dysphagia - bcpft.nhs.uk
TRANSCRIPT
Dysphagia Policy
Version 3.0 June 2019
Dysphagia
Target Audience
Who Should Read This Policy
Dysphagia –Trained staff
Speech and Language Therapists
Occupational Therapists
Physiotherapists and Dietetics
Medical Staff
Service Managers and Group Managers
Dysphagia Policy
Version 3.0 June 2019
2
Ref. Contents Page
1.0 Introduction .................................................................................................... 6
2.0 Purpose ......................................................................................................... 6
3.0 Objectives ...................................................................................................... 6
4.0 Process .......................................................................................................... 7
4.1 Access to the Service .................................................................................... 7
4.2 Response Times ............................................................................................ 7
4.3 Documentation ............................................................................................... 8
4.4 Responsibility for the Implementation of Dysphagia Recommendations........ 9
4.5 Referrals to Other Agencies ......................................................................... 10
4.6 Intervention .................................................................................................. 10
4.8 Infection Control ........................................................................................... 12
4.9 Storage of Food/ Food Hygiene ................................................................... 12
4.10 Medicine Format .......................................................................................... 13
5.0 Procedures Connected and Attached to this Policy ..................................... 13
6.0 Links to Relevant Legislation ....................................................................... 13
6.1 Links to Relevant National Standards .......................................................... 14
6.2 Links to other Trust Policies and Standard Operating Procedures (SOPs) . 15
6.3 References .................................................................................................. 16
7.0 Roles and Responsibilities for this Policy ..................................................... 17
8.0 Training ........................................................................................................ 19
9.0 Equality Impact Assessment ........................................................................ 20
10.0 Data Protection and Freedom of Information ............................................... 20
11.0 Monitoring this Policy is Working in Practice ................................................ 22
Appendices 1.0 Speech and Language Therapy Dysphagia Assessment for Adults ............ 23
2.0 LD Swallowing Problems (Dysphagia) Checklist – LD Inpatients ................ 25
3.0 Swallowing (Dysphagia) and Communication Checklist- OAS ..................... 26
4.0 Adult Mental Health – Swallowing (Dysphagia) Checklist ............................ 28
5.0 Dysphagia Referral to Initial Assessment Pathway- LD .............................. 30
Dysphagia Policy
Version 3.0 June 2019
3
Explanation of terms used in this policy
Dysphagia - Is the term used to describe difficulties arising during the eating, drinking and
swallowing process. Dysphagia can arise in any stage of the swallowing process: the oral, pharyngeal and/or laryngeal stages. The term dysphagia is synonymous with the phrase swallowing problem and
may arise from a wide range of neurological, structural, medical, behavioural and psychological conditions.
Adults with Learning Disabilities (ALD) - Valuing People: A New Strategy for Learning Disability for the 21st Century, the Government White Paper for England about Health and Social Care Support
for People with a Learning Disability (2001) explains that a learning disability includes the presence of: A significantly reduced ability to understand new or complex information or to learn new skills
A reduced ability to cope independently
An impairment that started before adulthood, with a lasting effect on development
This means that the person will find it harder to understand, learn and remember new things, and means that the person may have problems with a range of things such as communication, being
aware of risks or managing everyday tasks.
Challenge on Dementia 2020. The Prime Minister’s challenge on dementia 2020 set out more than
50 specific commitments that aim to make England the world-leader in dementia care, research and awareness by 2020.
Chartered Society of Physiotherapy (CSP) - is the professional body of Physiotherapists.
College of Occupational Therapy (COT) - Professional body of Occupational Therapists.
Did Not Attend (DNA) - Any scheduled appointment missed without prior arrangement by the
service user. Types of defaulted appointments are any pre-arranged contact with a service user whether that is at their home, community clinic, at a community team building, within a hospital
setting or any other type of contact arranged relating to the provision of service unless they contact in advance.
Deprivation of Liberty Safeguards/Liberty Protection Safeguards (from October 2020) -
The Deprivation of Liberty Safeguards (DoLS/LPS) are part of the Mental Capacity Act 2005.
The safeguards aim to make sure that people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom. The 2020 LPS extends this to all locations a
person may reside.
No Access Visit (NAV) – Client not being available at home to be seen for a pre-arranged visit.
Ear Nose and Throat (ENT) Specialist - Diagnoses, manages and treats disorders of the head and
neck, including the ears, nose throat, sinuses, voice box (larynx) and other structures.
Fibre-optic Endoscopic Evaluation of Swallowing (FEES) - Procedure that allows physicians to assess areas surrounding the voice box and opening of the oesophagus, through the use of a small
flexible telescope to determine why the patient has difficulty swallowing.
General Practitioner (GP) - A physician whose practice is not oriented to a specific medical
specialty but instead covers a variety of medical problems in patients of all ages in primary care.
Health and Care Professions Council (HCPC) - Is the regulator of health and care professions in
the UK. Their role is to protect the public. By law, healthcare professional staff must be registered with the HCPC to work in the UK.
IDDSI- International Dysphagia Diet Standardisation Initiative
The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global standard with terminology and definitions to describe texture modified foods and thickened fluids
used for individuals with dysphagia of all ages, in all settings, and for all cultures.
Dysphagia Policy
Version 3.0 June 2019
4
Independent Mental Capacity Advocate (IMCA) - A role created by the Mental Capacity Act
2005. A local council or NHS body has a duty to involve an IMCA when a vulnerable person who lacks mental capacity needs to make a decision about serious medical treatment, or an accommodation
move.
Independent Mental Health Advocate (IMHA) - An Independent Mental Health Advocate is
someone who is specially trained to work within the framework of the Mental Health Act to meet the needs of patients. There is now a legal duty to provide IMHA to patients who qualify under the Mental
Health Act 1983.
Learning Disability Mortality Review (LeDeR) Programme (2019): Action from Learning. This
report provides examples of the local changes that have been made to services so far and highlights the extensive work which is happening nationally in response to common themes raised through
reviews of deaths in the learning disability population across the country.
Mental Capacity Act (2005)-The Mental Capacity Act (MCA) is designed to protect and empower
people who may lack the mental capacity to make their own decisions about their care and treatment. It applies to people aged 16 and over. It covers decisions about day-to-day things like what to wear
or what to buy for the weekly shop, or serious life-changing decisions like whether to move into a care home or have major surgery.
Multi-disciplinary Team (MDT) - A multidisciplinary team is composed of members from different healthcare professions with specialised skills and expertise. The members collaborate together to
make treatment recommendations that facilitate quality patient care.
Mental Health Act (MHA) - The Mental Health Act is the law in England and Wales that allows
people with a 'mental disorder' to be admitted to hospital, detained and treated without their consent – either for their own health and safety, or for the protection of other people.
National Dementia Strategy- Strategic framework for making quality improvements to dementia
services and addressing health inequalities.
National Institute for Health and Care Excellence (NICE) - An agency of the National Health
Service charged with promoting clinical excellence in NHS service providers in England and Wales, by developing guidance and recommendations on the effectiveness of treatments and medical
procedures.
Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric
tube or NG tube) through the nose, past the throat, and down into the stomach. Oro-gastric intubation is a similar process involving the insertion of a plastic tube (orogastric tube) through the
mouth. The methods can be used to deliver food, fluids and/or medication directly into the stomach.
National Patient Safety Agency (NPSA) - The National Patient Safety Agency (NPSA) was a
special health authority of the National Health Service (NHS) in England. It was established in 2001 to monitor patient safety incidents, including medication and prescribing error reporting, in the NHS.
Older Adults (OA) – Patients and service users over the age of 65 are classed as older adults in
BCPFT.
Occupational Therapy (OT) - is a science degree-based, health and social care profession,
regulated by the Health and Care Professions Council. Occupational Therapy takes a “whole-person approach” to both mental and physical health and wellbeing and enables individuals to achieve their
full potential.
Percutaneous Endoscopic Gastrostomy (PEG) – Percutaneous Endoscopic Gastrostomy
(PEG) –A type of gastrostomy by which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding/hydration and/or medication when oral
intake is not adequate (for example, because of dysphagia or sedation).
Dysphagia Policy
Version 3.0 June 2019
5
Percutaneous Endoscopic Jejunostomy (PEJ) – (DPEJ) – Endoscopic medical procedure in
which a feeding tube is passed directly into the jejunum, it maybe considered should a patient have delayed gastric emptying or have had upper GI surgery. The feeding tube maybe the same type as a
PEG hence it is important to check the feeding route. The care of a DPEJ is different to that of a PEG.
PEG with a jejunal extension (PEG-J) – A PEG tube has a smaller inner tube inserted through the PEG
tube and then guided into the jejunum. This maybe used for delayed gastric emptying. The care of a PEG-J is different to that of a PEG or DPEJ.
Physiotherapist (PT) - is a science degree-based, health and social care profession, regulated by the Health and Care Professions Council that assesses, diagnoses, treats, and works to prevent
disease and disability through physical means.
Risk feeding is when a person continues to eat and drink despite a significant risk of aspiration and or choking. This option is often appropriate when ensuring quality of life is the highest priority. It
allows continued enjoyment, comfort, pleasure and social interaction associated with eating and
drinking.
Royal College of Speech and Language Therapists (RCSLT) - The professional body for speech and language therapists in the UK; providing leadership and setting professional standards for the
care for individuals with communication, swallowing, eating and drinking difficulties
Speech and Language Therapy (SLT) - Is a science degree-based, health and social care
profession, regulated by the Health and Care Professions Council. SLTs work with babies, children and adults who have various levels of speech, language and communication problems, and with those who
have swallowing, drinking or eating difficulties.
Dysphagia Policy
Version 3.0 June 2019
6
1.0 Introduction 1.1 This policy is written to clarify the role and best practice of clinicians providing high standards of care within specialist clinical dysphagia service provision in Black Country Partnership NHS Foundation Trust (BCPFT). The Trust currently provides dysphagia services for:
Adults with learning disabilities
Older adults and adults with mental health needs who are inpatients in BCPFT locations.
Paediatrics (Dudley)
1.2 Whilst the clinical process may differ depending upon the service-user group and setting in which they receive their care, the core principles are the same. 1.3 Swallowing difficulties can have serious effects on physical health including complications such as malnutrition, pulmonary aspiration (fluid or food going into the lungs) and the emotional and psychological problems associated with it. If not recognised and managed correctly, dysphagia can be fatal. 2.0 Purpose 2.1 The policy outlines the way in which BCPFT dysphagia–trained professionals should work as core members of multi-disciplinary teams to adopt best clinical practice in the assessment, treatment and outcomes for service users/patients with dysphagia both internally and in conjunction with external agencies. 2.2 The responsible medical officer for each patient always has overall clinical responsibility where physical health is concerned. This may be the General Practitioner or Responsible Medical Officer (RMO) in community and/or inpatient settings. 2.3 The policy is based on current professional and national guidance on best practice and competency frameworks. These are listed on page 14. 2.4 The composition and establishment of BCPFT dysphagia services will vary depending upon the community, outreach, in-reach or inpatient setting and the interaction with mainstream service support and availability.
3.0 Objectives 3.1 The principle aims of this policy are:
To provide guidance on the key aspects of multi-disciplinary assessment and intervention in dysphagia which is committed to sharing knowledge, skills, expertise and information to all those involved with the care of the client.
To deliver dysphagia risk-identification, risk management advice and effective, efficient dysphagia services to a variety of populations served by the Trust in partnership with care organisations, families and external organisations.
To serve as a guide to commissioners and service managers, in conjunction with professional leads on the type and level of service required where commissioning arrangements for service users/ patients with dysphagia do not exist currently.
To adhere to Royal College of Speech and Language Therapists dysphagia competencies, assessment and intervention guidelines.
Dysphagia Policy
Version 3.0 June 2019
7
To adhere to relevant multi-disciplinary (Allied Health Professional) guidance documentation where appropriate to the field of dysphagia management.
Clarify the training, competencies and role of clinicians working in dysphagia.
For use as a basis for regular audit of clinical practice and benchmarking with other similar service provision nationally.
To clarify the practical application of changes to practice and new developments in the clinical field.
4.0 Process
4.1 Access to the Service
4.1.1 RCSLT (2003) states that a “medical referral for dysphagia is no longer requisite”. Therefore, referrals can be made by anyone including the service user/patient. Due to the role of the RMO in dysphagia, it is essential for members of the multi-disciplinary team dealing with the referral to make initial contact with the GP/RMO following referral regarding dysphagia to gather medical information, facilitate communication across services and enable further assessment/investigations to be accessed in a timely way. Referrals may also come directly from the GP or a RMO.
4.1.2 Adults with Learning Disabilities: specialist clinical services for people with learning disabilities in the community now operate a single point of access open referral system between the hours of 9am and 5pm Monday to Friday. The single point of access notifies all of the community multi-disciplinary professions in the team for appropriate clinical response co-ordination. Learning disability inpatient services operate a dysphagia checklist on admission (Appendix 2.0) highlighting any concerns to the named or cover SLT for the unit for specialist follow-up assessment.
4.1.3 Older adults and adults with mental health needs can access specialist dysphagia assessment on admission to BCPFT mental health wards through ward staff completing the Swallowing (Dysphagia) Checklist (Appendix 3.0 – Older Adults & Appendix 4.0 - Adults) and either e-mailing it to [email protected] or leaving it for the SLT in the agreed location on the ward (staff to inform SLT via telephone or e-mail that a referral has been completed). 4.1.4 For information on access to service for paediatric services please see Standard Operating Procedure 1 (SOP 1) Paediatric Dysphagia.
