Current and future practices in hospital foodservice.

OBJECTIVES: To identify current operational practices and expectations for future practices in hospital foodservice; establish the probability that current practices will change; and determine whether differences in practices exist on the basis of profit status and hospital size. DESIGN: A questionnaire, to determine current practices, probability of change, and expectations for future practices, was mailed to foodservice directors. SUBJECTS: A random sample of 500 foodservice directors in US hospitals with 200 or more beds. A total of 214 questionnaires were returned for a response rate of 43%. STATISTICAL ANALYSIS: Descriptive statistics were used to report current practices, probability of change, and expectations for future practices. The Kruskal-Wallis test was conducted to examine whether the probability of change ratings differed on the basis of hospital profit status and size. chi 2 Analysis was used to examine whether expectations for future practices differed based on hospital profit status and size. RESULTS: Currently 81% of hospital foodservice departments have fewer than 100 employees; 73% have revenue budgets of less than $2 million; 49% have expense budgets greater than $2 million; 55% use a selective menu, often (43%) 1-week in length; 74% use conventional food production technology; 81% have a centralized, hot tray line; 91% operate a cafeteria; 96% do on-site catering; 69% have differential pricing for employee meals; 58% have subsidized employee meals; and 19% have coffee kiosks. Changes in current practices are expected in several areas. Foodservice directors expect to serve meals to fewer inpatients (71%), employ less staff (73%), have smaller expense budgets (70%), and generate more revenue (61%). Kruskal-Wallis and chi 2 analyses indicated few differences on the basis of hospital profit status and size. There was little consensus among directors on how to best respond to these environmental changes. APPLICATIONS: Hospital foodservice practices will change in the future. Foodservice directors are using a variety of strategies (e.g., revenue-generating ventures, menu changes) to respond to current environmental changes. Increased emphasis will be placed on running a hospital foodservice department as a profit center rather than a cost center.

Value-added services that increase physicians' intent to refer patients to an outpatient nutrition clinic.

We surveyed 378 practicing physicians to identify value-added services that would increase their patient referrals to registered dietitians at an outpatient nutrition clinic. One hundred thirty-nine completed surveys were used in compiling the results. In the survey we presented 16 value-added services specifically designed to overcome physicians' barriers to referral as noted in the literature, and we requested demographic information. Frequency distributions revealed that the services physicians most strongly agreed would increase their referrals were help patients receive reimbursement from third-party graphic information. Frequency distributions revealed that the services physicians most strongly agreed would increase their referrals were help patients receive reimbursement from third-party payers (92.1%), provide a free initial meeting with the patient (82.4%), and offer group cooking classes (81.3%). The services physicians most strongly disagreed would increase their referrals were provide a list of physicians currently using the outpatient nutrition clinic who can provide recommendations (33.1%) and provide a free consultation for the physician (30.2%). Our findings indicate that (a) value-added services most likely to stimulate referrals are those that moderate the cost of nutrition counseling, document its effectiveness, and provide skills training in the form of cooking classes, and (b) value-added services least likely to stimulate referrals are those that require physicians' time.

Percutaneous urinary diversion in patients with hormone-refractory prostate cancer.

Twenty-two patients with hormone-refractory prostate cancer underwent percutaneous urinary diversion; at the time, all but one had metastatic disease. Eleven patients received postnephrostomy therapy. The median survival time for all the patients was one hundred nineteen days. Overall, 41 percent of the patients' remaining lifetime was spent in the hospital. Six never left the hospital and 10 required rehospitalization; the remaining 6 patients were never rehospitalized. The median survival time for this group of patients was shorter than the expected survival of similar patients without ureteral obstruction. It appears that percutaneous urinary diversion does not improve the quality of life of these patients.

Credentials and skills required for hospital food and nutrition department directors.

