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West London Mental Health NHS Trust of 57

Policy D16/01 | First issued in August 2016 This is version 01.2 / May 2018

Policy: Insert Policy no.

Policy: D16 Dysphagia Policy

Policy relates to: F7 - Food and Nutrition policy

Version: 01.2

Ratified by: Integrated Physical Health & Environment Committee

Date ratified: 22nd August 2016

Title of Authors: Speech & Language Therapist Manager & Highly Specialist Speech & Language Therapist

Title of responsible Director

Director of Nursing & Patient Experience

Governance Committee Integrated Physical Health & Environment Committee

Date issued: 17th May 2018

Review date: January 2019

Target audience: Dieticians, Nursing staff, HCAs and any other staff Involved in offering food to patients

Disclosure Status B: Can be disclosed to patients and the public

EIA / Sustainability n/a


Policy D16/01 | First issued in August 2016 This is version 01.2/ May 2018

Equality & Diversity Statement

The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all relevant policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed.

Sustainable Development Statement

The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All relevant policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed.



Policy Name & Number Template

Version Control Sheet

Version Date Title of Author Status Comment

01 August 2016

Sarah Kramer & Eve Brotzel

New policy ratified & issued

01.1 January 2017

Sarah Kramer & Eve Brotzel

Reissued Amendment to 5.7

01.2 May 2018 Sarah Kramer & Eve Brotzel

Amended and reissued

Addition of Appendix 17



1. Flowcharts 5

2. Introduction 11

3. Scope 14

4. Definitions 14

5. Duties 16

6. Systems and Recording 19

7. Process 20

8. Training 20

9. Monitoring 21

10. Fraud Statement 22

11. Supporting Documents (trust documents) 22

12. References 22

13. Appendices

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Appendix 1 Medication induced dysphagia

Appendix 2 Dysphagia competencies for wards

Appendix 3 Dysphagia Screen

Appendix 4 Information regarding high risk foods

Appendix 5 Information regarding Category C (puree) diet

Appendix 6 Information regarding Category D (pre-mash) diet

Appendix 7 Information regarding Category E (fork mashable) diet

Appendix 8 Thickening Fluids

Appendix 9 Care Plan for service user displaying one or more acute signs of aspiration

Appendix 10 Care Plan for service user displaying three or more chronic signs of aspiration

Appendix 11 Care plan for service user displaying low risk of choking

Appendix 12 Care plan for service user displaying medium risk of choking

Appendix 13 Care plan for service user displaying high risk of choking

Appendix 14 Pamphlet – help with dysphagia

Appendix 15 Requirements for service

Appendix 16 Risk feeding form and guidance

Appendix 17 Modified texture food/fluids and thickening products: Selection, ordering and monitoring procedure

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1. FLOWCHARTS



Dysphagia Pathway – Assessment to Management

Assessment Completed

Difficulties identified through

assessment

No difficulties identified through

assessment

Information provided by

SLT re: outcome of assessment

Discharge from SLT dysphagia caseload

Recommendations made re: further

assessment / management

strategies

Further assessment

indicated or referral on (e.g. dietetics/

videofluroscopy)

Joint management plan (with MDT and pt)

1. To reduce the risk of aspiration and/or choking with food and drink 2. To maximise nutrition and hydration 3. To enable the patient to eat and drink with comfort

Pt agrees to follow

recommendations

Pt refuses to follow

recommendations

Review / reassessment plan agreed

with MDT and pt as

appropriate

See Dysphagia Pathway – Refusal

to Follow

Recommendations

WLMHT SLT DYSPHAGIA PATHWAYS (adapted from Nottinghamshire Healthcare NHS Foundation

Trust 2014)

Recommendations not followed by

ward team

Review MDT plan in conjunction with staff

team and

Initiate safeguarding procedure/ IR1 as

appropriate



Pathway for Management of Choking - Accidental

Accidental choking by

patient

Choking incident

managed by supporting

staff

IR1 completed

SLT service made aware of incident

SLT team discuss whether referral for

dysphagia assessment is

indicated with MDT

If referral initiated See Dysphagia

Pathway – Concern

to Assessment


Trust 2014)



Pathway for Management of Choking - Deliberate

Deliberate choking by

patient

Choking incident

managed by supporting

staff

IR1 completed

SLT service made aware of incident

MDT discuss with SLT whether referral to SLT for

dysphagia assessment/input to development of

management plan is indicated

If assessment initiated See

Dysphagia Pathway – Concern to

Assessment

Risk Management Plans developed

by MDT with input from SLT

Review / monitoring plan

agreed with MDT (and pt)

Decision not to refer to SLT

Rationale for decision and

relevant management

plans documented on

RIO


Trust 2014)



Pathway for Management of Choking Risk - Seclusion

Decision made for pt to be nursed in

seclusion

MDT complete screen re: choking /

dysphagia risk factors

No risk factors identified

Screen filed in pt records & SLT alerted

Screen reviewed by MDT at each CPA

Risk factors identified

Screen filed in pt records & SLT alerted

MDT discuss with SLT whether referral to SLT for

dysphagia assessment/input to development of

management plan is indicated

If assessment initiated See

Dysphagia Pathway – Concern to

Assessment

Risk Management Plans developed

by MDT with input from SLT

Review / monitoring plan

agreed with MDT (and pt)

Decision not to refer to SLT

Rationale for decision and

relevant management

plans documented on

RIO


Trust 2014)



2. Introduction The aim of this policy is to ensure safe and effective management for service users with actual or suspected dysphagia. Dysphagia is the term used to describe an eating, drinking or swallowing problem. 2.1 Significance of dysphagia Dysphagia has well documented effects on physical health and can be life threatening (Crawley, 2007, NPSA, 2004, RCSLT, 2006), as summarised in the following table. Table 1: Health Risks Associated with Dysphagia

Associated Health Risk

Source

Aspiration pneumonia is a common sequelae of dysphagia and is associated with higher costs of care

Katzan et al 2007

Increased choking risk

Concoran and Walsh, 2003

Undernutrition, dehydration and chest infections Harding and Wright,2010, NPSA, 2004, RCSLT, 2006

Significant adverse effects on self-esteem, socialisation and enjoyment of life

Costa Bandeira et al, 2008, Ekberg et al., 2002

Slower recovery from comorbidities McCulloch et al, in Perlman and Schutze-Delrieu 1997, Carrau and Murray, 1998

More frequent chest pain, heartburn and regurgitation than those without dysphagia.

Tibbling & Gustafsson (1991)

2.2 Dysphagia prevalence

Dysphagia Setting Source

30% (approx.) All psychiatric settings Regan, Sowman and Walsh, 2006, Walsh et al., 2007

68% Dementia/care home Steele et al, 1997

Facts about choking in mental health Source

10% of all sudden deaths in adult mental health are due to choking

Concoran and Walsh 2003

Patients with schizophrenia have 20 fold greater risk of death by choking as compared to general population

Ruschena et al., 2003



Common Causes of Dysphagia in Mental Health

Common Causes Of Dysphagia In Mental Health Source

Eating and swallowing problems are compounded within a mentally ill client group due to the side effects of medication (please find more detail in Appendix 1). These may include:

(1) Medications altering levels of alertness, for example, antipsychotic and anticonvulsant medications and Benzodiazepines.

(2) Medications altering muscle tone/ co-ordination, for example Baclofen and some antidepressants.

(3) Antipsychotic medications that delay swallow process or increase salivation.

Polypharmacy is common in both institutional settings and community care, increasing the likelihood of side effects.

Risk of asphyxiation increases 100 fold in psychiatric patients, with 40% of these choking incidents due to the extrapyramidal symptoms associated with dopamine blockage. Dysphagia and aspiration can result from tardive dyskinesia.

Wyllie et al., 1986 Hughes et al.,1994, Sokoloff et al.,1997 Beange, 2002 Carl and Johnson, 2005

Higher levels of poor oral health are recorded among people with mental illness. Respiratory pathogens present in the dental plaque of individuals with very poor dental hygiene may be aspirated, and predispose the individual to the development of lung infections

Malmstrom et al., 2002

The psychological effects of institutionalisation make this population more susceptible to choking incidents e.g. eating too quickly and cramming food

Samuels & Chadwick, 2006; Anderson & Abdelnoor, 1999

A link between feeding skills and mortality has been noted in the US literature and mortality rates from acute aspiration have ranged between 30 and 60 per cent.

