Establishing a Permanent Food Pantry in a Pediatric Emergency Department

A pediatric emergency department (ED)-based food pantry was established to prioritize the distribution of food and resource information to families who needed it, address concerns related to food assistance stigma, and maintain respect for frontline provider time. The objectives of this analysis are to report the number of households, children, adults, and seniors who received aid from the pantry and to describe potential improvements to the development and implementation of the food assistance process. Cost of food per recipient family was also analyzed.

In January 2021, a permanent food pantry was opened in the emergency department at Norton Children’s Hospital, Louisville, Kentucky. Norton Children’s is an urban, tertiary care, free-standing children’s hospital providing care to approximately 50 000 ED patients annually. The food pantry is in an office just outside the ED. Each month, food is ordered and delivered by a local food bank based upon usage during the previous month. A 90-day pilot began on January 25, 2021 to provide data for a formative evaluation. During this time, incremental infrastructure was added with the goal of making all caregivers in the ED aware of food resources. Results are reported for January 25, 2021 through April 30, 2022, unless otherwise noted. The fast-track area of the ED was selected as the initial area of focus because the higher acuity of the main ED limited interaction time with families.

This project was implemented in collaboration with Norton Children’s Prevention and Wellness, which had previously opened more than 20 food pantries in primary care clinics around the city. Established in 1991, Norton’s Prevention and Wellness focuses on childhood injury prevention and healthy lifestyle promotion. This project greatly benefited from the expertise of this organization and their previous work. For this project, a local food bank, Dare to Care, supplied nonperishable foods to the pantry during monthly deliveries. Funding was primarily provided by the Norton Children’s Hospital Foundation, the philanthropic arm of the Norton Healthcare Systems. The Foundation’s Board of Trustees and members include healthcare providers and community stakeholders from multiple disciplines. Ongoing communication with stakeholders throughout programmatic development and implementation has contributed toward sustainability.

The interdisciplinary team discussed the ethics of interacting with families in the ED who may need food assistance. A core tenet of our project was the distribution of food to ED families in a respectful manner. Consideration was given to the use of validated food insecurity or hunger screeners.^18,19  However, given established high rates of food insecurity in pediatric EDs,^20,21  concerns about increased nursing burden with screening^22,23  and potential caregiver discomfort with formal screening in an environment where families do not have an established relationship with the care team,²⁴  the decision was made to simply notify families of the food pantry and offer a bag of groceries.

Resource allocation equity was also considered. Food insecurity screening procedures were discussed by the team and consensus was reached that screening could potentially contribute to hesitancy to accept food and would also add additional workload to our healthcare personnel. Although offering food resources to all is equality, rather than equity, dignity and comfort were central values. Caregivers in one ED-based study reported fear of negative consequences, including judgement if they disclosed food insecurity to ED personnel but were more comfortable reporting food insecurity to their established primary care provider.²⁴ 

Based on the current evidence of stigma and concerns of negative consequences, resources were offered in the absence of food insecurity screening. It is certainly possible that families who would not have screened positive for food insecurity may have accepted resources. However, food distribution occurred during a time when the economic effects of the coronavirus disease 2019 (COVID-19) pandemic were still prevalent and in a location known to provide services for families with low economic resources. Therefore, the greater community need not justify the provision of food resources without screening procedures.

This evaluation was considered nonhuman subjects research by the University of Louisville Institutional Review Board.

Pantry usage data for the first 15 months were analyzed. Data included the number of people in the household, age of household members, number of children, and whether food was accepted. Age was categorized as preschool (ie, <6 years), school age (ie, 6 to <18 years), adults (ie, 18 to <60 years), and seniors (ie, 60+ years). These categories were selected at the request of the regional food bank that supplied the food items and are reflective of aggregate data reported by the US Department of Agriculture (USDA) Food and Nutrition Services.⁵  These data also provided insight into how much food should be distributed to each household. Because of concern that patients may be hesitant to discuss food insecurity if their acceptance of food became part of the medical record, responses were recorded on paper forms. No identifying information was collected. Food allergies were queried before distribution.