The perceptions of hospital administrators, food and nutrition department directors, and management dietetic educators were compared with respect to the credentials and administrative skills required for a director of a food and nutrition department in a hospital with 300 beds or more. Questionnaires were mailed to the director of food and nutrition services and the vice president of hospital operations at 132 hospitals in five midwestern states. Fifty-six questionnaires were mailed to all educators on the 1986 to 1988 membership list of the Foodservice Systems Management Education Council. Response rates of directors, administrators, and educators were 68%, 53%, and 82%, respectively. The questionnaire consisted of three parts. Part one addressed credentials required; part two required participants to rank 14 skill categories in order of importance; and part three focused on facility descriptors and credentials of participating administrators and directors. Findings of the survey indicate that the minimum qualifications for department directors were registered dietitian status, at least a bachelor's degree in food and nutrition, and work experience in foodservice systems management. Although administrators ranked foodservice management skills higher than nutrition skills, they ranked nutrition skills significantly (p less than .001) higher than did directors or educators. These findings may guide career development of practitioners who aspire to department director positions.

Interstitial gold and external beam irradiation for prostate cancer.

We treated 65 patients with prostatic cancer confined clinically to the prostate or periprostatic area during an 8-year period. Seven patients had stage A2, 38 stage B and 20 stage C disease. All 65 patients underwent staging pelvic lymphadenectomy and implantation of gold grains into the prostate (mean dose 3,167 rad). A total of 64 patients then completed a course of external beam irradiation to a mean total tumor dose of 6,965 rad. Complications of therapy were mild and limited (less than 3 months in duration) in most patients, and they included radiation cystitis (32 per cent), diarrhea (31 per cent), extremity lymphedema (7.7 per cent) and wound infection (3 per cent). Two patients suffered urinary incontinence after therapy and 2 (3 per cent) had diarrhea more than 3 months in duration. The actuarial 5-year survival rate for all patients was 87 per cent and the 5-year survival free of disease was 72 per cent.

Monitor of tray error rates for quality control.

Accuracy of tray assembly is essential for providing appropriate nutrition care to patients and maintaining patient satisfaction. A monitoring system of tray assembly error rates was designed to evaluate patient tray accuracy and to identify types of assembly errors. Data were collected during two morning, five noon, and five evening meals. Errors were classified according to type: omission, addition, or substitution. They were also classified by severity: error of convenience (not critical with respect to diet) or error of compliance (contradictory to diet order). Error rates were determined and compared by meal, weekday vs. weekend, and first half of assembly period vs. second half. An average error rate of 12.9% was calculated from the 6,553 trays studied, with error rates of 12.5%, 10.9%, and 15.1% for breakfast, lunch, and dinner, respectively. Evaluation of data revealed no significant difference in error rate as sorted by type of error, among meals, or between weekday and weekend. Only 2.7% of the trays had errors contradictory to the diet order. The error rate was significantly higher during the second half of the assembly period, and the highest error rates were observed for the evening meal. The methodology used in this study serves as the basis for quality control monitoring and as a motivational tool to stimulate improved performance by trayline employees.

Iatrogenic ureteral injury.

We treated 27 patients with iatrogenic ureteral injuries during a 6-year period. Gynecological operations were the most common antecedent surgical procedures (52 per cent). The diagnosis of ureteral injury was made immediately in 4 patients and was delayed 1 to 34 days in 23. Three of the 4 injuries recognized during an operation were repaired successfully at the time of injury; the primary repair in the remaining patient leaked and ultimately resulted in a nephrectomy. In the delayed diagnosis group retrograde ureteral catheterization was successful in only 1 of 20 attempts. Of the 23 patients with injuries recognized in the postoperative period 11 were managed successfully with percutaneous nephrostomy (with or without stenting) alone, 3 required surgical repair after temporary percutaneous nephrostomy drainage, 4 were treated surgically without prior nephrostomy drainage and 1 had spontaneous resolution of hydronephrosis. The remaining 3 patients required nephrectomy: 1 because of a urinary fistula in a previously irradiated field, 1 because of a concomitant (ipsilateral) renal cell carcinoma and 1 because of renal hypertension. Percutaneous nephrostomy or ureteral stenting was successful as primary therapy in 73 per cent of the patients in whom it was used.