4.2 Response Times
4.2.1 All clinical response times start from the time an appropriate referral or dysphagia checklist (Inpatients) is received by the dysphagia team or therapist, not from the time the referral is made. There is no access to BCPFT dysphagia services in the evenings, at weekends or on Bank Holidays. Service users are encouraged to access their GP or RMO the event of urgent need or medical emergency. 4.2.2 Inpatients in older adult, adults and adult learning disability services should be screened on admission with the dysphagia checklist s (see appendices 2.0, 3.0 and 4.0). if they have any concerns about a patient prior to referral to SLT. Screening can be undertaken by any member of the nursing, medical or Allied Health Professional teams who have undertaken a BCPFT or other recognised swallowing awareness course or eLearning as a minimum.
Dysphagia Policy
Version 3.0 June 2019
8
4.2.3 For information on response times for paediatric services please see Standard Operating Procedure 1 (SOP 1) Paediatric Dysphagia. 4.2.4 Adults with Learning Disabilities (inpatient and community), adults with mental health needs (inpatients) and older adults (inpatients) aim to be seen within the following time frames following completion of the clinical prioritisation form and subject to adequate service commissioning. Please refer to Appendix 5.0 and 6.0 for the ALD service dysphagia pathways:
High Priority (Soon)-within 10 working days or sooner depending upon service ability to respond.
Low Priority-(Routine) within 28 days (calendar days) 4.2.5 Response times may be affected by staff vacancies in all divisions. Where vacancies might negatively impact upon response times, the relevant Divisional Director will be informed by the relevant dysphagia clinician and the issue placed on the Trust Divisional risk register. 4.2.6 Dysphagia Qualified Clinicians in all services reserve the right to prioritise referrals in line with their professional judgement, according to the information received and according to team prioritisation criteria to determine risk and urgency of response.
4.3 Documentation
4.3.1 The full details of each dysphagia assessment and intervention must be recorded in the relevant case notes and/or electronic case note system as per professional guidance and Trust policy. This will include all relevant information and clients’ medical history. 4.3.2 Details of assessing capacity and seeking consent for assessment and treatment in dysphagia must also be detailed on the appropriate capacity forms as per BCPFT Consent SOP1: http://luna.smhsct.local/documents/policies-a-z/m/5461-mental-capacity-act-sop-01-assessment-of-mental-capacity-and-best-interest-decisions/file For information on consent within paediatric services please see appropriate pathway within Standard Operating Procedure 1 (SOP 1) Paediatric Dysphagia. Where an individual lacks the ability to make decisions about a particular course of treatment this should be clearly documented using the best interest decision Trust form located in the linked BCPFT policy above. Wherever possible, it is good practice to gain as much information as possible from the client as to their capacity and their wishes and preferences. This may be verbally or non-verbally communicated and, therefore, may require being detailed in the clinical notes as an adjunct to the forms. Where an individual has capacity to consent to a treatment or has a relevant advanced directive or advanced care plan, their wishes to adhere to treatment or not must be upheld. This may lead to a discharge from the service with existing clinical risks. 4.3.3 Video and photographic consent. This should be sought in accordance with the BCPFT Assessment of Mental Capacity and Best Interest Decisions Standard Operating Procedure 1 (SOP 1) policy and the Information Governance Trust Policy:
Dysphagia Policy
Version 3.0 June 2019
9
http://luna.smhsct.local/documents/policies-a-z/m/5461-mental-capacity-act-sop-01-assessment-of-mental-capacity-and-best-interest-decisions/file http://luna.smhsct.local/documents/policies-a-z/i/5447-information-governance/file 4.3.4 In addition the clinician carrying out the dysphagia assessment and intervention will provide a written report and/or dysphagia recommendations summary to be shared with the individual and relevant parties at appropriate points in the therapeutic intervention. These recommendations are to support the implementation of care in the setting the person lives. Reports may be compiled in conjunction with other members of the MDT who are involved as clinically relevant and incorporated into MDT shared care formulations. 4.4 Responsibility for the Implementation of Dysphagia Recommendations 4.4.1 Following assessment the dysphagia qualified clinician will provide dysphagia recommendations to reduce risk, compensate for, improve, develop or maintain the person’s functioning. These may take the form of initial or interim risk management recommendations which are then followed up at a later date with full report recommendations. Recommendations are sent to the person and all known care providers for the individual including wards, family carers, respite, day services and residential care. Recommendations may be made for onward assessment via the GP or RMO and/or referral to further specialist investigations including Videofluoroscopy to aid making a diagnosis and future clinical management.
4.4.2 It is good clinical practice to explain dysphagia recommendations clearly to patients and carers with clear written information. In addition, it is good practice to provide additional supportive information, publication/awareness material and demonstrations (e.g. food modification, positioning or equipment use) as relevant to the client’s individual setting. It remains the responsibility of the family, inpatient ward team or day-service, respite or residential care team providing individualised care to the service user concerned to follow the dysphagia guidance provided in their day to day care and seek further advice, explanation and training from dysphagia services if required. Clinicians diagnose and highlight dysphagia risks and recommend optimal management strategies. It is the responsibility of inpatient wards, carers and care providers to have a continuous approach to risk assessment for the individual and report any changes via re-referral, if necessary, to the dysphagia service as appropriate to the setting. 4.4.3 Dysphagia awareness training is available throughout the year for Trust adult services inpatient and community team staff to access in order for them to carry out their roles safely. This may take the form of a short eLearning or a basic dysphagia awareness level face to face course. 4.4.4 Dysphagia awareness training in Adult learning disability services across BCPFT is regularly available throughout the year to book onto by external care staff and/or family providing care from any location the service user accesses (e.g. residential home, respite, day service, family home). Those requiring a training place must be supporting a service user who has been recently referred for dysphagia assessment, is actively receiving a dysphagia service from BCPFT or has been discharged by the service within one calendar year from the date of training request. More advanced levels of dysphagia training and competency assessment/reviews
Dysphagia Policy
Version 3.0 June 2019
10
are not able to be provided by BCPFT currently and must be sourced from an approved external provider. Training numbers from each external organisation are limited to 3 maximum places at each training session date. However, there are up to 12 dates per year. 4.4.5 It remains the responsibility of the referred client’s care/ ward team to seek and book on appropriate dysphagia training when required from the service or externally as appropriate.
4.5 Referrals to Other Agencies 4.5.1 At any time the Dysphagia Qualified clinician may refer on or recommend referral via the GP or responsible medic to the following clinical specialities and agencies as appropriate/ available. For example:
Dentistry
Pharmacy
Dietetics
ENT
Videofluoroscopy clinics
General Practitioner or responsible medical professional
Gastroenterology
Neurology
Nursing Team/Community Nursing (adults and paediatrics)
Epilepsy, dementia, or diabetes Specialist Nurse
Rehab and hospital avoidance community teams
End of life care
Social worker
Other Medical Consultants
4.5.2 The following services for adults are available within the Trust via a single point of referral or ward checklist as part of a high-quality multi-disciplinary approach:
Psychiatry
Dietetics (internal or external provision which varies across the areas)
Community Nursing
PAMHS/Health Facilitation
Behaviour support team
Clinical Psychology
Occupational Therapy
Physiotherapy
Epilepsy and/or diabetic specialist nursing 4.6 Intervention 4.6.1 Aims of intervention: To provide assessment, management and direct or indirect intervention for service users with dysphagia to:
Support the person to achieve their potential.