Rogers et al., 1992

Fast eating syndrome correlates with increased choking incidents.

Bazemore et al.1991



2.3 Relevant guidance

Source of Guidance Recommendations

NICE guidelines (CG32) Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition 2006

Persons who present with any obvious or less obvious indicators of dysphagia should be referred to healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders.

Guidelines produced by the Royal College of Physicians (2012)

There is a requirement for early diagnosis and effective management of dysphagia which has been found to reduce the incidence of pneumonia and improve quality of care and outcomes

NICE Guidance (CG138) Patient experience in adult NHS Services 2013

Requirement for appropriate support for the patient’s eating and drinking requirements e.g. staff are trained in the provision of thickened fluids

NPSA Guidance

Individuals should receive specialist assessment by SLT, a regularly updated individual dysphagia management plan and accessible information for the patient and significant others.

Royal College of Speech and Language Therapists (2006)

Patients should be seen within 2 working days for inpatient/acute dysphagia referrals, and 10 days for community/chronic dysphagia referrals.

CQC Guidance on Essential standards of quality and safety

Ensure personalised care by providing adequate nutrition, hydration and support. Where the service provides food and drink, people who use services have their care, treatment and support needs met because: - Staff identify where the person who uses services

has swallowing difficulties, when they first begin to use the service and as their needs change. - Action is taken where any difficulty in swallowing is

noted, and a referral is made to appropriate services. - Any difficulties swallowing are identified and

reviewed. - A care plan includes how any identified risks will be

managed. They are enabled to eat their food and drink as independently as possible.

- All assistance necessary is provided to ensure service users actually eat and drink, where they want to but are unable to do so independently.

- Service users have supportive equipment available to



them that allows them to eat and drink independently, wherever needed.

- Service users are helped into an appropriate position that allows them to eat and drink safely, wherever needed.

- Service users will have any special diets or dietary supplements that their needs require arranged on the advice of an appropriately qualified or experienced person.

- Service users have access to specialist advice and techniques for receiving nutrition where their needs require it.

- The service takes into account relevant guidance, including that from the Care Quality Commission’s Schedule of Applicable Publications

Essence of Care Benchmarking. Food and Drink. Factors 9 and 10.

- A system must be in place to ensure those people requiring assistance to eat and drink receive it

- The level of assistance required is assessed on every occasion that food and drink is served.

- Assistance to eat and drink is provided according to people’s needs. This may include the positioning of people requiring care and providing appropriate utensils.

- Relevant staff are involved in providing advice and/or assistance, for example speech and language therapists.

- Food and drink intake is monitored and documented by people, carers and staff (as appropriate)

3. Scope This policy applies to all clinical staff within the Trust and its purpose is to ensure the health and safety of patients who have dysphagia.

4. Definitions Dysphagia is the term used to refer to an eating, drinking or swallowing problem. Signs and symptoms of dysphagia: Dysphagia can present in many ways, and the patient may demonstrate one or several of the following symptoms: ACUTE

CHRONIC

Food spillage from lips

Taking a long time to finish a meal

Poor chewing ability

Weight loss

Repeated chest infections



Dry mouth

Drooling

Nasal regurgitation

Food sticking in the throat

Coughing and choking

Regurgitation

Aspiration is defined as the inhalation of food/drink particles into the lungs. This can be either acute or chronic in presentation. Symptoms suggestive of aspiration include: ACUTE CHRONIC

Coughing/spluttering when drinking

Wet/gurgly voice after drinking

Throat clearing when swallowing

food/liquids

Increased shortness of breath or

respiratory rate after swallowing

Absent swallow

Frequent chest infections

Unexplained temperature spikes

Food refusal

Long mealtimes

Choking is defined as the introduction of a foreign object (food) into the airway, which becomes lodged in the airway and reduces or obstructs the air flow into the lungs. This can be a consequence of dysphagia.

Factors that may increase the risk/negative sequelae for those at risk of aspiration and choking:

Reduced dentition

Psychotropic medication

Polypharmacy

Lack of interest or attention to food and drink and the feeding environment

Cramming/overloading of food into mouth

Speed of eating

Pacing and agitation whilst eating

Taking food from others

Holding food/drink in the mouth

Putting non-food items into the mouth

Swallowing without chewing

Having issues relating to eating with others

Mood levels

Levels of alertness

Little insight into own difficulties

Poor oral hygiene



5. Duties

5.1 Chief executive

The Chief Executive is responsible for ensuring that the trust has a dysphagia policy in place and that this complies with legal and regulatory requirements.

5.2.1 Duties of medical director The Medical Director is accountable to the Board for trust-wide implementation and ensuring compliance with this policy across the trust. 5.2.2 Duties of the director of nursing and patient experience Operational responsibility to ensure staff compliance with this policy and to ensure adequate dysphagia educational opportunities are available to meet nursing/HCA requirements and that there is adequate SLT to meet WLMHT dysphagia requirements. 5.3.1 Duties of clinical managers, inpatient service managers Responsible for ensuring policies are communicated and implemented within their CSU / Directorate as well as co-ordinating and systematically filing monitoring reports. Areas of poor performance should be raised by managers at the CSU / Directorate SMT meetings. Managers should ensure adequate staff education on dysphagia-related matters. 5.3.2 Duties of team managers Responsible for ensuring policies are communicated and implemented within their CSU / Directorate as well as co-ordinating and systematically filing monitoring reports. Areas of poor performance should be raised by managers at the CSU / Directorate SMT meetings. Managers should ensure adequate staff education on dysphagia-related matters. Managers should ensure their team’s compliance with WLMHT Dysphagia Policy. Managers should raise an IR1 and safeguarding alert where appropriate if a dysphagia management plan is not followed. 5.3.3 Duties of ward managers Promoting awareness of the policy and ensuring adequate staff education on dysphagia-related matters. Ensuring aspiration and choking risk screens are completed. To ensure that processes and documentation are in place to support adherence with SLT care plans e.g. list of service users on a modified diet displayed on the ward, nursing staff have easy access to information for service users and families.

To appraise annually nursing staff competencies in dysphagia management (Please see Appendix 2 for form)

Ward managers should raise an IR1 and safeguarding alert where appropriate if a dysphagia management plan is not followed

5.4.1 Duties of ward nursing staff To carry out the appropriate swallow screening tool and to identify patients suspected of having dysphagia (see Rio Core Assessments or Appendices 3 and 4).



To refer all patients failing the swallow screen and suspected of having dysphagia to a Speech and Language Therapist (SLT) for a full swallowing assessment as per the guidance within the screens and within the WLMHT Dysphagia Policy.

To clearly document referral to SLT within RIO.

To ensure compliance with SLT care plans as recommended in the WLMHT Dysphagia Policy post screening where no SLT assessment has taken place.

To ensure compliance with SLT care plans post SLT dysphagia assessment, as documented in RIO care planning.

To document evidence of compliance with SLT care plans within RIO progress notes.

To review the need for alternative medications if dysphagia impacts on the patient’s ability to swallow tablets safely e.g. liquid solutions.

To promote good oral hygiene practice and support regular mouth care for all patients with dysphagia.

To ensure service users receive the correct modified diet, including snacks, and thicken fluids to the correct consistency as recommended by SLT.

To ensure mealtime supervision or assistance with thickening fluids and drinking are provided if needed.

To ensure safe feeding strategies advised by SLT are carried out e.g. feed using a teaspoon, feed slowly, allow time for extra clearing swallows.

