if an item that they chose is restricted it is very easy to go right back in the room and ask what the patient would like instead, rather than the call center employees picking a different item that the patient may not like which would just add to the food waste. The computer on wheels would be an option within the budget to go about solving this issue and would take anywhere from 4 to 63 minutes off of the waiting time for the meals. If this is not the way the facility wants to handle this issue there are other options, such as getting the ambassadors hand held computers that can fit into the aprons of the uniform. These computers will allow the ambassador to place the order while the patient is ordering, just as if the phone call was being made to the call center. The ambassador would not have to leave the room if there were any restrictions, and it allows the ambassador to get exactly what the patient wants. The price for the hand held computers would vary depending on the distributors to the hospital and how many the hospital would need to buy to ensure that every ambassador would be able to use one on the floor. Training would also have to be available to the ambassador on how to use the hand held computer and the software for food ordering. In the end both of these ideas would decrease the amount of malnutrition in the hospital and decrease the length of stay, which increases customer satisfaction.

Allison Miner Resources 1. Edwards J, Hartwell H. Hospital food service: a comparative analysis of systems and introducing the Steamplicity concept. Journal Of Human Nutrition & Dietetics. December 2006;19(6):421-430. Available from: Academic Search Complete, Ipswich, MA. Accessed November 5, 2013. 2. Fessler T.A. Malnutrition: A serious concern for hospitalized patients. Todays Dietitian. July 2008; 10(7):44. http://www.todaysdietitian.com/newarchives/063008p44.shtml. Accessed December 3, 2013. 3. Hickson M, Connolly A, Whelan K. Impact of protected mealtimes on ward mealtime environment, patient experience and nutrient intake in hospitalized patients. Journal Of Human Nutrition & Dietetics. August 2011; 24(4):370-374. Available from: Academic Search Complete, Ipswich, MA. Accessed November 5, 2013. 4. Tappenden K, Quatrara B, Parkhurst M, Malone A, Fanjiang G, Ziegler T. Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition. MEDSURG Nursing. May 2013;22(3):147-165. Available from: Academic Search Complete, Ipswich, MA. Accessed November 5, 2013. 5. Theurer V.A. Improving patient satisfaction in a hospital foodservice system using lowcost interventions: determining whether a room service system is the next step. April 1, 2011. http://digitalcommons.usu.edu/cgi/viewcontent.cgi?article=1029&context=gradreports. Accessed December 3, 2013. 6. U.S. Census Bureau. Health and nutrition. Statistical Abstract of the United States. Available from www.census.gov. Accessed December 3, 2013.

Allison Miner 7. Wilson A, Evans S, Frost G. A comparison of the amount of food served and consumed according to meal service system. Journal Of Human Nutrition & Dietetics. August 200-;13(4):271-275. Available from: Academic Search Complete, Ipswich, MA. Accessed November 5, 2013. 8. Xia C, McCutcheon H. Mealtimes in hospital who does what? Journal Of Clinical Nursing. October 2006; 15(10):1221-1227. Available from Academic Search Complete, Ipswich, MA. Accessed November 5, 2013. 9. Ziqi W, Robson S, Hollis B. The Application of Hospitality Elements in Hospitals. Journal Of Healthcare Management. January 2013;58(1):47-62. Available from: Academic Search Complete, Ipswich, MA. Accessed November 5, 2013.

Allison Miner APPENDIX 1 NIH Certificate

Allison Miner APPENDIX 2 August 26, 2013 Rayane AbuSabha Dietetic Internship Director The Sage Colleges 65 First Street Troy, NY 12180 Dear Rayane, As the Administrative Dietitian at Concord Hospital I am very interested in collaborating with The Sage Colleges to conduct a quality/process improvement project in my facility. I would like to confirm my willingness and commitment to help with this valuable project. My role as the preceptor will be to help oversee the intern as she conducts the project, facilitate communication with staff, and secure their collaboration. I understand that the findings will be reported within the facility and to the public at large in a confidential manner: Survey responses will be reported in aggregate form and no individual responses will be identified. I look forward to a successful working relationship with the Sage Graduate School Dietetic Internship at The Sage Colleges. Sincerely, Kate Pfeifle, MS, RD, LD Administrative Dietitian, Manager Concord Hospital 250 Pleasant Street Concord, NH 03301 IRB Consent Form