Enable the person to maintain or develop skills or function.
Reduce, compensate for and manage the risks associated with dysphagia
Provide supportive advice and information to an individual’s care providers to reduce the risks associated with dysphagia.
Dysphagia Policy
Version 3.0 June 2019
11
Intervention is always dependent upon the day to day support for eating, drinking and swallowing provided by the person’s own care providers. This may be family, adult placement, residential, inpatient ward, respite care, day service and/or college. Intervention may be indirect or direct depending on the findings of the assessment. 4.6.2 The clinician will consider and potentially modify or advise on the following aspects of eating and drinking as part of the intervention (in conjunction with other multi-disciplinary findings and recommendations) in conjunction with the above care providers in all settings:
Presentation of food and fluids
Modifying Consistency/ texture of food and fluids
Eating and communication environment including utensils
Interest in food/ appetite
Posture/ position
Sensory needs and development
Oral motor skills
Oral stimulation
Reducing oral aversions and hypersensitivity
Frequency, timing of meals
Anxiety, emotional responses and/or mood regarding feeding
Saliva management
Raise awareness of the client and carers of difficulties experienced by the individual
4.6.3 The clinician will work with those who support the client. Advice and training may be given as appropriate on:
Meal and drink textures
Use of liquid thickeners
Feeding techniques
Mealtime interaction/ best practice
Positioning
Environment including reducing distractions
Strategies including cues
The new IDDSI framework (2018) is now used to describe the food and drink textures recommended and in line with the BCPFT catering provision for inpatients. 4.6.4 The clinician may provide therapy to maintain and/ or improve oro-motor function as appropriate. This may include:
Exercises to improve speed, range of movement and coordination of all muscles involved in the swallowing process
Thermal/ tactile, sensory oral stimulation
Exercises to improve or counteract abnormal oral motor patterns 4.6.5 The dysphagia qualified practitioner will provide information to the clients and all significant others on:
The actual swallowing problem
The risks of the presenting problem
Best practice risk reducing recommendations
Best practice treatment and management options
Dysphagia Policy
Version 3.0 June 2019
12
4.6.6 The practitioner can recommend further assessment and investigations as appropriate such as Videofluoroscopy if available.
4.6.7 The dysphagia qualified practitioner may review the individual within the
period of the duty of care to identify progress with therapy or adjustments and risks management until a period of clinical stability is reached or dysphagia clinical intervention has been maximally effective. Outcome measures are used for treatment episodes of care such as Therapy Outcome Measures (Enderby). Dysphagia clinicians are reliant on the service user’s care team detecting and raising any changes in their physical and swallowing status following an episode of intervention. Indicators of change are discussed and recorded on the recommendations or report, in awareness training, in publications and in discussion with carers.
4.7.1 Criteria for discharge from a dysphagia episode of care:
The client has made a full recovery
Intervention is not indicated at the present time
The client has recovered to a level that satisfies the client and/ or carer/ MDT
Client has reached their potential and the risks have been minimised to an appropriate level for their condition
Swallowing issues are no longer a health priority (for example palliative or end of life care)
No further progress has been made e.g. Nil by mouth on a PEG/ Nasogastric tube or clients’ functioning/ development has reached a plateau
The client/ carer is not able or not willing to comply with recommendations or persistently not attending or cancelling appointment visits (safeguarding processes will be adhered to)
The client is to be fed orally at risk of aspiration after discussion and agreement of the medical team and the carers/ family as appropriate, capacity and best interests’ assessment and paperwork completed.
The problem is primarily outside of an individual clinician’s or team’s scope of intervention e.g. gastrointestinal problems, food or drink refusal, behavioural difficulties, physical difficulties, sensory impairment, and oral care
The client moves to another district/ transfers to other service
The client dies
The client is deemed to have capacity and does not wish to adhere to recommendations or treatment is complete.
4.8 Infection Control 4.8.1 Current infection control guidelines will be followed as per the relevant Trust policies and departmental procedures. All therapists involved in dysphagia must also complete required infection control training updates, in line with the Trust requirements outlined in the Trust’s Mandatory and Risk Management Training Needs Analysis.
4.9 Storage of Food/ Food Hygiene
4.9.1 Food or drink used in a dysphagia assessment will usually be part of/ provided by the patient’s own healthcare or community/ hospital setting. For example the patient or clients’ own food or that provided by the relevant healthcare provider. Food is sometimes used as part of training or demonstrations. Any food or supplement samples must be stored as per the Trust food storage and re-fridgeration requirements and used within the use by date. Liquid thickener is usually obtained for
Dysphagia Policy
Version 3.0 June 2019
13
assessment purposes in disposable one-use sachets and should only be stored unopened. Tins used for assessment and demonstration purposes will be used within expiry date and within 6 weeks of opening in the case of larger tins. Tins must be secured away from patients, in a lockable cupboard and always with the lid on. All dysphagia team clinicians should complete food hygiene training level 2, in accordance with the Trust’s Mandatory and Risk Management Training Needs Analysis.
4.10 Medicine Format
4.10.1 During assessment and intervention, Speech and Language Therapists may recommend modification of the texture of food or the thickness of drinks. This advice may also have a potential impact on the format of medication a patient is currently receiving. The dysphagia clinician will seek advice from the Pharmacy or GP where applicable and request that the format of medication is reviewed by the GP or relevant Medic. The clinician may recommend that the GP/ Medic consider changing the format of medication (i.e. to liquid/syrup/crushable format) however the prescribing and implementation of this remains the responsibility of the GP/ Medic. Clinicians are recommended to consult with guidance contained within the Trust Medicines Management policy as appropriate in addition.
5.0 Procedures Connected and Attached to this Policy Dysphagia - SOP 01 - Paediatric Dysphagia Dysphagia - SOP 02 - Clinical Procedure for Cervical Auscultation - Adults Dysphagia - SOP 03 - Clinical Procedure for Pulse Oximetry
6.0 Links to Relevant Legislation
The Disability Discrimination Act (DDA) 1995 and The Special Educational Needs and Disability Act 2001 was created in order to tackle discrimination in this sphere and extend the DDA 1995. This describes reasonable adjustments as alterations to normal practices and procedures, alterations to physical features and the provision of extra support. Equality Act 2010 Equality Act came into force on 1 October 2010 and brought together over 116 separate pieces of legislation into one single Act to provide a legal framework to protect the rights of individuals and advance equality of opportunity for all.
