CPI Part 2Choking Prevention

Initiative

Overview of Therapeutic Dining

Core Competency

Supporting Good Health

• Supporting Health and Wellness (competency P)

• Knowledge and understanding of individuals’ medical & physical needs. (Skill 2)

• Uses accepted methods to prevent illness (Skill 3)

• Recognizes and responds to symptoms of illness & medical emergencies (Skill 4)

• Understands & implements practices to support good health (Skill 7)

Warning Signs/Symptoms of DysphagiaDysphagia: difficulty with swallowing or dining process.

•Impaired speech•Presence of primitive oral reflexes (i.e., tongue thrust, bite reflex)•Wet, gurgly voice•Prolonged feeding time•Poor swallowing or no swallowing•Difficulty bringing food to mouth•Dehydration•Reflux/GERD•Decreased muscle coordination and/or tone•Dental concerns or problems•Taking medications that affect the muscles of the throat or mouth

•Excessive drooling•Food/drink leaking from mouth•Food/drink collecting in the mouth•Poor or no chewing•Coughing•Choking•Aspiration•Frequent pneumonia•Refusal to eat or drink•Forgetting how to use utensil•Forgetting to eat•Postural changes/difficulty holding head up or sitting straight

At risk for Choking and Aspiration

Consequences of Improper Feeding/Swallowing

Aspiration pneumonia

Choking

DEATH

Swallowing Intervention Strategies

You can help people with dining and

swallowing difficulties!

Increase Supervision

Increased level of supervision while eating, drinking, and/or medication administrations may be required.

Most common levels are continuous eyes-on supervision and one-to-one supervision.

Refer to IPOP or Therapeutic Dining Plan for person-specific statements regarding supervision.

•IPOP examples

IPOP Example #1

Person needs for supervision while at home:*John requires intermittent-eyes-on checks every 15 minutes during waking hours (undocumented) and 30 minute checks (documented) during hours of sleep.*John has a tendency to pull objects off walls, out of cupboards and any objects that are laying around and will often attempt to place them in his mouth and/or over his head.*John prefers to keep his shoes and socks off while at home and will continuously take them off even with redirection.*John is unable to call emergency services independently and is reliant upon staff to call 911 in the case of an emergency.

Dietary/Dining/Eating Guidelines:*John is currently on a 1400-1600 reduced calorie diet. *John requires continuous eyes on supervision during eating, drinking, and whenever food is present. He CANNOT be left unsupervised in the kitchen. If food is on the counters or table in the kitchen he cannot be left unsupervised in the dining room. Food must be stored in sealed containers (not simply wrapped or covered) whenever John is unsupervised in the dining room. *Staff must follow the most recent copy of his Therapeutic Dining Plan located in the clinical section IV of his habilitation binder.*Adaptive dining equipment: inner lip plate, high sided dish, plate guard, or scoop-bowl; large maroon spoon, built-up-handle teaspoon, built-up-handle souper spoon or built-up hand tablespoon, built up handle fork; 6 ounce plastic cup or 6-8 oz. Styrofoam cup; Dycem mat may be offered but is not required. Avoid paper plates and plastic flatware. No larger cups.*Food texture and liquid consistency: All foods cut into 1/2" pieces cut to size. Thin liquids.

*This is an example of when we

increase level of supervision during

meal times/eating since this person

needs more support during this activity.

IPOP Example #2

Person needs for supervision while at home:Connie receives direct supervision at home. Connie receives documented checks every two hours throughout the night to ensure her safety.Please refer to Connie's Behavior plan for specifics regarding her cell phone use.Connie may utilize the internet with continuous eyes on supervision.Connie can call for assistance in an emergency independently.

Dietary/Dining/Eating Guidelines:Connie is on a 2000 calorie restricted, low fat, and no concentrated sweets diet.

Whole texture with thin liquids.

Whole hotdogs/sausage ok. Hotdogs/sausages with casing ok.

*This is an example of when we do not

need to increase the level of supervision

during meal times/eating since this

person is safe eating/drinking. Use the

level of supervision while at home/in

community.

Alternate Food with Liquids

• Unless the person has a known preference or a specific clause in the dining guideline that states otherwise.

• This helps clear food from the person’s mouth and promotes hydration in the event that the person becomes too distracted, tired, or weak to finish their entire meal.

• Good Practice – 3 bites of food and then a drink! Repeat until the person is finished or no longer wants anymore to eat or drink.

Maintain a calm environment

while eating and drinking.

Importance of the Bite Size

• Most people take normal size bites.

• Some people may need to take smaller bites.

• Some people may need to take larger bites.

In order to facilitate a safe and pleasant dining

experience, food textures may be changed or

dining adaptive equipment may be used,

along with supervision, to help support an

appropriate bite size for a person.

Cut Up” Food Textures1 inch, ½ inch, ¼ inch

These sizes are not a “bite size.” It refers

to size of a piece of food. People may put

more than one piece of food in their mouth.

Pacing

Different types of food can be eaten safely at different rates because of the natural texture.

For Example: Pudding can be usually eaten much faster than steak since pudding does not require chewing.

*On the other hand, some people may load an appropriate amount of food into their mouth by spooning multiple tiny amounts before swallowing. The safety of the bite size is dependent upon the person’s chewing/swallowing skills, the texture of the food, and the amount of food they place in their mouth prior to swallowing. If you have any specific questions when you meet the people with whom you work, please contact SLP and OT.