Allison Miner APPENDIX 3 Observational Tool

Allison Miner APPENDIX 4 PERT CHART

Allison Miner APPENDIX 5 Table 1

The Time A Tray Spent On The Tray Line For Breakfast Time Spent Time Time on Tray Ticket Meal Spent on Line Time Left Tray Line 0:19 MIN 7:45 AM 8:20 AM 0:35 0:19 MIN 7:46 AM 8:22 AM 0:36 0:19 MIN 7:48 AM 8:20 AM 0:32 0:15 MIN 7:48 AM 8:20 AM 0:32 0:13 MIN 7:49 AM 8:22 AM 0:33 0:13 MIN 7:50 AM 8:20 AM 0:30 0:12 MIN 7:59 AM 8:37 AM 0:38 0:28 MIN 8:02 AM 8:37 AM 0:35 0:17 MIN 8:05 AM 8:41 AM 0:36 0:26 MIN 8:05 AM 8:37 AM 0:32 0:15 MIN 8:09 AM 8:56 AM 0:47 0:14 MIN 8:11 AM 8:41 AM 0:30 0:23 MIN 8:12 AM 8:41 AM 0:29 0:12 MIN 8:13 AM 8:56 AM 0:43 0:20 MIN 8:14 AM 8:41 AM 0:27 0:37 MIN 8:14 AM 8:56 AM 0:42 0:19 MIN 8:16 AM 8:56 AM 0:40 0:14 MIN 8:16 AM 8:56 AM 0:40 0:32 MIN 8:22 AM 8:56 AM 0:34 0:31 MIN 8:29 AM 9:18 AM 0:49 0:30 MIN 8:32 AM 8:56 AM 0:24 0:30 MIN 8:48 AM 9:18 AM 0:30 0:28 MIN 8:48 AM 9:18 AM 0:30 0:09 MIN 8:48 AM 9:18 AM 0:30 0:26 MIN 8:51 AM 9:18 AM 0:27 0:27 MIN 8:56 AM 9:18 AM 0:22 0:25 MIN 8:59 AM 9:18 AM 0:19 0:24 MIN 0:24 MIN 0:24 MIN 0:24 MIN 0:24 MIN 0:22 MIN 0:21 MIN 0:21 MIN 0:40 MIN 0:41 MIN 0:40 MIN 0:37 MIN 0:37 MIN 0:37 MIN 0:36 MIN 0:38 MIN

Ticket Time 7:07 7:07 7:07 7:11 7:13 7:13 7:14 7:15 7:16 7:17 7:18 7:19 7:20 7:21 7:23 7:24 7:27 7:29 7:29 7:30 7:31 7:31 7:33 7:34 7:35 7:34 7:36 7:37 7:37 7:37 7:37 7:37 7:39 7:40 7:40 7:40 7:41 7:42 7:43 7:43 7:43 7:44 7:44

AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM

Time Meal Left 7:26 7:26 7:26 7:26 7:26 7:26 7:26 7:43 7:33 7:43 7:33 7:33 7:43 7:33 7:43 8:01 7:46 7:43 8:01 8:01 8:01 8:01 8:01 7:43 8:01 8:01 8:01 8:01 8:01 8:01 8:01 8:01 8:01 8:01 8:01 8:20 8:22 8:22 8:20 8:20 8:20 8:20 8:22

AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM AM

MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN

Average Time Spent on Tray Line 0:28

MIN

Allison Miner APPENDIX 6

Time between order taken and time ticket was printed 26 37 16 35 8 29 30 23 12 13 4 16 16 34 7 17 41 26 32 7 9 34 27 19 37 36 47 45 63 55 57 5 1 26 35 57 56 56 60 38 22 MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN *MIN MIN MIN MIN MIN MIN MIN MIN MIN

Table 2
Time from printed ticket to delivery time of meal 38 58 41 55 37 54 57 46 41 39 35 43 45 29 29 47 32 38 37 30 48 37 49 38 50 40 42 38 41 48 55 32 23 18 52 59 40 43 43 28 25 MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN *MIN MIN MIN MIN MIN MIN MIN MIN MIN

*Called meal down to office, ticket was not delivered by hand

Meal BRK BRK BRK BRK BRK BRK BRK BRK BRK BRK BRK LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN LUN

Total Wait Time for Meal 64 95 57 90 45 83 87 69 53 52 39 59 61 63 36 64 73 64 69 37 57 71 76 57 87 76 89 83 104 103 112 37 24 44 87 116 96 99 103 66 47 MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN MIN *MIN MIN MIN MIN MIN MIN MIN MIN MIN

Average Time Between Order Taken and Time Ticket was Printed for BRK 21

Average Time Between Order Taken and Time Ticket was Printed for LUN 33

Average Time Between Order Taken and Time Ticket was Printed Overall 30

Average Time Between Printed Ticket and Delivery Time of Meal for BRK 46

Average Time Between Printed Ticket and Delivery Time of Meal for LUN 39

Average Time Between Printed Ticket and Delivery Time Overall 41

Average Total Wait Time for Meal (Breakfast) 67

Average Total Wait Time for Meal (Lunch) 72

Average Total Wait Time for Breakfast and Lunch 71