Human Rights Act 1998
There are a number of specific rights that are particularly relevant to people with learning disabilities, and the issues that they still face in day-to-day life. Some of these include, but are not limited to Article 2, 3 and 14. Mental Capacity Act 2005 Mental Capacity Act 2005, covering England and Wales, provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they may lack capacity in the future. The Act sets out who can take decisions, in which situations, and how they should go about this. In addition - in some cases, people lack the capacity to consent to particular treatment or care that is recognised by others as being in their best interests, or which will protect them from harm. Where this care might involve depriving adults at risk of their liberty in either a hospital or a care home, extra
Dysphagia Policy
Version 3.0 June 2019
14
safeguards have been introduced in law – Deprivation of Liberty Safeguards/Liberty Protection Safeguards (2020), to protect their rights and ensure that the care or treatment they receive is in their best interests. 6.1 Links to Relevant National Standards CQC Regulation 14: Meeting Nutritional and Hydration Needs The intention of this regulation is to make sure that people who use services have adequate nutrition and hydration to sustain life and good health and reduce the risks of malnutrition and dehydration while they receive care and treatment. IDDSI- International Dysphagia Diet Standardisation Initiative The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global standard with terminology and definitions to describe texture modified foods and thickened fluids used for individuals with dysphagia of all ages, in all settings, and for all cultures. NICE Clinical Guidelines CG32 - Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition (2006) The NICE guideline on nutrition support in adults covers the care of patients with malnutrition or at risk of malnutrition, whether they are in hospital or at home. NICE Clinical Guidelines CG68 - Diagnosis and Management of Acute Stroke and Transient Ischaemic Attack (2008) The advice in the NICE guideline covers:
How healthcare professionals should recognise the symptoms of a stroke or
transient ischaemic attack (TIA) and make a diagnosis quickly
When people should have a brain scan and other types of scan
Specialist care for people in the first 2 weeks after a stroke
Drug treatments for people who have had a stroke
Surgery for people who have had a stroke
Other relevant NICE Guidelines (Not exhaustive list):
CG68 CG32 QS96 CG162 IPG513 NG83 NG96 NG62 NG11 Transforming Care 2019- Learning disabilities The NHS programme called transforming care is all about making health and care services better so that more people with a learning disability, autism or both can live in the community, with the right support, and close to home. Challenge on Dementia 2020 – Published 21/2/15. Progress review 22/2/2019- Department of Health and Social Care. The Learning Disability Mortality Review Programme (LeDer). May 2019- NHS England and NHS Improvement.
Dysphagia Policy
Version 3.0 June 2019
15
6.2 Links to other Trust Policies and Standard Operating Procedures (SOPs)
Mental Capacity Act SOP- Assessment of mental capacity and Best Interests Decisions http://luna.smhsct.local/documents/policies-a-z/m/5461-mental-capacity-act-sop-01-
assessment-of-mental-capacity-and-best-interest-decisions/file
Infection Prevention and Control Assurance Policy http://luna.smhsct.local/documents/policies-a-z/i/4387-infection-control-assurance/file The aim of the policy is to:
Ensure that robust arrangements for the prevention and control of infection are in place within the Trust
Ensure that infection prevention and control is embedded at all levels of the organisation ‘from the Board to the Ward’
Ensure Standard Operating Procedures and policies for effective infection prevention and control are in place
Medical Devices Policy http://luna.smhsct.local/documents/policies-a-z/m/4495-medical-devices/file This policy covers the provision for systems and process to ensure that whenever/ wherever a device is used it is:
Suitable for its intended purpose
Properly understood by the professional and end user
Maintained in a safe and reliable condition
This policy and the related standard operating procedures include reference to three factors, which have a significant impact on device safety:
Training of staff and end users including parents/carers of children or adults with complex health care needs who have a medical device(s) for use at home
Maintenance of the medical device
Decontamination of the medical device End of Life Care for Adults Policy http://luna.smhsct.local/documents/policies-a-z/e/4390-end-of-life-care-for-adults/file The main aim of this policy is to provide staff with a framework, clear direction and standards, to deliver planned, compassionate and competent person-centred care for patients as they approach the end of their life. Nutrition and Hydration (Adults) Policy http://luna.smhsct.local/documents/policies-a-z/n/2964-nutrition-hydration-policy-adults/file
Dysphagia Policy
Version 3.0 June 2019
16
The policy includes guidance for managing nutrition and hydration outlining what is good nutrition and hydration, what staff need to do to monitor and manage this and what to do when service users need additional support. Resuscitation Policy http://luna.smhsct.local/documents/policies-a-z/r/5961-resuscitation-and-management-of-deteriorating-patient-policy/file The purpose of this policy is to provide direction and guidance for the co-ordinated approach to identifying any physiological changes in patients and the subsequent actions that aim to prevent further deterioration and possible subsequent cardio-respiratory arrest by seeking expert help in a timely manner.
6.3 References
Boaden E, Davies S, Storey L, Watkins C (2009) Inter-professional Dysphagia Framework National Dysphagia Competence Cichero Jay, Murdoch BE 1998. The physiological cause of swallowing sounds: answers from heart sounds and vocal tract acoustics. Dysphagia 13: 39-52 Department of Health. Living well with dementia: a National Dementia Strategy (2009). Crown Publishers Department of Health. Mental Capacity Act Code of Practice (2008). Crown Publishers. DDA- https://www.legislation.gov.uk/ukpga/1995/50/contents Equality Act 2010 https://www.legislation.gov.uk/ukpga/2010/15/contents Hibberd J, Shale A, Miles K, Hibberd J, Bowers S, 2001 “Pulse oximetry. Is it a useful indicator of aspiration at the bedside?” Human Rights Act 1998 https://www.legislation.gov.uk/ukpga/1998/42/contents IDDSI https://iddsi.org/ Learning Disability Mortality Review (LeDeR) Programme: Action from Learning 21 May 2019. http://www.bristol.ac.uk/sps/leder/resources/annual-reports/ Logemann J 1993 Manual for the Videofluorographic Study of Swallowing: Winslow Press Mental Capacity Act http://www.bristol.ac.uk/sps/leder/resources/annual-reports/ NPSA (2007) Problems Swallowing: Ensuring Safer Practice for Adults With Learning Disabilities Who Have Dysphagia Sherman B, Nisenboum JM, Jesberger BL, Morrow CA and Jesberger JA, 1999 Takahashi K, Groher M, Michi K 1994: Methodology for detecting swallowing sounds. Dysphagia 9: 54-62 The Assessment of dysphagia with the use of pulse oximetry, Dysphagia 14: pp 152-159. Therapy Outcome Measures for Rehabilitation Professionals. Third Edition. Pamela Enderby and Alexandra John 2015. Transforming Care 2019- Learning disabilities.
