Developing a meal service model for COVID‐19 hotel quarantine—Lessons in emergency response planning for dietitians

The COVID‐19 pandemic provided unique challenges across the world and highlighted the need for considered emergency response planning across public and private sectors, and particularly for health and aged care. What are the lessons for dietitians' role in this emergency response? Reflecting the theme of this issue, this case study describes the role of dietitians in developing a meal service model to meet the needs and expectations of those completing mandatory COVID‐19 hotel quarantine and shares lessons with our profession for use in future emergency responses.

From late March 2020, returning travellers to Australia were required to undertake a period of hotel quarantine to mitigate the risk of spread of COVID‐19 to the Australian community. Jurisdictions across Australia had just 48 h to establish hotel quarantine. In New South Wales (NSW), returning travellers with COVID‐19 symptoms, or with other health support needs, were managed in Special Health Accommodation managed by NSW Health. At the peak of the pandemic, there were six Special Health Accommodation sites supporting up to 1500 individuals. Amongst a range of other health staff, dietitians were co‐opted into roles within Special Health Accommodation, including site manager, clinical and food service dietitians.

NSW Health used serviced apartments to provide quarantine services. Using serviced apartments provided access to a larger suite of rooms, including internal laundry facilities and balconies. The latter facilitated access to fresh air, which has been identified by many returning travellers as critical to their well‐being. ¹ , ² Whilst fully functioning kitchens were available in each apartment, generally, cooking was not permitted due to the risk of activating fire alarms and the consequent evacuation and infection control risks.

There were no commercial kitchens, chefs or food service staff available in the serviced apartments. However, fridges and microwaves were available in all guest suites. The meal service model had to be developed from the ground up within the resources available.

Space on the ground floor of each serviced apartment complex was co‐opted to provide a functional area from which to coordinate the delivery of commercial ready‐to‐eat food to returning travellers. Initially, a combination of shelving, domestic refrigerators/freezers and chest‐freezers provided storage space. An investment was then made in commercial refrigerators and freezers to expand storage capacity. Trestle tables provided a place to pack meals for individual rooms. No food preparation occurred on site.

Fresh sandwiches/wraps/poke bowls, shelf‐stable snack packs and breakfast packs, and frozen meals and desserts were delivered daily to each apartment complex by an airline caterer. These were immediately packed in large paper bags and distributed to individual rooms via contactless delivery. Only leftover product needed to be stored in the limited refrigeration and freezer space. Support staff monitored the shelf‐life of these products and discarded expired stock.

A menu was quickly developed with the airline caterer for the most common diets—standard, Halal, vegetarian, vegan, gluten‐free and child. A range of additional grocery items, purchased through commercial distributors and retail grocery stores, supplemented these core menus. These additional grocery items assisted to support a range of special diets, cultural practices and personal preferences within the physical constraints of the service. Using retail grocery stores provided greater flexibility to access niche products not readily available through the usual commercial distributors. Highly specialised products were sourced through local hospitals, for example, puree meals, oral supplements. In the absence of a computer‐based menu and diet management system, a paper‐based diet/allergy matrix was developed to support SHA staff to identify suitable food items for a range of diets (e.g., gluten‐free, vegan). For returning travellers with highly specialised diets (e.g., multiple allergies, texture aversions) an individual meal plan was developed by a dietitian after telephone consultation. When the needs for these highly specialised diets could not be accommodated through the existing meal service (e.g., phenylketonuria), a personal grocery shop was organised and simple meal preparation was permitted within the apartment once a risk assessment had been completed. Dietitians provided basic food safety and special diet training to support staff.

In June 2020, student dietitians reviewed the standard, Halal, vegetarian, vegan, gluten‐free and child menus that had been established early in the quarantine hotel response. Nutritional parameters measured included protein, energy, saturated fat, sodium and serves of Core Food Groups. ³ Variety was measured by counting the number of unique menu items available for each menu.

Nutritional information was obtained from the airline caterer, FoodWorks™ and HealthShare NSW CBORD™ database. Results of this analysis were used to identify areas of focus to improve nutrition in the meals provided. After a number of quality improvement activities were implemented, the menu analysis was repeated in October 2021. Improvements to protein, energy, percent energy from saturated fat, sodium, serves of core food groups and overall variety were achieved between these time periods. (RPA Ethics Committee – X22‐0041 and 2022/EHT00294).

There were challenges in using traditional satisfaction surveys to gauge feedback on the meal service provided in Special Health Accommodation. Infection control requirements meant paper surveys could not be distributed and collected from returning travellers. Whilst there was potential for electronic satisfaction surveys, these posed their own challenges. Quarantine is recognised as a source of psychological distress and has been identified within returning travellers. ² We were mindful of the potential psychological burden of asking returning travellers to complete an electronic feedback survey whilst in mandatory quarantine.