To feedback any concerns regarding a patient’s swallowing to SLT. To raise an IR1 and safeguarding alert where appropriate if a dysphagia management plan is not followed To ensure the supplies of thickener are re-ordered as appropriate To comply with the procedure for ordering texture modified foods, thickeners and pre-thickened drinks (see appendix 17) 5.5.1 Duties of SLT service manager Operational responsibility for ensuring compliance with this policy by the SLT Dept and implementation of dysphagia training. In collaboration with managers. Accountable for ensuring that SLT audit WLMHT dysphagia practice. Accountable for evaluation of adverse incidents relating to dysphagia (IR1s) and ensure provision of targeted intervention and/ or training to prevent recurrence To comply with the procedure for ordering texture modified foods, thickeners and pre-thickened drinks (see appendix 17)



Accountable for raising an IR1 and safeguarding alert where appropriate if a dysphagia management plan is not followed 5.5.2 Duties of SLT To respond to dysphagia referrals presenting on any ward as promptly as possible. To assess, diagnose and treat patients with swallowing problems providing an individual care plan. To communicate assessment findings, risks and feeding recommendations clearly within RIO progress notes and RIO care plan. To discuss ethical dilemmas regarding feeding decisions with the medical team taking into consideration risks, best interests, quality of life, consent, capacity and wishes of the patient. To instigate discussion around ‘risk feeding’ where appropriate (please see Appendix 17) To recommend further investigation using instrumental assessment if clinically indicated e.g. Videofluoroscopy (VFS, a dynamic X Ray using barium consistencies) and Fibreoptic Endoscopic Evaluation of Swallowing (FEES). To provide, as appropriate, support and information to service users, relatives and carers regarding the swallowing difficulty, enabling informed decisions concerning eating and drinking to be made. To carry out dysphagia rehabilitation exercises if indicated. To promote an approach to dysphagia management emphasising the highest quality of patient care.

To liaise closely with dietetics regarding the provision of texture modified diets and the management of nutritional support in patients with dysphagia.

To provide an appropriate level of training to other professionals regarding dysphagia.

To highlight issues relating to management of patients with dysphagia within the trust to appropriate senior members of staff. To comply with the procedure for ordering texture modified foods, thickeners and pre-thickened drinks (see appendix 17) To raise an IR1 and safeguarding alert where appropriate if a dysphagia management plan is not followed 5.6 Duties of dietitians To assess, devise and manage a nutritional care plan for those referred with dysphagia requiring dietetic intervention, organising special diets and other products as required.



To liaise closely with SLT and catering regarding the provision of texture modified diets and the management of nutritional support in patients with dysphagia.

To advise on oral supplements which are appropriate to the diet and fluid consistencies recommended by SLT.

To comply with the procedure for ordering texture modified foods, thickeners and pre-thickened drinks (see appendix 17) To raise an IR1 and safeguarding alert where appropriate if a dysphagia management plan is not followed 5. 7 Duties of SaLT and Dietician joint working SaLT and dieticians to work closely to determine texture and to agree in each individual case the liaison with catering to ensure the provision of the appropriate diet 5.8 Duties of pharmacists To advise doctors on alternative medications if the patient is unsafe to swallow tablets.

To advise doctors on possible alternative medications where side-effects affecting eating/drinking are a concern.

6. Systems / Documentation

6.1.1 Where recorded: screening information recorded in RIO dysphagia screens

6.1.2 Recorded by (name/title): Nurse

6.1.3 When recorded: as part of admission assessment

6.2.1 Where recorded: assessment and reviews recorded in RIO progress notes

recommendations in progress notes

6.2.2 Recorded by (name/title): Speech and language therapist (SLT)

6.2.3 When recorded: within 24 hours (in line with HCPC guidance)

6.3.1 Where recorded: actions in response to recommendations by SLT in care plan

in RIO progress notes

6.3.2 Recorded by (name/title): ward staff (HCA/nurse)

6.3.3 When recorded in line with NMC/RGN guidance



7. Process 7.1 WLMHT dysphagia pathway (see flowcharts) 7.1.1 Adult inpatient service users and those attending services where food/drink is

provided will routinely be screened for aspiration and risk of choking by ward staff as part of the admission assessment (inpatients/day services) (quality statement 1, NICE Quality Standard for nutrition support in adults), with appropriate screens available as appendices 3 and 4, and also stored on WLMHT G drive.

7.1.2 Service users will be managed using an appropriate care plan as indicated by the

screen/assessment (quality statement 2, NICE Quality Standard for nutrition support in adults). This will include appropriate care plans for service users with acute/chronic symptoms of aspiration and/or at a low, medium or high risk of choking, as seen in appendices -7, and also stored on WLMHT G drive. The care plans will include a process for review of the suitability of the care plan at appropriate points (quality statement 5, NICE Quality Standard for nutrition support in adults).

7.1.3 Where the service user does not consent to assessment and/or the proposed care

plan this will be managed in line with MCA legislation. 7.1.4 The outcomes of the screening/assessment process and the care plan will be

documented in the individual’s notes, and will be communicated in writing where the service user is transferred within/between organisations (quality statement 3, NICE Quality Standard for nutrition support in adults).

7.1.5 The management plan will be drawn up in conjunction with the service user and the

staff team. Please see Dysphagia pathway – Refusal to follow recommendations for full details on the process where a service user does not follow the recommendations for eating and drinking. When the management plan is not followed by the staff team, for example by providing non-recommended food texture, an IR1 will be recorded and safeguarding procedure instigated where appropriate.

7.1.6 Service users will be offered a review of their eating/drinking at planned junctures.

8. Training

Dysphagia Awareness Raising will be accomplished by the following means:

Posters (A4 and A3)

Screen-savers

Plasma screen adverts / slides

information sheet for staff with the key information

Quick-reference pocket guides



Articles for The Exchange

Updates in Monday Matters, Team Brief and WLMHT bulletins

Targeted training / briefing for wards

Levels of dysphagia training required by WLMHT staff NICE Guidance (2006) specifies the requirement for staff to be able to identify service users who may potentially have dysphagia and to refer these service users to professionals with the relevant skills and training in the diagnosis, assessment and management of dysphagia. The Inter-professional Dysphagia Competence Framework (Boaden, 2006) is a framework that is recognised by a number of professional associations including the Royal College of Physicians, the Royal College of Nurses, the Royal College of Speech and Language Therapists, the British Dietetics Association, and also by Skills for Health. It aims to inform strategies for developing the skills, knowledge and ability of speech and language therapists, nurses and other healthcare professionals/non-registered staff, to contribute more effectively in the identification and management of feeding/swallowing difficulties. Utilising this framework, 8.1 Ward staff require those skills demonstrated by Assistant Dysphagia Practitioners (Boaden et al., 2006), Assistant Dysphagia Practitioners contribute to the implementation of dysphagia management plans prepared by others. They may also prepare oral intake for individuals and contribute to feeding and providing fluids. They require knowledge of relevant policies, procedures and guidelines. The Assistant dysphagia practitioner in directly linked to the Skills for Health competence units: AHP 26 Provide support to individuals to develop their skills in managing dysphagia AHP 27 Assist others to monitor individuals attempts at managing dysphagia. 8.2 Staff performing the screen will require those skills demonstrated by Foundation Dysphagia Practitioner in order to undertake a protocol guided assessment of swallowing. 8.3 Training is available within WLMHT via the following routes:

dysphagia e learning package available via WLMHT

dysphagia awareness session available at staff handover sessions by request

bespoke dysphagia training packages

dysphagia competencies checklist signed off within nursing supervision sessions

9. Monitoring The key performance indicators which will be measured are

1. Percentage of service users per ward with a completed aspiration risk and choking

risk screen within audits of dysphagia screening.



2. No. of service users where the dysphagia care plan is/is not being followed upon

service user review, as documented in IR1s.

3. Evidence of provision of relevant information regarding modified diets to significant

others in sample of service users seen for dysphagia.

4. Audit of appropriacy of mealtime environment and materials associated with meals

e.g. accessible menus.

10. Fraud statement

Not applicable to all policies (N/A)

11. Supporting documents (trust documents) Physical Healthcare

Food and Nutrition

Seclusion

12. References Anderson &Abdelnoor, 1999 in Thacker, A,, Abdelnoor, A., Anderson, C., White, S., and Hollins, S. Indicators of choking risk in adults with learning disabilities: A questionnaire survey and interview study. Disability and Rehabilitation. 2008, Vol. 30, No. 15 , Pages 1131-1138 (doi:10.1080/09638280701461625)

Bazemore PH, Tonkonogi J, Ananth R. Dysphagia in psychiatric patients: clinical and videofluroscopy study. Dysphagia. 1991;6(1):2-5.

Beange, H., McElduff, A., Baker, W. Medical disorders of adults with mental retardation: a population study. Journal of Intellectual and developmental Disability 2002; 27 (2): 92-105.

Boaden, E., Davis, S., Storey, L. and Watkins, C. (2006) Interprofessional Dysphagia Competency Framework. National Dysphagia Competence Steering Group. Carl, L. and Johnson, P. (2005) Drugs and dysphagia: How medications can affect eating and swallowing, Austin, TX: Pro-Ed.