https://www.england.nhs.uk/wp-content/uploads/2015/01/transform-care-nxt-stps.pdf
Dysphagia Policy
Version 3.0 June 2019
17
7.0 Roles and Responsibilities for this Policy
Title Role Key Responsibilities
Community and Inpatient Nurses
Operational Clinical
Local services skill mix and protocols will determine the exact role and scope that the nurse has within the management of dysphagia in the MDT. Key responsibilities may include:
- Ensure service-users are enabled to eat/ drink and take medication in a safe and comfortable way - Assist carers/ staff to recognise the signs and symptoms of dysphagia and be aware of the referral process
- Ensure a risk assessment for eating/ drinking difficulties is carried out if there are concerns regarding services –users
- Ensure staff are aware of emergency protocol in the event of a choking incident or CPR (see Resuscitation Policy) - Oversee the implementation of eating/drinking plans devised by MDT in meeting hydration and nutritional needs
- Support Service-users and carers in attending Nutrition clinics/ gastroenterology appointments. To be involved in MDT process making best interest decisions regarding enteral feeding
- Ensure the Eating/ Drinking care plan advice is included in the Health Action Plan and care planning documentation - Ensure that clients needing thickened liquids receive medication in an appropriate consistency
- Implement/ensure implementation of eating and drinking care plans
- In some inpatient units Nurses are able and trained to provide oral suction only (i.e. obstructions visible in the oral cavity)
Speech and Language
Therapists
Operational
Clinical
- Provide assessments and intervention for clients referred with organic and/ or functional dysphagia
- Identify unmet needs in all areas that can impact on swallowing and make onward referrals to MD colleagues and other
agencies as appropriate (see 4.5 Referrals to other Agencies) - Assess and diagnose client’s oral and pharyngeal swallowing difficulties through a variety of means detailed in Appendix 1
for Adult Services [Please see Standard Operating Procedure 1 (SOP 1) Paediatric Dysphagia for children’s service] - Give opinion upon the safety of the swallow and associated risks
- Advise on suitable textures for food and fluids from locally and nationally agreed texture and fluid descriptors
- Advise on equipment specific to the oral intake of food and/or fluids in conjunction with Occupational Therapy - Provide information, advice and training if appropriate to support staff providing modified diets to patients
- Recommend referral for consideration of a non-oral feeding route when swallow deemed to be unsafe, as clinically appropriate
- Provide a professional view in a best interest discussion with family, carers and medics when a patient is unable to make an informed decision
- Provide accessible information to clients who may have capacity to make their own decisions about their health as part of a
specific assessment of capacity in relation to dysphagia - Liaise with SLTs in acute and rehab services as appropriate to the management of the patient
- Provide, demonstrate or advise client-specific treatment to improve function if appropriate
Medical Professionals- RMO
Clinical - Overall responsibility for care of an individual with dysphagia, prescribing and onward specialist referrals- community-based GP or inpatient RMO.
Occupational Therapists Clinical - Provide assessment and advice regarding the use of equipment to assist with eating and drinking e.g. plates, cutlery and
cups, in close consultation with SLT advice - Provide assessment, observation and advice about the impact that the environment can have upon the activity of eating
and drinking
Dysphagia Policy
Version 3.0 June 2019
18
Title Role Key Responsibilities
Physiotherapists Clinical - Provide assessment of respiratory status to inform SLT dysphagia assessment - Identify any differential respiratory diagnosis
- Provide episodic intervention, carer support and advice on self-management for those people who have treatable respiratory symptoms. Interventions may include postural drainage, teaching of positions/ procedures to assist cough reflex
and advice/ education on the prevention of chest infections. The focus of this work is to:
• Treat acute episodes of chest infection whilst a patient awaits full assessment of their dysphagia and treatment plan. A medical consultation with G.P. or other medical officer must also take place
• Equip carers to manage chronic recurrence of chest infections in situations where dysphagia has been assessed and it has been decided to feed at risk
• Treat acute episodes of chest infection in situations where dysphagia has been assessed, it has been decided
to feed at risk and home carer management is not effective for this episode. A medical consultation with G.P. or other medical officer must also take place
• The Trust does not provide an out of hours or emergency physiotherapy respiratory service. For Trust inpatients, where there is any cause for concern as to a patient’s immediate welfare because of respiratory
problems, appropriate medical support must be sought immediately • Trust physiotherapists will not carry out, or teach others to carry out, any form of vacuum suction removal of
respiratory tract or oral secretions
Occupational Therapists/ Physiotherapists
Clinical (Shared Roles)
The roles listed below can be carried out by either profession, if they have the required level of knowledge and skills. Local service skill mix and protocols will determine which profession carries out the role on any specific occasion. On occasions, some
of the roles below may be carried out jointly by both professions:
- Provide 24 hour postural care assessment, intervention and advice on people’s posture and positioning at meal times - Review wheelchairs in conjunction with Wheelchair Services, dining room seating and specialized leisure seating
- Provide advice about night time positioning in relation to patients fed by enteral feeds at night. This needs to occur in collaboration with the relevant enterology nurses, dieticians and carers
- Provide assessment and guidance with reference to presentation of sensory dysfunction and its impact on eating, drinking and swallowing e.g. facial sensitivities
Clinical Team Leads
(Dysphagia/ Occupational Therapy/ Speech and
Language Therapy/
Physiotherapy) Allied Health Professional
Group Leads in conjunction with Service
Managers and Group Managers
Implementation
Governance
- Ensure staff, within their areas of responsibility, have an awareness of recognising and managing patients who are at risk
of dysphagia - Implement Dysphagia Policy and SOP
- Ensure staff, within their areas of responsibility, attend appropriate training
- Ensure that those who are required to work with people with dysphagia have the necessary qualifications and competencies to do this work
- Ensure that all members of staff responsible for the care of patients with dysphagia are aware of safe swallowing recommendations and to ensure that their staff have the appropriate knowledge and skills to refer patients as necessary
Trust Board Strategic - Strategic overview and final responsibility for safe and high quality care within service areas across the Trust in accordance
with its Assurance Framework and strategic priorities
Dysphagia Policy
Version 3.0 June 2019
19
Title Role Key Responsibilities
Executive Director of Nursing, AHPs and
Governance
Executive Lead - Lead responsibility for overseeing the implementation of this policy - Allocation of required Trust resources to support the implementation of this policy
- Ensure any serious concerns regarding the implementation of this policy are brought to the attention of the Board of Directors
8.0 Training
What aspect(s) of this policy will
require staff training?
Which staff groups require this
training?
Is this training covered in the Trust’s Mandatory & Specialist Mandatory
Training Needs Analysis document?
If no, how will the training be delivered?
Who will deliver the training?
How often will staff require
training
Who will ensure and monitor that staff have
this training?
Food Hygiene–
level 2
All dysphagia team
clinicians
Yes, staff will receive
specialist mandatory training in relation to this policy where
it is identified in their individual training needs
analysis as part of their
development for their particular role and
responsibilities
Internally Learning and
Development team
On
appointment and 3 yearly
refresher training
Line Managers/ Learning
and Development Team Individual’s responsibility.
Infection Prevention &
Control (including Hand Hygiene &
Inoculation Incidents)
All therapists involved in
dysphagia
Yes Learning and Development Team
On induction and annually
thereafter
Workforce Development Group
Post Graduate
Post-Basic Dysphagia
Training
Newly qualified
SLTS or non-dysphagia trained
SLTs
No, staff will receive specific
training in relation to this policy where it is identified in
their individual training needs
analysis as part of their development for their
particular role and responsibilities
External course approved
by RCSLT - 5-6 days plus 50-70 hours of supervised
practice - Exam and
accredited written modules/specified hours
of supervised practice records. Recorded in CPD
log
External course
approved by RCSLT
One-off Clinical Team Leads
Professional Leads (AHP and Nursing)
Dysphagia Policy
Version 3.0 June 2019
20
What aspect(s) of this policy will
require staff training?