We considered alternative means by which to understand the returning traveller experience without imposing an undue psychological burden and to develop an iterative process for service development and improvement. Using an experiential evidence gathering ⁴ approach, two arms of information gathering were used—staff feedback and social media.

Two main groups of staff informed the staff feedback—reception staff and accommodation assistants, who would routinely receive verbal feedback and requests from returning travellers in Special Health Accommodation; and dietitians, who provided clinical support to those on special diets and with more complex needs. Feedback was routinely sought from support staff through staff meetings and targeted emails, to inform the development and refinement of menu products, as well as the expansion of grocery items used to supplement the core meal service. A survey was completed amongst dietitians to identify which additional grocery items would support the range of special dietary requests within the physical constraints of the meal service model.

Social media has rapidly evolved and offers an opportunity to inform health research, although it also brings ethical challenges. ⁵ , ⁶ The potential to support responses to the COVID‐19 pandemic has also been noted. ⁷ , ⁸ A number of social media groups were established by returning travellers in mandatory hotel quarantine. Some had a broad approach, whilst others had a particular focus (e.g., food, a particular site), some were public, and others were private members only. Two social media sites were regularly reviewed for posts regarding food in hotel quarantine. Given the ethical considerations, the author chose not to represent themselves as a person in mandatory quarantine, using only public social media sites, and not responding to or participating in any posts or discussion threads.

Ongoing staff feedback informed a series of quality improvement cycles to make incremental improvements to the meal service over time. Whilst there were relatively few public social media posts regarding Special Health Accommodation meal services as such, the broader themes from hotel quarantine across Australia were informative regarding what those in mandatory quarantine expected from their meal service. This feedback contributed to the quality improvement activities undertaken in Special Health Accommodation, including increasing the range of cultural options, introduction of healthy snacks and meals free from additives, and the development of ‘clean’ or ‘pantry‐style’ labels.

What then, are the lessons for dietitians who find themselves supporting the food and nutrition response in an emergency? Here are some key learnings from our experience.

• Evolve your response over time. Focus on identifying resources you do have rather than the systems and processes currently absent. However, you may need to be at the front‐line of the response to understand what these resources are.

• Work closely with new or emergency suppliers to understand the unique needs of your business. An airline caterer provided us a flexible response, but was working from different assumptions requiring clarification over time, for example, all airlines mandate adding salt to vegetables while healthcare services were looking for healthier options.

• Look for staff resources with similar skill sets who can be redeployed, but also be aware where skill sets will be different. Be prepared to identify and address these skill gaps.

• Do not overlook humble solutions in an emergency. A paper allergy/diet matrix worked in the absence of a computerised diet system, paper bags with room number and diet written on the side allowed contactless delivery and supported right‐meal‐right‐person.

• Think outside the square when seeking feedback. Staff can be a valuable source of information. Social media can also tell a story, but requires careful navigation.

• Expectations will vary enormously. You are likely to be dealing with a very heterogeneous population with different beliefs of what ‘normal’ looks like and who, paradoxically, may struggle to articulate this.

• Little things matter. Everyone wants to be heard and validated. Simple things like extra rice, unleavened bread, vegan yoghurt, etc., made a real difference.

• Consider options that solve multiple problems within resource constraints. Gluten‐free wraps were acceptable to the general population, provided diet options, streamlined procurement and minimised the risk of errors.

• Nutrition is important to many people, but nutrition beliefs may be less conventional. These expectations will need to be balanced within other priorities in the context of the emergency situation. Decisions may be influenced by factors outside the usual evidence‐based nutrition practices.

Dietitians are well placed to support emergency response planning, with underlying knowledge of food services but also skills in critical thinking to identify when services and supports can be flexed, and when patient safety necessitates unique solutions for unique times.

AUTHOR CONTRIBUTIONS

Suzanne Kennewell was responsible for the conceptualisation and design, data analysis and preparation of this manuscript.

CONFLICT OF INTEREST

The author provided oversight and coordination of the meal service model developed within the Special Health Accommodation as part of her paid role as Director Nutrition & Dietetics in Sydney Local Health District.

ETHICS STATEMENT

Ethical approval received from Royal Prince Alfred Hospital Ethics Committee Protocol X22‐0041 and 2022/ETH00294.

DATA AVAILABILITY STATEMENT

The data that support the findings of this case study are available from the corresponding author upon reasonable request.