Allow sufficient time for the

person to swallow foods.

Ensure correct posture

*Depends on the needs of the person.• When sitting in a chair - Sit upright with hips and knees at 90

degrees with their feet firmly supported.

• When sitting in a wheelchair – Sit upright (tilt marker indicates degrees of tilt) which for most people is 0-10 degrees of tilt. Feet firmly supported.

• Individualized seating information may also be included in the Therapeutic Dining Plan/IPOP.

* *If pillows or rolled towels are used for additional support, they must be removed immediately after the meal/snack/drink is completed.

If staff feed/give drinks to the person:

• Sit in front of or next to the person and face him/her. • Present all food and liquids from midline.

Periodically ask the individual to speak or listen as he/she makes vocal sounds.

If his/her voice seems “wet” or “gurgly,” prompt the person to clear his/her throat, or cough, and then swallow.

Repeat procedure until his/her voice is clear.

Bite Reflex

If a bite reflex is triggered, leave the spoon in the person’s mouth until his/her teeth release it.

• Happens each time.Obligatory

• Only happens some of the time.

Non-obligatory

GERD PrecautionsPeople with GERD must remain upright for 30 minutes to one hour after meals (or as per the doctor’s orders). This

will help guard again reflux and possible aspiration on reflux.

Make sure that the person swallows and

clears all food or beverage in their mouth after each meal or snack.

Food stuck behind the person’s teeth may be difficult for the person to remove, which could turn into a choking/aspiration hazard if the food should fall from the back of the teeth when the person is

lying down or sitting in a reclined position.

*End meal with a drink if possible.

*Complete oral care after meals.

No tandem feeding!!

One staff member may only feed one person at a time.

***You may feed yourself and/or supervise other people while

they eat or drink.

Chin Tuck

• What it is: Chin tucked downward while swallowing. This position helps protect the person from aspirating.

• A person may use this strategy if he/she has aspirations precautions. It will be indicated in Therapeutic Dining Plan and/or IPOP if person uses chin tuck.

• Use verbal or gesture cues, modeling, adaptive equipment, or touch cues if necessary, to help the person achieve this position.

Double Swallow

If the person has aspiration precautions, encourage the person to “doubleswallow.”

Prompting the person to “double swallow” can be completed in a couple ofdifferent ways. You can verbally instruct the person to “swallow again” orwait! Time will prompt the person the “swallow again.”

If the person uses this strategy, it will be stated in the Therapeutic DiningPlan or IPOP.

Dining Adaptive Equipment

Read the person’s Therapeutic Dining Plan or IPOP to learn if he/she uses any adaptive equipment.

You must use the recommended adaptive equipment for all meals, drinks, snacks, and medication administration.

Small and Large Maroon Spoons

Cut-out Cups

Inner Lip Plate

Kennedy Cup

Divided PlateBuilt-up Handle Spoon Built-up Handle Weighted

Spoon

Weighted Mug

Use only the specific adaptive equipment approved for the individual. There are many types of built up handle spoons and many different

reasons why the Occupational Therapist may require a specific piece of equipment for the individual.

Make sure there is enough adaptive equipment for three meals.

Substitutions cannot be made without the permission of the Occupational Therapist

or Speech Language Pathologist.

If additional dining adaptive equipment is needed, it is your responsibility to contact the

Occupational Therapist and Speech-Language Pathologist so that equipment can be replaced.

Food Texture and Liquid Consistency Changes

Read the person’s Therapeutic Dining Plan and IPOP to learn if she/he has anyfood texture or liquid consistency changes.

Food textures and liquid consistencies are changed because the person usuallyhas difficulty chewing and/or swallowing. The SLP determines the appropriatefood texture or liquid consistencies that are safe for people to swallow.

Modified food textures and liquid consistencies are ordered by the person’sdoctor and must be followed by law!

OPWDD has mandated specific guidelines to promote standardization.

Food Textures

• Whole

• 1 inch pieces

• ½ inch pieces

• ¼ inch pieces

• Ground

• Pureed

Liquid Consistencies

• Thin

• Nectar

• Honey

• Pudding

Watch OPWDD Videos to learn about food textures and liquid consistencies.

https://www.youtube.com/watch?v=umAB7zD-4Ek

OPWDD Choking Prevention Initiative Preparations Guidelines for Food and Liquid Consistency binder is located in each residence and day program.

Refer to this binder EACH time you prepare foods to make sure that foods and liquids are prepared and modified accurately!

If you have additional questions regarding food textures or liquid consistency changes, it is your responsibility to

contact the Speech-Language Pathologist or Occupational Therapist for more training.

REMEMBER!!!!•Ice cream, sherbet, Jell-O, ice chips, etc. turn into thin liquids in the mouth. If the individual is prescribed thickened liquids, these items and similar items must be avoided.

•This statement is included in the Dietary/Dining/Eating Guidelines in IPOP and/or Therapeutic Dining Plan.

How can you contact us?

Elizabeth Eldredge, OTR/L

Occupational Therapist

Carrie Nutt, SLP

Speech-Language Pathologist

See you in the Break Room for some hands on experience preparing food

textures and liquid consistencies.