Which staff groups require this
training?
Is this training covered in the Trust’s Mandatory & Specialist Mandatory
Training Needs Analysis document?
If no, how will the training be delivered?
Who will deliver the training?
How often will staff require
training
Who will ensure and monitor that staff have
this training?
Internal post
graduate dysphagia
competencies
Newly qualified
SLTs, Assistant Practitioners,
clinicians
developing or changing
specialisms.
No.
The appropriate
competency level is identified at appraisal and
progression is mentored
and supervised by appropriately experienced
lead clinicians and in accordance with RCSLT
competencies. Please see appendix –
RCSLT competencies.
Lead dysphagia
clinicians experienced in an appropriate
clinical area.
Competency
development, recording and
supervised
practice will typically take 1
year. To achieve the
level.
The relevant SLT or AHP
clinical lead and operational manager.
Cervical Auscultation
Any practising dysphagia SLT
No, staff will receive specific training in relation to this
policy where it is identified in
their individual training needs analysis as part of their
development for their particular role and
responsibilities
External course - 1 day - Monitored in practice by
professional team
leads/line managers through case notes
check, use of assessment protocol
External course One-off Clinical Team Leads
9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected] 10.0 Data Protection and Freedom of Information
Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4%
Dysphagia Policy
Version 3.0 June 2019
21
of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities; unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act. All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.
Dysphagia Policy
Version 3.0 June 2019
22
11.0 Monitoring this Policy is Working in Practice
What key elements will be monitored?
(measurable policy objectives)
Where described in
policy?
How will they be monitored?
(method + sample size)
Who will undertake this
monitoring?
How Frequently?
Group/Committee that will receive and
review results
Group/Committee to ensure actions
are completed
Evidence this has
happened
Relevant training undertaken 8.0 Training Training Records – checked and evidenced
during supervision and appraisal
Line Manager Annually Group Quality and Safety Group/ AHP
Forum
Relevant AHP Group Lead
Minutes of Meetings/
Signed off action plans
Yearly Training Report Line Manager Annually Group Quality and
Safety Group/ AHP Forum
Relevant AHP
Group Lead Minutes of
Meetings/ Signed off
action plans
Adherence to process and guidelines
4.0 Process Datix Incidents Governance Assurance Unit/
Service Manager
As required Group Quality and Safety Group/ AHP
Forum
Relevant AHP Group Lead
Minutes of Meetings/
Signed off action plans
Waiting times 4.2 Response
Times
Report Service Manager Quarterly Business and
Performance Committee
Business and
Performance Committee
Minutes of
Meetings/ Signed off
action plans
Dysphagia Policy
Version 3.0 June 2019
23
Appendix 1.0
Speech and Language Therapy Dysphagia Assessment for Adults
Purpose of Assessment
Assess the physiology of the swallow process and determine the possibility of oral food/ fluid intake and risks associated with eating, drinking and swallowing
Assess for the presence of delayed/ disordered eating, drinking and swallowing difficulties where appropriate
Provide verbal and written feedback and explanation of difficulties (as appropriate) to all those involved including recommendations
Identify potential treatment approaches as appropriate to the individual
Assess or refer on for advice on postural care, good nutrition, appropriate seating or equipment and chest health where appropriate
An assessment will always commence with the gathering of information from appropriate sources to inform further assessment methods and determine whether assessment and/ or intervention is appropriate. An assessment of the client’s ability to eat, drink and swallow will be carried out in order to determine the safety and efficiency of this process and will be specific to the age, needs and difficulties of the client. The clinician will place the eating, drinking and swallowing disorder within the context of the client’s overall:
Development/ pre-morbid state
Emotional, psychological and behavioural well-being
Medical and surgical status
MHA section if applicable
Medical diagnosis
Respiratory and nutritional status
Prognosis and quality of life
Physical environment and social setting The clinician will always seek consent for any dysphagia assessment or intervention following the guidance of the Mental Capacity Act and involving an IMCA/ IMHA where appropriate. The clinician will inform the client, the multi-disciplinary team, carers and significant others of the nature of intervention. The timing of the intervention will be discussed and agreed with those involved as appropriate. After consideration of the above factors, it may become apparent that further intervention for dysphagia is not appropriate. Where the client is at risk of aspiration the medical practitioner will be informed to make further decisions as appropriate including feed at risk. The clinician will contribute to the multidisciplinary decision regarding the potential need for non-oral nutrition and hydration but this is ultimately a medical decision. The clinician will follow Mental Capacity Act guidance on best interest decisions where the client lacks capacity to make decisions. The SLT may use the following in assessment as appropriate:
Oro-facial examination
Observation of the client
Dysphagia Policy
Version 3.0 June 2019
24
Observation of the eating and drinking environment including the effectiveness of the person or persons supporting the individual to eat and drink safely
Assessment of:
Vocal tract function
Gross and fine motor skills/ posture and use
The clients’ management of secretions
The clients’ cognitive level
Levels of alertness
Information regarding:
Clients’ nutrition and hydration
Client’s respiratory status
Gastro-oesophageal conditions
Oral hygiene
Dental health
Dietary preferences
Individual’s ability to participate
Mealtime interaction and environment
Carer’s pacing and presentation of food and drink versus optimal pacing and presentation
Information on current and past feeding pattern
Effects of emotional state, mood and behaviour
Participation of other professionals
Eating, drinking and swallowing history including birth, early and subsequent development
Eating and drinking equipment and utensils current vs. optimum
Information from:
Videofluoroscopy
Cervical auscultation
Pulse Oximetry
FEES
Videoing the client eating or drinking
Observation
Laryngeal palpation
(As available locally) For Children’s services please see Standard Operating Procedure 1 (SOP 1) Paediatric Dysphagia.
Dysphagia Policy
Version 3.0 June 2019
25
Appendix 2.0
Learning Disability Swallowing Problems Dysphagia) Checklist –Learning Disability Inpatients Instructions: Named nurse to complete on admission for all inpatients. Repeat 3 monthly. Repeat if there are any changes to mental health, physical health or medication.
Signs of possible swallowing problem
If any boxes are ticked – discuss with Speech and Language Therapy
Coughing / red eyes / eyes watering / changes to breathing / wheezing / wet or gurgly voice when eating or soon after
Coughing / red eyes / eyes watering / changes to breathing / wheezing / wet or gurgly voice when drinking or soon after
Choking
Difficulties chewing food E.g. slow, takes a long time, picking out lumps from mouth
Refusal to eat
Refusal to drink
Behaviour difficulties or distress at mealtimes Egg. increased anxiety
Losing food/drink from the front of the mouth
Cramming food into mouth / rushing
Food/drink coming down the nose
Taking a long time to eat / drink
Chest infections in the past year
Signs of malnutrition e.g. Weight loss, skin breakdown, fatigue
Signs of dehydration e.g. Urinary tract infections, dry skin, constipation, dry mouth, strong urine
Anything else?
