Catering for the recovering

The simplest and probably the most ideal system is for food to be prepared from basic ingredients each day, on site. However, this requires a large kitchen, a variety of cooking equipment and storage facilities for the raw materials and, of course, skilled staff for the preparation of all parts of the meal. The food is prepared hot for distribution to patients for each meal. As with all kitchens, this leaves quiet periods and peaks of activity just prior to mealtimes.
    
To try to iron out the peaks and troughs, some hospitals have developed this system further to enable them to prepare more food in advance. Known as a ‘cook-chill’ system, food is prepared up to five days in advance and chilled to a temperature of between 1oC-5oC. The additional shelf life provided by chilled storage allows most production to be done over five days and within a more evenly spread production rather than working to meal times.
    
This approach requires all the food preparation areas and equipment needed for prime cooking but additionally needs blast chilling facilities and refrigerated storage for the finished products. Investment in this type of facility is such that these kitchens are usually used to provide food to other hospitals either within the same Trust or the neighbouring Trusts, unless the hospital is particularly large.

A lack of skill and space
Space in hospitals is at a premium. Frequently within new hospital buildings, prime cooking facilities are often very limited. In older hospitals, kitchen space on the ground floor is used to house heavy clinical equipment, such as scanners, so food preparation areas have been reduced.
    
Availability of skilled staff is also a frequent problem. The catering sector is now recognised as one of the potential areas of future staff shortages, as chefs and other catering staff retire.
    
In new hospitals, catering systems are often planned without prime cooking facilities, but planners are urged to include the essential provision of food in the design of a new hospital from the earliest stage. In these hospitals, food is purchased fully prepared – either chilled or frozen. This is able to satisfy the needs of most patients on normal diets and the majority of special diets, but some prime cooking facilities should be available to prepare food for the most complex of special diets, which are required in very small numbers.
    
The supply of frozen or chilled food can either be from commercial producers or from a cook-chill production unit within another Trust. Chilled food is produced to a planned production pattern so this dictates the menu pattern for the end user. Frozen food, with a longer shelf life, can allow for greater variation in menu planning.
    
In either case, storage facilities are required, as well as space for sorting the food in preparation for distribution to patients, with some hospitals preparing some of the food, often cold desserts and salads, on site.

Food distribution within a hospital
There are several methods of food distribution within a hospital. These can be split into bulk or plated; hot or cold. Food prepared on the day in the same hospital is always distributed hot, but this could be in bulk or ready plated. For large sites, particularly with buildings at a distance from the kitchen and possibly requiring transport outside, it can be very challenging to deliver hot food that is still at a safe temperature (over
65 oC) when it is served to the patient.
    
Most chilled or frozen systems distribute the food to more local kitchens, serving one or more wards, where food is reheated for hot service. Chilled food allows for central service and reheating of individual portions. Frozen food is probably best reheated from its frozen state and therefore must be reheated before service.

The choices between bulk service and ready plated often depend upon the equipment in the hospital, although the current trend is towards bulk service. This means food is served from a hostess-type trolley for each patient, possibly allowing for choice at the point of service and, with appropriate training, better presentation of food on the plate. Plated service with reheating of individual portions may offer a more controlled presentation, however, there are challenges in ensuring each part of the meal is of the correct consistency to not become too dry during the reheating.

Case study
Bradford Teaching Hospitals consists of two hospital sites with approximately 1,000 beds. Due to site redevelopment some 15 years ago, catering provision moved to two different systems with cook from fresh ingredients at the Bradford Royal Infirmary site (800 beds) and plated regenerated from chilled food at St Luke’s (200 beds). Recent interim arrangements have resulted in a move to bulk regenerated frozen food across the whole St Luke’s site and some ten outlying wards at the Infirmary.
    
There is currently a two-week menu cycle used across both sites, which aims to meet the needs of all the patients. There is a wide range of ages, medical conditions, cultural and dietary requirements.
    
The catering team, including diet cooks, catering managers and the dietetics department, complete regular ward food audits on both sites to monitor food quality, the portion size served, temperature at service and patient satisfaction. Ward checks have shown that food temperature and how the food looks on the plate are the most important factors in both patient and staff opinion on food quality.

Freshly cooked vs. regenerated
Student dietitians are placed within the catering department in Bradford as part of their training. They are asked to follow the system for food production on both a cook from fresh and regeneration ward and then assess patient satisfaction and which food they personally felt was the better. Each set of students was surprised to report on how much better they felt the regenerated food was and this was always due to the fact it was a better temperature.
    
This is the same for both fresh cooked and regenerated foods, and has shown that whatever production system is used it is essential that food is distributed to the ward and served appropriately to ensure that both the temperature and the look on the plate remains appetising.
    
The bulk regeneration system has definitely improved the temperature of the food and has also allowed patients more choice at ward level. Portion sizes can now be decided at the particular mealtime and food combinations requested at the last minute. Regeneration of larger food volumes has prevented food drying on the plate and service at ward level has allowed food to look better once plated.
    
Currently Bradford is working on a catering strategy to review the whole catering system for both hospital sites and it is likely that it will move to a completely bulk regeneration system in the future.

Well-needed nutrition
The catering system used in each hospital is as diverse as the hospital estates. Whichever system is used, food remains a critical part of the care of patients, providing the nutrients required for recovery.
    
Caterers, those delivering the food to wards and those serving food to patients all have a part to play in ensuring food looks appetising and is therefore more likely to be eaten. This is the most important measure in the quality of all catering systems as food not eaten is of no nutritional value.