Duration of dietary restrictions of patients on a gastrointestinal ward
Authors: White E. , Goff L. , De Jabrun A. 
Published: May 2009

Background:  The use of dietary restrictions for hospital patients is common. Gastrointestinal patients are at high risk of malnutrition (Thomas & Bishop, 2007). In this study, surgical patients included those under the Enhanced Recovery After Surgery programme, which promotes feeding on the day of surgery because this has been shown to increase recovery time and shorten hospital stays (Lassen et al., 2005). The Malnutrition Universal Screening Tool (MUST) is used to assess risk of malnutrition and to determine the necessity of a dietitian referral (Stratton et al., 2004). This study aimed to quantify the duration of dietary restrictions and the frequency of dietetic referrals of patients on a gastrointestinal ward, which included surgical patients.

Methods:  Data were collected from University College London Hospital over a 5‐week period on a gastrointestinal ward. Nursing handover notes were used to identify and track patients undergoing any dietary restriction and all of these patients were included in the data collection. The restrictions were nil by mouth, sips only, clear fluids only or free fluids only. Whether patients were referred to Dietetic services was also recorded. The ward was visited 4 days every week to confirm the accuracy of nursing handover notes from nursing staff and doctors. MUST scores were noted and compared to incidents of referrals to a dietitian. All data were anonymised at the end of the collection period. Frequency data were used and mean (SD) values for duration of restricted diets calculated.

Results:  Eighty‐three patients had completed periods of dietary restrictions (i.e. beginning and end date) with 24 of those patients undergoing two or more different types of dietary restriction.

Number of patients
Mean (SD) number of days of dietary restriction

Nil by mouth
52
1.6 (1.0)

Sips
32
3.4 (2.0)

Clear fluids
 3
3.3 (1.5)

Free fluids
23
1.9 (0.9)

Thirty‐two patients were screened with MUST. Only 15 out of 83 patients were referred to dietetic services eight of which were not screened with MUST. Patients were restricted to sips the longest, which lasted up to 9 days, whereas nil by mouth duration was shortest. The mean (SD) length of time of dietary restriction was 3.0 (2.2) days (range 1–12 days).

Discussion:  Some patients were left on restricted diets despite lack of evidence to support such practice. For example, one patient was restricted to sips for 9 days after a Whipples operation, whereas three patients awaiting nasojejunal or percutaneous endoscopic gastrostomy tube reinsertions due to blockage, waited between 3 and 5 days for the procedures. Although the total number of patients in need of dietetic input was not ascertained, patients that were not referred were identified as being in need of nutrition support.

Conclusions:  Some gastroenterology patients have restricted diets for unnecessarily long periods of time, even though they are vulnerable to malnutrition. Despite this, relatively few patients are screened for the risk of malnutrition or referred to dietitians although there is a clinical need.

References  Guyton, A.C. & Hall, J.E. (2006) Textbook of Medical Physiology, 11th edn. China: Elsevier.

Stratton, R.J., Hackston, A., Longmore, D., Dixon, R., Price, S., Stroud, M., King, C. & Elia, M. (2004) Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br. J. Nutr.92(5), 799–808.

Lassen, K., Hannemann, P., Ljungqvist, O., Fearon, K., Dejong C.H.C, von Meyenfeldt, M.F., Hausel, J., Nygren, J., Andersen, J. & Revhaug, A. (2005) On behalf of the Enhanced Recovery After Surgery (ERAS) Group. Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 330, 1420–1421.

Thomas, B. & Bishop, J. (2007) The Manual of Dietetic Practice, 4th edn. Oxford: Blackwell Synergy.