Carrau R. and Murray T. 1998. (eds): Comprehensive Management of Swallowing Disorders. pub. Singular Publishing Group San Diego, CA. Colodny, N., 2001. Construction and Validation of the Mealtime and Dysphagia Questionnaire: An Instrument Designed to Assess Nursing Staff Reasons for



Noncompliance with SLP Dysphagia and Feeding Recommendations. Dysphagia, 16 (4):263-271. Costa Bandeira, A., Azevedo, E., Vartanian, J. G., Nishimoto, I., Kowalski, L. and Carrara-de Angelis, E., 2008. Quality of Life Related to Swallowing After Tongue Cancer Treatment. Anna Karinne, Dysphagia, 23 (2):183. Crary, M. and Groher, M. 2003. Introduction to Adult Swallowing Disorders, pub: Butterworth-Heinemann.

Crawley, H. 2007. Nutrition and Eating Disorders. Nursing Times. June.

Ekberg, O. et al., 2002. Social and psychological burden of dysphagia: its impact on

diagnosis and treatment. Dysphagia, 17 (2):139-46.

(Harding and Wright,2010)

Hinchey, J. A., Shephard, T., Furie, K., Smith, D., Wang, D.,Tonn, S. 2005. Formal

Dysphagia Screening Protocols Prevent Pneumonia. Stroke, 2005, 36:1972-1976.

Hines, S. et al., 2011. Identification and nursing management of dysphagia in individuals

with acute neurological impairment (update). International journal of evidence-based

healthcare, 9 (2):148-50.

Hughes, J.C., Enderby, P.M., Langton Hewer, R. 1994 Dysphagia and multiple sclerosis: a study and discussion of its nature and impact. Clin Rehab. 8: 18-26 Hussar, A. E. & Bragg, D. G. (1969) The effect of chlorpromazine on the swallowing function in chronic schizophrenic patients. American Journal of Psychiatry, 126, 570– 573.

Katzan, I. L., Dawson, N. V., Thomas, M. E., Votruba, M. E. and Cebul, R. D. 2007. The

Cost of Pneumonia after Acute Stroke. Neurology, 68:1938-1943.

Kelly, J., Wright, D. and Wood, J., 2011. Medicine administration errors in patients with

dysphagia in secondary care: a multi-centre observational study. Journal of advanced

nursing, 67 (12):2615-27.

Langmore, S.E. (2001) Endoscopic Evaluation and Treatment of Swallowing Disorders. Thieme. Langmore, S.E..Skarupski, K.A., Park, P.S..Fries, B.E. (2002) Predictors of Aspiration Pneumonia in Nursing Home Residents.. Dysphagia 17:298-307. Logemann, J.A. (1998) Evaluation and Treatment of Swallowing Disorders. ProEd. Malmstrom, K., Lu, S. et al., 2002 Concomitant mon AGA technical review on management of oropharangeal dysphagia. Chest 2002: 121: 361-9. NICE guidance, Feb 2006. Nutrition Support in Adults. NPSA, 2004. Understanding the patient safety issues for people with learning disabilities.



Odderson, R., Keaton, J. and McKenna, B. 1995. Swallowing Management in Patients on

Acute Stroke Pathway: Quality Is Cost-Effective. Archives of Physical Medicine and

Rehabilitation, 76 (12):1130-1113.

Perlman , A.L. and Schulze Delrieu, K. 1997. Deglutition and its Disorders . Singular

Publishing Group, San Diego Perlman, Schulze-Delrieu, Disorders

Regan J, Sowman R & Walsh I Prevalence of Dysphagia in Acute and Community Mental health Settings Dysphagia 2006: 65-101 Rogers et al 1992 in Chadwick, D.D, Jollliffe, J. Goldbart, J. and Bruton, M.H. Barriers to Caregiver Compliance with Eating and Drinking Recommendations for Adults with Intellectual Disabilities and Dysphagia. Journal of Applied Research in Intellectual Disabilities. Volume 19, Issue 2, pp 153-162. June 2006 Royal College of Speech and Language Therapists (1996). Communicating Quality 3. 2nd Edn. ISBN: 0-947589-55-4 RCSLT Position Paper: Speech and Language Therapy in Adult Critical Care, 2006. Rosenvinge, S. and Starke, I. 2005. Improving care for patients with dysphagia. Age and

Ageing, 34 (6):587-593.

Royal College of Physicians Intercollegiate Stroke Working Party. 2008. National clinical

guidelines for stroke, Royal College of Physicians.

Royal College of Physicians (RCP): Oral feeding difficulties and dilemmas: A guide to practical care, particularly towards the end of life. Jan 2010.

Samuels, R. & Chadwick, D.D. 2006 Predictors of Ashpyxiation Risk in Adults with Intellectual Disabilities and Dysphagia. Journal of Intellectual Disability Research, vol. 50, No. 5, pp. 362-370. Sokoloff, L.G., Pavvlakovi, R. Neuroleptic-induced dysphagia. Dysphagia 1997,12: 177-9. Steele, C., Greenwood, C., Ens, I., Robertson, C. and Seidman-Carlson, C. 1997. Mealtime Difficulties in a Home for the Aged: Not Just Dysphagia. Dysphagia, 12:43-50. Tibbling, L., Gustafsson, B. 1991. Dysphagia and its consequences in elderly people.

Dysphagia, 6:200-202.

Wyllie, R., Cruse, R.P., et al. The mechanism of nitrazepam-induced drooling and aspiration. N Eng. J. Med. 1986. 314: 353-358.



13. Appendices

Appendix 1 Medication induced dysphagia

Appendix 2 Ward staff dysphagia competencies

Appendix 3 Dysphagia Screen

Appendix 4 Information about a texture modified diet - high risk food

Appendix 6 Information about a texture modified diet - puree (texture c)

Appendix 7 Information about a texture modified diet - pre-mash (texture d)

Appendix 8 Information about a texture modified diet - fork mashable food (texture e)

Appendix 9 Thickening fluids

Appendix 10 Care plan for service user displaying one/more acute signs of aspiration

Appendix 11 Care plan for service user displaying three/more chronic signs of aspiration

Appendix 12 Care plan for service user displaying a low risk of choking

Appendix 13 Care plan for service user displaying a medium risk of choking

Appendix 14 Care plan for service user displaying a high risk of choking

Appendix 15 Requirements for service

Appendix 16 Risk Feeding Form and Guidance

Appendix 17 Modified texture food/fluids and thickening products: Selection, ordering and monitoring procedure



APPENDIX 1- Medication induced dysphagia

There are a number of proposed mechanisms for medication- induced dysphagia.

Medications that affect the smooth and striated muscles of the oesophagus that are involved in swallowing may cause dysphagia (anticholinergic or antimuscarinic effects)

Medication Indication Procyclidine Extra Pyramidal Side-Effects (EPSE) Trihexyphenidyl EPSE Orphenadrine EPSE Hyoscine Clozapine induced hypersalivation Pirenzepine Clozapine induced hypersalivation Oxybutynin Urinary incontinence Tolterodine Urinary incontinence Ipratropium (Inhaler) Chronic Obstructive Pulmonary Disease (COPD) Tiotropium (Inhaler) COPD

Medications that cause dry mouth (xerostomia) may interfere with swallowing by impairing the person’s ability to move food Medication Classes and examples

Indication

ACE Inhibitors Lisinopril Ramopril

used for high blood pressure

Antiemetics Metoclopramide Prochlorperazine

Nausea and vomiting

Antihistamines Chlorpheniramine Diphenhydramine

Nightime Sedation Allergy Hayfever

Decongestants Pseudoephedrine

Nasal Congestion

Calcium channel blockers- Amlodipine

Angina

Diuretics Furosemide

Fluid Retention

Antidepressants Citalopram Fluoxetine Paroxetine Sertraline Venlafaxine

Moderate to severe Depression Anxiety Disorders

Mood Stabiliser Lithium

treatment and prophylaxis of mania, bipolar disorder, and recurrent depression; aggressive or self-harming behaviour

* see also Antipsychotic medication list below



Medications that depress the Central Nervous System (CNS) can decrease awareness and voluntary muscle control that may affect swallowing. Group of Medication Examples Antiepileptic drugs- for mood stabilisation or seizures