Name: NHS number: Date of birth:
Date checklist completed: Person completing checklist: Signature:
What next? If you have ticked any of the boxes, please contact Speech and Language Therapy to discuss further. Contact: Inpatient Speech and Language therapist Name: Number:
Dysphagia Policy
Version 3.0 June 2019
26
Appendix 3.0
Swallowing (Dysphagia) and Communication Checklist- Older Adult Services Instructions: MDT to complete within 1 week of admission for all patients and when concerns are identified during hospital stay. Please complete all sections. If a referral is indicated, please e-mail completed checklist or leave in dedicated SLT referrals pigeon hole on Chance or Salter Ward. E-mail [email protected] If referral is not required, file completed form in assessment section of nursing notes
Checklist:
Date completed: _______________ Is this a new patient admission? YES NO
Patient details Affix label here:
Name:
Date of Birth:
NHS no.:
Oasis no.:
Diagnosis:
Date of admission:
Ward:
Consultant:
Person completing checklist, designation & signature:
Signs of Possible Swallowing Problem YES/NO If Yes – Please Circle as Relevant
Comments
Coughing/red eyes/eyes watering/changes to breathing/wheezing/wet or gurgly voice when eating or soon after
More than 3 times a week
Coughing/red eyes/eyes watering/changes to breathing/wheezing/wet or gurgly voice when drinking or soon after
More than 3 times a week
Choking More than 1 incident of
choking in the past 6
Dysphagia Policy
Version 3.0 June 2019
27
If SLT is not available, the Doctor will need to make the decision regarding management e.g. if the patient’s swallowing difficulty is severe and needs an urgent transfer to an Acute Trust.
For SLT to complete:
Priority Tick Response Time Target
Low Within 25 working days
High Within 10 working days
Referral received on:
Patient seen on:
Adult Inpatient Mental Health Speech and Language Therapy Service – July 2019 Based on Southern Health NHS Foundation Trust Dysphagia Risk Assessment
months
Difficulties chewing food
Resulting in concerns about choking
Losing food/fluid from mouth
Concerns about malnutrition or dehydration
Difficulty swallowing tablets
Occurs with all tablets
Results in choking incidents
Food/drink coming down the nose Every meal/drink
Already on modified diet or fluid recommendations
No care plan in place
List recommendations:
Cramming food into mouth/rushing
Additional Information Comments:
Chest infections in the past year (2 or more)
Signs of malnutrition/dehydration
Behaviour difficulties or distress at meal times e.g. increased anxiety
Reduced intake of food or fluids
Taking a long time to eat/drink
Communication Concerns Describe difficulties:
Communication difficulties are having a significant impact on the client/carers
Staff need additional advice on the best way to support this person’s communication
ACTION: 1 or more YES, please refer to SLT
REFERRAL? Please circle: YES NO
Dysphagia Policy
Version 3.0 June 2019
28
Appendix 4.0
Adult Mental Health – Swallowing (Dysphagia) Checklist
Instructions: MDT to complete when concerns are identified during hospital stay. Please complete all sections. If a referral is indicated, please e-mail completed checklist to [email protected] If referral is not required, file completed form in assessment section of nursing notes. Date completed: _________________
Patient details Affix label here:
Name:
Date of Birth:
NHS no.:
Oasis no.:
Diagnosis:
Date of admission:
Ward:
Consultant:
Person completing checklist, designation & signature: Signs of Possible Swallowing Problem YES/NO If Yes – Please Circle as Relevant
Comments
Coughing/red eyes/eyes watering/changes to breathing/wheezing/wet or gurgly voice when eating or soon after
More than 3 times a week
Coughing/red eyes/eyes watering/changes to breathing/wheezing/wet or gurgly voice when drinking or soon after
More than 3 times a week
Choking
More than 1 incident of choking in the past 6 months
Difficulties chewing food
Resulting in concerns about choking
Losing food/fluid from mouth
Concerns about malnutrition or dehydration
Difficulty swallowing tablets
Occurs with all tablets
Results in choking incidents
Food/drink coming down the nose Every meal/drink
Already on modified diet or fluid recommendations
No care plan in place
List recommendations:
Cramming food into mouth/rushing
Dysphagia Policy
Version 3.0 June 2019
29
If SLT is not available, the Doctor will need to make the decision regarding management e.g. if the patient’s swallowing difficulty
is severe and needs an urgent transfer to an Acute Trust.
For SLT to complete:
Priority Tick Response Time Target
Low Within 25 working days
High Within 10 working days
Referral received on:
Patient seen on:
Adult Inpatient Mental Health Speech and Language Therapy Service – July 2019 Based on Southern Health NHS Foundation Trust Dysphagia Risk Assessment
Additional Information Comments:
Chest infections in the past year (2 or more)
Signs of malnutrition/dehydration
Behaviour difficulties or distress at meal times e.g. increased anxiety
Reduced intake of food or fluids
Taking a long time to eat/drink
Communication Concerns Describe difficulties:
Communication difficulties are having a significant impact on the client/carers
Staff need additional advice on the best way to support this person’s communication
ACTION: 1 or more YES, please refer to SLT
REFERRAL? Please circle: YES NO
Dysphagia Policy
Version 3.0 June 2019
30
Appendix 5.0
Dysphagia Referral to Initial Assessment Pathway- LD Community Services
Appendix 6.0
Very High Priority (urgent)
High Priority (Soon)
Low Priority (routine)
Dysphagia Policy
Version 3.0 June 2019
31
Dysphagia Referral to Initial Assessment Pathway- LD Inpatient Services
Low Priority (routine)
High Priority (Soon)
Very High Priority (urgent)
Dysphagia Policy
Version 3.0 June 2019
32
Policy Details
* For more information on the consultation process, implementation plan, equality impact assessment, or archiving arrangements, please contact Corporate Governance
Review and Amendment History
Version Date Details of Change
3.0 Jun 2019 Policy fully reviewed with amendments made to reflect current processes, in line with national standards and legislation.
2.0 Feb 2016 Full Policy review and new policy format
1.0 Jan 2013 New aligned policy for BCPFT
Title of Policy Dysphagia Policy
Unique Identifier for this policy BCPFT-PH-POL-03
State if policy is New or Revised Revised
Previous Policy Title where applicable The Management of Dysphagia Policy – Adults
Policy Category Clinical, HR, H&S, Infection Control etc.
Physical Health
Executive Director whose portfolio this policy comes under
Executive Director of Nursing, AHPs and Governance
Policy Lead/Author Job titles only
Principal Speech and Language Therapist
Committee/Group responsible for the approval of this policy
AHP Forum
Month/year consultation process completed *
July 2019
Month/year policy approved September 2019
Month/year policy ratified and issued October 2019
Next review date September 2022
Implementation Plan completed * Yes
Equality Impact Assessment completed * Yes
Previous version(s) archived * Yes
Disclosure status ‘B’ can be disclosed to patients and the public
Key Words for this policy
Access to service, response times, documentation, responsibility for implementation of advice, referrals to other agencies, intervention, discharge, infection control, storage of food/ food hygiene, medicine format