Initially, when families accepted food, they were given a checklist of foods to choose from, and a staff member packed a bag with the foods selected. However, because this was time-consuming and most families checked all options, personnel began prepackaging bags and storing several near the nurses’ station. All food was shelf-stable and included canned fruits and vegetables, soups, beans, rice, whole wheat pasta, milk, and cereal. Opaque, reusable grocery bags were used for ease of carrying. In addition to food, each bag contained a handout with Quick Response codes for more information about resources, including the Supplemental Nutrition Assistance Program, Women Infants and Children, school meal programs, and local community-based organizations. Recipes using food from the pantry were included, along with other donated items when available.

The pilot phase was implemented on weekends and evenings in the fast-track area of the ED, an 8-bed unit within the main ED, where, in 2021, approximately 10 000 lower acuity patients received care. We later expanded to round-the-clock assistance with the goal of offering food to every family seen in fast-track. Signage in English and Spanish was placed in all ED rooms to encourage families to ask providers about the pantry service if it was not formally offered to them. Interpreters were used if needed.

An interdisciplinary food pantry council was formed in April 2021 to address challenges in our process. The 20 members of the council include attending and resident physicians, nurse practitioners, nurses, patient care technicians, a volunteer coordinator, Prevention and Wellness staff, and environmental services staff. This council identified frontline staff (nurses and physicians) burden as a barrier to the food pantry’s success. The pilot phase took place early in the COVID-19 pandemic, a time of lower patient volumes, and it became clear as ED volumes returned to prepandemic levels that additional support was necessary. Initially, ED clinical staff were responsible for all operations of the pantry, including ordering food, unloading the truck, stocking shelves, packing bags, offering food, and collecting data. Council members aimed to improve frontline provider acceptance of the project by asking interested staff to join the council, providing educational opportunities and identifying opportunities to ease the daily burden of the operation of the pantry.

Although there were challenges in adapting the program to an emergency department environment, a formative evaluation with the first 10 families was conducted in the first 90 days and procedures were revised to provide services more efficiently. Early in the program, bags were filled with large quantities of food and more money was spent on the contents in each bag. However, families were leaving bags behind because they were too heavy. Flexibility and the input from the interdisciplinary teams was critical to the financial sustainability of the program.

From January 25, 2021 through April 30, 2022, total ED volume was 54 775; of these, 12 705 (23.2%) were seen in the fast-track. A total of 3981 families (31.3% of fast-track patients) were offered food from the ED pantry. Of these, 2199 (55%) families accepted food. These families were comprised of 8811 people: 2253 children <6 years old, 2445 children aged 6 to <18 years, 3565 adults aged 18 to <60 years, and 140 seniors (60+). Family size was documented beginning March 1, 2021 through April 30, 2022. Average family size was 4.1 members and family size ranged 1 to 13 members. The pantry distributed 35 600 pounds of food at a cost of $25 208 when purchased through the food bank. The cost per family served was approximately $11.

Pediatric ED food pantries have a significant potential benefit given patrons’ high rates of food insecurity, the unique ability to provide services to those who do not have an established primary care physician, and the inherent accessibility at times when other resources are unavailable. These services also help develop a strong emotional connection and increased trust with the care center.^14,24  Previous studies have shown that around 20% of ED patients screen positive for food insecurity.¹⁸  In our program, 55% of families accepted food when offered. Inconsistent data collection may have contributed to this discrepancy, with possibly fewer staff completing a form if a family declined food assistance. Despite these potential missing data, the ED-based food pantry was generally well-received and highly used. There are several factors in the process that may have contributed to this level of usage. Support was offered by asking patients and families if they wanted a bag of food instead of asking screening questions. Food was immediately available to take home from their ED visit, overcoming resource inaccessibility (limited transportation, wait times at food assistance agencies), which can be challenging to navigate. Food acceptance was not recorded in the medical record and therefore, families may have been more willing to accept resources. Additionally, food pantries in clinical settings transition the perception of food assistance from charity to “food as medicine” and part of health care.^9,10 

Rates of food insecurity increased during the COVID-19 pandemic.²⁴  This program took place during the initial phases of the COVID-19 pandemic and this may also partially explain why there were higher acceptance rates than reported in previous studies. The USDA forecasts continued food price increases in 2023.⁵  This anticipated increase in food costs will likely exacerbate food insecurity in low and middle-income households, particularly those with children. Food insecurity will continue to be an essential health issue, and innovative strategies to increase food assistance options are vital to meet nutritional needs.