Valproic acid Carbamazepine Lamotrigine Phenytoin Topiramate

Benzodiazepines – hypnotics/anxiolytics

Clonazepam Diazepam Lorazepam

Opioid Analgesia Codeine Fentanyl

Skeletal muscle relaxants- relieves muscle spasms and relaxes muscles

Baclofen

Medications that cause movement disorders that impact the muscles of the face and tongue which are involved in swallowing. (Antipsychotic medications also have antimuscarinic effects and cause dry mouth as an adverse effect). Medication Likelihood First Generation EPSE Anti-

muscarinic Sedation

Chlorpromazine ++ ++ +++ Flupentixol ++ ++ + Fluphenazine +++ ++ + Haloperidol +++ + + Pipotiazine ++ ++ + Trifluoperazine +++ + + Zuclopenthixol ++ ++ ++

Second Generation

Amisulpride ++ + + Aripirazole + 0 + Clozapine + +++ +++ Olanzapine + + +++

Paliperidone ++ + + Quetiapine + + +++ Risperidone ++ + +



Medications that cause local irritation of the oesophagus which may lead to injury. This can happen because the person is in a reclining position shortly after taking the medication or because an inadequate amount of fluid is taken with the medication. In both instances, the medications remain in the oesophagus too long, potentially causing damage and affecting swallowing. Medication Class Examples Antibiotics Clindamycin

Doxycycline Erythromycin Tetracycline

Bisphosphonates- given for osteoporosis

Alendronate

Methylxanthines- bronchodilators Theophylline Nonsteroidal anti-inflammatory drugs Aspirin

Ibuprofen Naproxen

Vitamins and Minerals Iron Containing supplements Potassium chloride supplements Vitamin C (ascorbic acid) supplements

Medications that act as local anaesthetics e.g. Benzydamine Mouth Wash/Spray which may temporarily cause a loss of sensation that may affect swallowing Where medication may be indicated regular review of the continuing need for that medication should be undertaken. Where medication is required it may be appropriate to change to a medication with less risk of causing dysphagia. Where individuals have dysphagia careful consideration should be made to administration of medication and alternative formulations to solid dose forms (tablets and capsules) may be appropriate. References and useful reading: Balzer, K. M. Drug-Induced Dysphagia. Int J MS Care 2000; 2(1); 6.

http://www.choiceandmedication.org/wlmht or www.bnf.org.uk Kelly J, Wright D Administering medication to adult patients with dysphagia. Nursing Standard. 2009;23(29):61-68. Kelly J, Wright D Administering medication to adult patients with dysphagia: part two. Nursing Standard. 2010; 24(26):61-68. Griffith, R. Advising patients with medication related dysphagia: caution required. B J Community Nursing 2005;10(11):528-31

http://www.choiceandmedication.org/wlmht

http://www.bnf.org.uk/



APPENDIX 2 Ward staff dysphagia competencies

Name of competency: Supporting clients with swallowing impairments and their carers Standard statement: Speech and Language Therapists (SLT) assess and intervene with clients experiencing difficulty swallowing liquid and solids. Clinical Support Workers have a key role to play in ensuring that SLT swallow guidelines and recommendations are adhered to and that swallow safety is maintained at all times. Learning outcomes: On completion the support worker will:

understand and recognise swallowing difficulties

demonstrate ability to provide intervention to support safe swallowing with support from the Speech and Language Therapist.

List of steps to complete: Competency/knowledge demonstrated Partially

met Fully

met/Competent

1 Demonstrate an understanding of the causes, impact and risks of nutrition and swallowing problems.

2 Demonstrate knowledge of the basic signs of difficulties with eating and drinking and an ability to report these appropriately.

3 Demonstrate an understanding of therapeutic recommendations for safer swallowing including: positioning, environment, oral hygiene and strategies.

4 Demonstrate an ability to carry out rehabilitation related to swallowing as recommended by the Speech and Language Therapist.

5 Demonstrate an ability to thicken liquids to specifications and provide information regarding modified diets.

6 Demonstrate understanding of a range of basic eating and drinking equipment and how to assist clients to use these.

7 Demonstrate an understanding of different methods of feeding.



Process or protocol – link with policy: Dysphagia Policy KSF Core 1 Communication, Core 3, Health, safety and security, Core 5 quality, Core 6 equality & diversity, HWB4 enablement to address health and well-being needs, HWB7 interventions & treatment

Sign off: Able to demonstrate all elements of the competency: Assessor’s Name: -------------------------------------------------------------------- Signature: -------------------------------------------------------------------- Clinical Support worker - I agree with the above assessment: Signature: ----------------------------------------------------------- Date: ---------------- Review date: Annually



Appendix 3 - Dysphagia screen

RISK FACTOR YES NO WEIGHTING SCORE

EA

TIN

G

AN

D

DR

INK

ING

Coughs at most meals and snacks

10

Wet gargly voice quality or changes in voice quality when/after eating/drinking

10

Sudden change in eating and drinking skills

5

RE

SP

IRA

TO

RY

RIS

KS

History of chest infections

5

Breathing difficulties/COPD

5

Known to aspirate

10

Has choked in the past 10

PH

YS

ICA

L R

ISK

S

Postural problems e.g. increased rigidity/ does not sit upright /poor head control

5

Difficulties chewing or prolonged chewing time

5

Problems with oral hygiene

5

Slurred speech and/or facial weakness

5

Any known injury/trauma to neck or throat

5

Unexplained weight loss

5

Ill-fitting dentures/poor dentition

5

RIS

KS

AS

SO

CIA

TE

D W

ITH

EA

TIN

G B

EH

AV

IOU

RS

Continues to eat or drink whilst coughing

5

Eats or drinks rapidly

10

Pockets food or drink in mouth (e.g. in cheek)

5

Swallows without chewing

10

History of deliberate airway occlusion

5

Pinches food from others/cupboards if not supervised

5

Dependent for eating or drinking

5

RIS

KS

AS

SO

CIA

TE

D

WIT

H E

AT

ING

EN

VIR

ON

ME

NT

Needs food cut up or prepared prior to eating

5

Is on a modified consistency diet

10

Requires thickened fluids

10

Will accept/put any item into mouth and swallow

5

OTHER Recent medication change has affected speech, saliva control and/or eating and drinking

10



RISK SCORE AND ACTIONS Please answer both questions: 1) Does the patient have any of the major risk factors for choking (in bold with score of

10)?

If Yes a) Meet with the multi-disciplinary team at next handover to determine whether to refer

to SLT for a swallowing assessment. b) Document decision in RIO notes c) Remember that if the patient has previously been seen by a SLT and their risk

status has increased they must be referred for a review. 2) What is the total risk score? Low Risk: no major risk factors (in bold with a score of 10) and 1-2 minor risk factors

a) Document result in RIO notes b) Staff to ensure that all food meets the service user’s requirements, seeking support

from SLT as necessary. c) Repeat the swallow screen at the next CPA or if there is any change in the service

user’s presentation, which gives rise to concern. Medium Risk: no major risk factors (in bold with a score of 10) and 3 minor risk factors or a major risk factor and 1-2 minor factors

a) MDT discussion to consider whether SLT assessment of swallowing required. Document decision in RIO notes.

b) Create care-plan based on swallow screen results documenting the supports/ adaptations required to maintain safety while eating and drinking

c) Inform MDT of the care-plan/ discuss with the service-user 3) High Risk: a major risk factor for choking (in bold with score of 10) and three or

more minor risk factors (with a score of 5) or 4 or more minor risk factors

a) Make a referral to SLT for a swallowing assessment b) Create an interim care-plan documenting supports/ adaptations to maintain safety

until seen by the SLT c) Document in RIO



APPENDIX 4 – Information about a texture modified diet - high risk food

WHY EAT A TEXTURE MODIFIED DIET?

Individuals may need to eat a texture modified diet because they are at risk of choking or

aspiration (food or liquid going into their airway).

Some reasons to suspect an increased risk of swallowing difficulties (dysphagia) include

when someone

is on a lot of medication,

has slurred or otherwise unclear speech,

has excessive saliva

has poor dentition

is generally in poor physical health.

WHAT DOES A TEXTURE MODIFIED DIET MEAN?

Guidance about modifying the texture of peoples’ diet was developed by the National

Patient Safety Agency, with representatives from nursing, speech and language therapy,

dietetics, hospital catering and industry. The guidance provides standard terminology and

definitions, used by all health professionals and food providers to ensure that people with

swallowing problems can eat safely.

FURTHER TO A SPECIALIST ASSSESSMENT YOU HAVE BEEN

RECOMMENDED TO AVOID HIGH RISK FOODS.

PLEASE AVOID THE FOLLOWING HIGH RISK FOODS:

Hotdogs

Peas, sweet corn and other fruit/vegetables with skins which have a

substantially different texture to the rest of the fruit/vegetable

Peanut butter

Dry crumbly foods such as cornbread or rice served without butter, jam,

sauce, etc.

Dry meats such as ground beef served without sauce, gravy.

Whole, raw vegetables served in large pieces

Whole hard fruits like apples or pears

Sweets

Popcorn

Hard nuts (in chocolates/salads/on their own)



APPENDIX 5 – Information about a texture modified diet - puree (texture c)





when someone




has poor dentition








FURTHER TO A SPECIALIST ASSSESSMENT YOU HAVE BEEN RECOMMENDED TO

ENSURE FOOD IS THICK PUREE (TEXTURE C), meaning food:

- does not require chewing

- smooth throughout with no ‘bits’

(no lumps, bits of shell/skin, bits of husk, particles of gristle/bone etc.)

- moist (not sticky/rubbery)

- no hard pieces, crust or skin have formed

- no fluid/gravy/sauce/custard in or on the food has thinned out or separated off.

EXAMPLES OF SUITABLE BREAKFASTS AND DESSERTS

- thick smooth porridge made from powder with no loose fluids

- Weetabix fully softened with milk fully absorbed

- thick blancmange or mousse with no ‘bits’

- Puree rice pudding

NB –NO ice cream or jelly unless advised by a speech and language therapist.



APPENDIX 6 – Information about a texture modified diet - pre-mash (texture d)





when someone




has poor dentition









RECOMMENDED TO ENSURE FOOD IS PRE-MASHED (TEXTURE D)

This means:

- food is soft, tender and moist, needing very little chewing.

- food has been mashed up before serving

- usually requires a very thick, smooth non-pouring sauce, gravy or custard

NO mixed thick-thin textures.

NO loose fluids.

NO hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy or crumbly bits.

NO pips, seeds, pith/inside skin.

NO skins or outer shells e.g. on peas, grapes.

NO husks.



NO skin, bone or gristle.

NO round or long-shaped foods e.g. sausages, grapes, sweets.

NO hard chunks e.g. pieces of apple.

NO sticky foods e.g. cheese chunks, marshmallows.

NO ‘floppy’ foods e.g. lettuce, cucumber, uncooked baby spinach leaves.

NO juicy food where juice separates off in the mouth to a mixed texture eg water melon.

EXAMPLES OF SUITABLE BREAKFASTS AND DESSERTS FOR

TEXTURE D

Bread – only if assessed as suitable by an SLT.

CEREAL

Very thick smooth porridge with no lumps

Fully softened Weetabix with milk fully absorbed

DESSERTS

Very thick smooth yoghurt (no bits)

Stewed apple in very thick custard

Soft sponge cake with smooth filling, fully softened by mashing and mixing in with very

thick,smooth non pouring custard

NO ice cream or jelly if a person requires thickened fluids because these can change to

normal fluid thickness in the mouth



APPENDIX 7 – Information about a texture modified diet fork mashable food texture e





when someone




has poor dentition









RECOMMENDED TO ENSURE FOOD IS FORK MASHABLE (TEXTURE E)

- Food is soft, tender and moist but needs some chewing.

- Food can be mashed with a fork.

- Food usually requires a thick, smooth sauce, gravy or custard.

NO mixed thick-thin textures. No thin fluid.

NO hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy or crumbly bits.

NO pips, seeds, pith/inside skin. NO skins or outer shells e.g. on peas, grapes. NO

husks.

NO skin, bone or gristle.

NO round or long-shaped foods e.g. sausages, grapes, sweets.



NO hard chunks e.g. pieces of apple.

NO sticky foods e.g. cheese chunks, marshmallows.

NO ‘floppy’ foods e.g. lettuce, cucumber, uncooked baby spinach leaves.

NO juicy food where juice separates off in the mouth to a mixed texture e.g. watermelon.

EXAMPLES OF SUITABLE BREAKFASTS AND DESSERTS FOR

TEXTURE E

Bread – only if assessed as suitable by an SLT.

CEREAL

Thick smooth porridge with no hard lumps (soft tender lumps no bigger than 15 mms are

acceptable)

Fully softened Weetabix with milk fully absorbed

DESSERTS

Thick smooth yoghurt (fork mashable or soft tender pieces of fruit no bigger than 15 mms

are acceptable)

Stewed apple in thick custard

Soft sponge cake with smooth filling, fully softened by mashing and mixing in with very

thick, smooth non pouring custard

NO ice cream or jelly if a person requires thickened fluids because these can change to

normal fluid thickness in the mouth



APPENDIX 8 - Thickening fluids

FOLLOW THE DIRECTIONS ON THE TIN OF THICKENER TO PRODUCE THE

RECOMMENDED THICKNESS.

Nectar consistency fluid Nectar consistency fluid should be prepared so that it · can be drunk through a straw · can be drunk from a cup · leaves a thin coat on the back of a spoon

Honey consistency fluid Honey consistency fluid should be prepared so that it · cannot be drunk through a straw · can be drunk from a cup · leaves a thick coat on the back of a spoon

Pudding consistency fluid Pudding consistency fluid should be prepared so that it · cannot be drunk through a straw · cannot be drunk from a cup · needs to be taken with a spoon

Any questions contact Sarah Kramer on [email protected] or on 07903 019 364

http://www.google.co.uk/imgres?imgurl=http://healthprotalk.com/wp-content/uploads/2012/07/glass-water-32.jpg&imgrefurl=http://healthprotalk.com/2012/07/16/8-glasses-of-water-a-day-is-it-necessary/glass-water-3-3/&usg=__LBd282J6ZmqgCKfXi3oDyEwWYrE=&h=1600&w=1200&sz=95&hl=en&start=20&sig2=atYoQeVvmUAsH-Eh0r8OfA&zoom=1&tbnid=553kU0uJzp6H2M:&tbnh=150&tbnw=113&ei=mQbpUbjvIIax0AXAsIHYAw&prev=/search%3Fq%3Dglass%26um%3D1%26safe%3Dactive%26hl%3Den%26tbm%3Disch&um=1&itbs=1&sa=X&ved=0CFIQrQMwEw

http://www.google.co.uk/imgres?imgurl=http://fc08.deviantart.net/fs70/i/2010/068/5/f/glass_of_water_NOW_WITH_STRAW_by_Jusseren.jpg&imgrefurl=http://jusseren.deviantart.com/art/glass-of-water-NOW-WITH-STRAW-156697808&usg=__TWTju6-t0qdiEN5Ng55k0hVzxZY=&h=1238&w=900&sz=127&hl=en&start=1&sig2=_X5P-pxyh6_6MKlSdur7lQ&zoom=1&tbnid=rB3h88yHeW75BM:&tbnh=150&tbnw=109&ei=JgfpUZ3FGIGH0AXohIDADw&prev=/search%3Fq%3Dglass%2Bwith%2Bstraw%26um%3D1%26safe%3Dactive%26hl%3Den%26tbm%3Disch&um=1&itbs=1&sa=X&ved=0CCwQrQMwAA

http://www.google.co.uk/imgres?imgurl=http://fc08.deviantart.net/fs70/i/2010/068/5/f/glass_of_water_NOW_WITH_STRAW_by_Jusseren.jpg&imgrefurl=http://jusseren.deviantart.com/art/glass-of-water-NOW-WITH-STRAW-156697808&usg=__TWTju6-t0qdiEN5Ng55k0hVzxZY=&h=1238&w=900&sz=127&hl=en&start=1&sig2=_X5P-pxyh6_6MKlSdur7lQ&zoom=1&tbnid=rB3h88yHeW75BM:&tbnh=150&tbnw=109&ei=JgfpUZ3FGIGH0AXohIDADw&prev=/search%3Fq%3Dglass%2Bwith%2Bstraw%26um%3D1%26safe%3Dactive%26hl%3Den%26tbm%3Disch&um=1&itbs=1&sa=X&ved=0CCwQrQMwAA



http://www.google.co.uk/imgres?imgurl=http://sweetclipart.com/multisite/sweetclipart/files/silver_spoon.png&imgrefurl=http://sweetclipart.com/silver-table-spoon-556&usg=__mneWp7zSMHMi01HwNYkLr6HZgZQ=&h=3467&w=7619&sz=958&hl=en&start=9&sig2=Bn-3WNzIjs1oJK24E0g5kA&zoom=1&tbnid=Ztdnw4tXln4dPM:&tbnh=68&tbnw=150&ei=0gnpUdn2FsvW7Qbpt4HoDA&prev=/search%3Fq%3Dspoon%26um%3D1%26safe%3Dactive%26hl%3Den%26tbm%3Disch&um=1&itbs=1&sa=X&ved=0CDwQrQMwCA

mailto:[email protected]



Safe use and storage of Food and Fluid thickeners

Food/fluid thickeners MUST be stored in a LOCKED cupboard to ensure

patients cannot access them.