Continuity of care in partnership with primary care providers poses a challenge. Future considerations for documentation of food security status in the electronic health record would provide a way to track food security outcomes over time. A core tenet of this project was to provide patient anonymity to enhance comfort in accepting food. Although a list of food resources was provided in each bag, future discussions will address how to notify primary care providers of the need for continued food assistance.

The interdisciplinary leadership team for the ED food pantry is unique compared with other projects in the healthcare setting. Monthly meetings of the food pantry council are well-attended. The council has engaged in other projects, such as the development of a novel medical student curriculum, nursing training, and the development of a hospital-wide food insecurity screening and resource referral. This continued process illustrates the impact that is possible when working together in healthcare outside of traditional silos. Further work to evaluate care provider perspectives and to complete development of the medical education program is underway. The education program with preclinical medical students, started in October 2021, includes educational modules, simulated conversations with families about food insecurity, and experiential volunteering in the pantry. Students can receive elective credit for participation. In addition, a series of Norton Children’s Nursing Grand Rounds are currently being conducted. These include presentations related to identification of food insecure children, reduction of stigma and fear of consequences, and enhanced awareness of food resources from food insecurity researchers, ED physicians, and Prevention and Wellness leaders.

The pediatric ED food pantry process is iterative. Although key emergency department personnel have responsibilities in the food pantry (delivery supervision, data collection, ordering of food items), volunteers now complete many tasks (packing bags, stocking shelves, and offering food) during times of high ED volume. Volunteers include preclinical medical students who have been integral in providing feedback to the team. Other ancillary staff (social workers, patient care techs, patient liaisons) now notify families of available resources. Although the pantry services are still centered upon the fast-track areas given the more complex flow of the main ED, there are signs in main ED rooms that notify families of the services. Many of the interventions were beneficial, but the team continues formative and summative evaluations to address challenges as they arise. Personnel who expressed interest in the project now hold key positions and have work time allocated to support the pantry.

Because there was no documentation in the medical record, there was no communication of need to primary care providers, who could have provided continued support for families. Replication of this type of service should include a communication pathway by which primary care providers are notified of the need for food assistance so that continuity of nutritional care can be established. Additionally, analysis of the program and its potential impact on health equity was limited by lack of granular data collection. Inclusion of demographic variables, such as self-reported race and insurance status, would strengthen future studies.

A qualitative study of recipients’ perceptions of the food pantry would inform future processes. Although formal feedback was not elicited, families did spontaneously report positive comments. Qualitative studies are needed to explore the impact on reduced stigma, quality of food and interaction with personnel, and the degree of comfort in seeking future food assistance. In addition, future impact analysis using a validated measure of food security (USDA Household Food Security Survey Module) will strengthen the rationale for continued funding of the pantry and replication in other facilities.¹⁹  In addition, rigorous methodologies should be employed to evaluate the impact of these resource-based primary prevention projects on frontline provider burnout and on racial and ethnic nutrition-related health disparities.^25,26 

This project demonstrates that an ED-based food pantry is a potential venue to provide emergency food assistance to the community. Educational and food insecurity impact outcomes will continue to be evaluated.

We thank Nicole Greenwell, Brenda O’Bryan, Tracy Morrison, Angie Garman, Adrienne Griten, Kelly Hibbs, Dr Erin Frazier, Norton Children’s Hospital Foundation, and Norton Children’s Hospital. This project was implemented in collaboration with Norton Children’s Prevention and Wellness, which had previously opened more than 20 food pantries in primary care clinics around the city. Established in 1991, Norton’s Prevention and Wellness focuses on childhood injury prevention and healthy lifestyle promotion, and the emergency department staff and volunteers who support this project.

ED

emergency department