Food/fluid thickeners MUST NOT be stored on drinks trolleys or within reach

of patients.

A poster must be attached to all drinks trolleys as a reminder that food

thickeners must not be stored on them.

A poster to highlight this risk must be attached to cupboards where the

fluid/food thickeners are stored. The poster can be downloaded from the

Exchange.

Pharmacy to put an alert sticker on the tubs of fluid/food thickeners (see

below).



APPENDIX 9 - Care plan for service user displaying one/more acute signs of aspiration.

1. Document evidence of probable aspiration (e.g. coughing) and when this was

observed (e.g. with cold drink/sandwich) in the service user’s progress notes and care plan.

2. Document in the service user’s progress notes in capital letters, and within the care plan: NEXT STEPS:

A. Observe service user when (s)he is eating/drinking for signs of aspiration, and document what is observed (whether signs of aspiration are present/absent).

B. Refer inpatients to speech and language therapist (to be seen within 2 working days). Refer community service users to SLT via their GP.

3. Provide service user and/or family members with the pamphlet ‘eating and drinking do you need help?’ as appropriate (Appendix 15 and on WLMHT G drive), and document to whom you are offering this pamphlet.

4. Make a referral to the speech and language therapist by emailing WLMHT trust SLT for inpatients of via their GP for service users in the community.



FLOW DIAGRAM - CARE PLAN FOR SERVICE USER DISPLAYING ONE/MORE ACUTE SIGNS OF ASPIRATION

DOCUMENT OBSERVED SIGNS OF OBSERVATION

REFER TO SPEECH AND LANGUAGE THERAPIST

DOCUMENT NEXT STEPS

On-going observations

PROVIDE WRITTEN INFORMATION



APPENDIX 10 - Care plan for service user displaying three/more chronic signs of aspiration.

1. Document evidence of probable aspiration (e.g. coughing) and when this was observed (e.g. with cold drink/sandwich) in the service user’s progress notes and care plan.

2. Document in the service user’s progress notes in capital letters, and within the care plan: NEXT STEPS:

a. Observe service user when (s)he is eating/drinking for signs of aspiration, and document what is observed (whether signs of aspiration are present/absent).

b. Refer inpatients to speech and language therapist (to be seen within 10 working days). Refer community service users to SLT via their GP .

3. Provide service user and/or family members with the pamphlet ‘eating and drinking do you need help?’ as appropriate (Appendix 15 and on WLMHT G drive), and document to whom you are offering this pamphlet.

4. Make a referral to the speech and language therapist by emailing WLMHT trust SLT for inpatients of via their GP for service users in the community.





FLOW DIAGRAM - CARE PLAN FOR SERVICE USER DISPLAYING THREE/MORE CHRONIC SIGNS OF ASPIRATION

DOCUMENT OBSERVED SIGNS OF OBSERVATION


DOCUMENT NEXT STEPS

On-going observations

PROVIDE WRITTEN INFORMATION



APPENDIX 11 - Care plan for service user displaying a low risk of choking 1. Question the service user and/or family members as appropriate about their

observations regarding the risks listed in the screen, and document their observations in the service user’s care plan.

2. Discuss with the service user and/or family members appropriate strategies for improving the service user’s eating habits and consider suitable environmental modifications in the delivery of meals. These should be customised to suit the service user’s presentation. Where staff would like additional guidance, they should contact the WLMHT trust SLT.

3. Ensure suitable supervision at mealtimes and where food/drink is available to the service user.

4. Document any choking incidents and ensure staff are equipped for first aid measures in case of a choking incident.

5. Document the specific risks of choking as identified in the screen, and related observations by the service user and/or the service user’s family in the service user’s progress notes.

6. Document in the service user’s progress notes in capital letters, and also within the service user’s care plan actions as identified in 2 and 3 (above).

7. Rescreen the service user where there is a marked change in health.



FLOW DIAGRAM OUTLINING CARE PLAN FOR SERVICE USER DISPLAYING A LOW RISK OF CHOKING

COLLATE OBSERVATIONS

DOCUMENT ANY CHOKING INCIDENTS & ENSURE FIRST AID MEASURES IN PLACE

ENSURE STRATEGIES IN PLACE

ENSURE SUPERVISION OF EATING AS APPROPRIATE

DOCUMENT SPECIFIC CHOKING RISKS

DOCUMENT CARE PLAN

RESCREEN WHERE MARKED CHANGE OF HEALTH



APPENDIX 12 Care plan for service user displaying a medium risk of choking

1. Question the service user and/or family members as appropriate about their observations regarding the risks listed in the screen, and document their observations in the service user’s care plan.

2. Discuss with the service user and/or family members appropriate strategies for improving the service user’s eating habits and consider suitable environmental modifications in the delivery of meals. These should be customised to suit the service user’s presentation. Where staff would like additional guidance, they should contact the WLMHT trust SLT.

3. Ensure the service user does not eat the following high risk foods:

Hotdogs

Grapes and other fruit/vegetables with skins which have a substantially different texture to the rest of the fruit/vegetable

Peanut butter

Dry crumbly foods such as cornbread or rice served without butter, jam, sauce etc.

Dry meats such as ground beef served without sauce, gravy.



Sweets

Pop corn

Hard nuts (in chocolates/salads/on their own) 4. Ensure suitable supervision at mealtimes and where food/drink is available to

the service user. 5. Document any choking incidents and ensure staff are equipped for first aid

measures in case of a choking incident. 6. Document the specific risks of choking as identified in the screen, and related

observations by the service user and/or the service user’s family in the service user’s progress notes.

7. Document in the service user’s progress notes in capital letters, and also within the service user’s care plan actions as identified in 2, 3 and 4 (above).

8. Where further guidance is required refer the service user to the WLMHT speech and language therapist (inpatients) or to a SLT via their GP (service users in the community)

9. Rescreen the service user where there is a marked change in health.



Flow diagram outlining care plan for service user displaying a medium risk of choking



DOCUMENT ANY CHOKING INCIDENTS AND ENSURE FIRST AID MEASURES IN


DOCUMENT PLAN OF ACTION IN CARE PLAN

ENSURE APPROPRIATE DIET AND SUPERVISION OF EATING AS APPROPRIATE



APPENDIX 13 Care plan for service user displaying a high risk of choking 1. Question the service user and/or family members as appropriate about their

observations regarding the risks listed in the screen, and document their observations in the service user’s care plan.

2. Discuss with the service user and/or family members appropriate strategies for improving the service user’s eating habits and consider suitable environmental modifications in the delivery of meals. These should be customised to suit the service user’s presentation. Where staff would like additional guidance, they should contact the WLMHT speech and language therapist.

3. Ensure the service user does not eat the following high risk foods:

Hotdogs

Grapes and other fruit/vegetables with skins which have a substantially different texture to the rest of the fruit/vegetable

Peanut butter

Dry crumbly foods such as cornbread or rice served without butter, jam, sauce, etc.

Dry meats such as ground beef served without sauce, gravy..



Sweets

Pop corn

Hard nuts (in chocolates/salads/on their own) 4. Ensure suitable supervision at mealtimes and where food/drink is available to

the service user. 5. Document any choking incidents and ensure staff are equipped for first aid

measures in case of a choking incident. 6. Document the specific risks of choking as identified in the screen, and related

observations by the service user and/or the service user’s family in the service user’s progress notes.

7. Document in the service user’s progress notes in capital letters, and also within the service user’s care plan actions as identified in 2, 3 and 4 (above).

8. Refer the service user to the WLMHT speech and language therapist (inpatients) or to a speech and language therapist via their GP (service users in the community), and document the referral in the service user’s progress notes.



Flow diagram outlining care plan for service user displaying a high risk of choking


DOCUMENT ANY CHOKING INCIDENTS & ENSURE FIRST AID MEASURES IN PLACE


ENSURE APPROPRIATE DIET AND SUPERVISION OF EATING AS

APPROPRIATE


DOCUMENT PLAN OF ACTION IN CARE PLAN




APPENDIX 14: Poster

Dysphagia poster A3.pdf

APPENDIX 15 Requirements for service

Essence of Care Benchmarking

• Screening: individuals identified as at risk on screening have a full nutritional

assessment

• Care: care is planned, implemented, continuously evaluated and revised to meet

individual needs and preferences for food and drink

• Assistance: individuals are provided with the care and assistance they require

with eating and drinking

• Provision: food and drink is provided to meet an individual’s needs and

preferences

• Promoting Health: individuals are encouraged to eat and drink in a way that

promotes health

CQC’s Essential Standards of Quality and Safety

Compliance to these regulations will:

• Reduce the risk of poor nutrition and dehydration by encouraging and supporting

people to receive adequate nutrition and hydration.

• Provide choices of food and drink for people to meet their diverse needs, making

sure the food and drink is nutritionally balanced and supports their health.

BAPEN make the following recommendations, based on the NICE Nutrition

Support

Guidelines

• Nutritional screening should be undertaken in:

i. All hospital inpatients - on admission and weekly or when there is clinical concern

ii. All hospital outpatients - at first outpatient appointment and where there is clinical

concern

iii. All residents of care homes - on admission and repeated monthly given the high

prevalence and general frailty of residents (particularly in nursing homes)

iv.At initial registration in GP surgeries, annually for those aged over 75 years,

where there is clinical concern, and at other opportunities such as health checks or

vaccinations



∙It is however also important to identify nutritional risk in care settings beyond those

addressed by NICE including day care, sheltered housing and domiciliary settings.

• Agreed local procedures and policies should be in place which ensure that

a detailed nutritional assessment is undertaken and recorded for all individuals

identified as malnourished, or at risk of malnutrition, when screened.

• Care plans: All individuals identified as malnourished or at risk should have an

appropriate care plan containing clearly identified goals of treatment which must be

recorded. This may include social measures to ensure provision of meals, help with

cooking or feeding, food and fluid intake records, modified menus, dietetic advice,

oral nutritional supplements and or

artificial nutritional support. They should then be monitored to ensure goals are met

with further action as necessary.

• Discharge/transition planning: the flow of nutritional information from one

setting to another is crucial to the delivery of good nutritional care.

• Training: All healthcare professionals should receive appropriate training in the

importance of nutritional care, how to screen for malnutrition, basic nutritional care

measures and the indications for onward referral for nutritional assessment and

support.

• Multi-disciplinary teams: MDTs are needed to ensure that care pathways are

appropriate and followed.

CQC 10 key issues in nutritional care

1. Fair access to care How do you ensure fair access to nutritional

screening, assessment and care:

a) Does your Trust have a nutrition team?

b) Do you provide multidisciplinary nutritional services across all areas to ensure

equality of access?

c) Do you undertake nutritional screening across all wards/departments/ care

homes/ areas of the community?

2. Person centred care: How do you ensure that your service supports users’

independence?

a) Are service users well informed about the nutrition services you provide and the importance of good choice and nutritional care? b) Do service users contribute to the design of your nutritional care pathways?

3. Prevention and early intervention: How have you ensured that your organisation: a) Embeds prevention of malnutrition into the public health agenda? b) Detects malnutrition early, in all areas?



c) Delivers effective early interventions to treat malnutrition?

4. Reducing health inequalities: How are you ensuring that: a) Individuals living in lower socio economic groups can access services? b) You identify high nutritional risk groups?

5. Tackling poor performance: How do you ensure that: a) All nutritional care delivered in your organisation is evidence based and safe? b) Management of an individual’s fluid balance is safe and appropriate to their needs to avoid dehydration and fluid overload? c) Outcome measures that you collect, across all areas, demonstrate that the care delivered is effective?

7. Staff training: How do you ensure that: a) Staff within your organisation are trained to deliver nutritional screening, assessment and care? b) You can demonstrate that staff have the required competencies to deliver safe nutritional care? NICE. Nutrition Support in Adults: oral nutrition support, enteral tube feeding and parenteral nutrition, CG32. London, National Institute for Health and Clinical Excellence. 2006. (Accessed on October 8, 2009, at http://guidance.nice.org.uk/CG32/niceguidance/pdf/English ) Care Quality Commission. Guidance about compliance, essential standards of quality and safety. What providers should do to comply with the section 20 regulations of the Health and Social Care Act (2008). December 2009. (Accessed on February 6, 2010, at http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_FINAL_081209.pdf.) Department of Health. Essence of Care; a consultation on the reviewed original benchmarks. 2009, pp51-54 (Accessed on February 20, 2010, at http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_103060.pdf.) Care Quality Commission. Our Strategy for 2010-15. 2009. (Accessed on March 17, 2010, at http://www.cqc.org.uk/_db/_documents/Strategy_2010-2015_tagged.pdf

http://www.google.com/url?q=http%3A%2F%2Fguidance.nice.org.uk%2FCG32%2Fniceguidance%2Fpdf%2FEnglish&sa=D&sntz=1&usg=AFQjCNEA9ga2brQAQbjsvLN3zEvcfdqjvw

http://www.google.com/url?q=http%3A%2F%2Fwww.cqc.org.uk%2F_db%2F_documents%2FEssential_standards_of_quality_and_safety_FINAL_081209.pdf&sa=D&sntz=1&usg=AFQjCNE3Wgam1yJEmeq-xCX2FfUOav2Fkg

http://www.google.com/url?q=http%3A%2F%2Fwww.cqc.org.uk%2F_db%2F_documents%2FEssential_standards_of_quality_and_safety_FINAL_081209.pdf&sa=D&sntz=1&usg=AFQjCNE3Wgam1yJEmeq-xCX2FfUOav2Fkg

http://www.google.com/url?q=http%3A%2F%2Fwww.dh.gov.uk%2Fdr_consum_dh%2Fgroups%2Fdh_digitalassets%2Fdocuments%2Fdigitalasset%2Fdh_103060.pdf&sa=D&sntz=1&usg=AFQjCNFldB9q3M0MMn4RMe62MKlkASkXmQ

http://www.google.com/url?q=http%3A%2F%2Fwww.dh.gov.uk%2Fdr_consum_dh%2Fgroups%2Fdh_digitalassets%2Fdocuments%2Fdigitalasset%2Fdh_103060.pdf&sa=D&sntz=1&usg=AFQjCNFldB9q3M0MMn4RMe62MKlkASkXmQ

http://www.google.com/url?q=http%3A%2F%2Fwww.cqc.org.uk%2F_db%2F_documents%2FStrategy_2010-2015_tagged.pdf&sa=D&sntz=1&usg=AFQjCNFK9m0Xf791omWXbO4RtHcpFSfChQ



APPENDIX 16 Risk Feeding Form and Guidance

NAME: DOB NHS NO.

RISK FEEDING GUIDELINES

(BASED ON THOSE OF QEH, LEWISHAM AND GREENWICH NHS TRUST)

These guidelines have been set out and agreed as the above named patient is at high risk of aspiration but is to continue

eating and drinking for the reasons outlined below.

The above patient is at risk of food and fluids entering his/her lungs as a result of a poor swallow.

As discussed with the medical team, the above named person is not appropriate for long term non-oral feeding due to (tick all those

applicable):

Palliative Care (eg: poor prognosis / short life expectancy)

Procedure risks outweigh benefits

Patient has declined artificial nutrition and hydration

Other: __________________________________________________

Capacity Assessment: The patient is able to:

yes no

understand the information relevant to the decision □ □

retain that information □ □

use or weigh that information as part of the process in arriving at the decision □ □

communicate the decision □ □

Based on the above assessment, the patient does/does not (delete as appropriate) have capacity in making a decision regarding

nutritional management

Signature of Patient/SLT/Doctor: ____________________Date of capacity assessment:________________

If a patient lacks capacity an MDT decision must be made and documented in the notes □ yes □ no

Feeding with the associated risk of possible aspiration pneumonia has been discussed with the patient/patients

family/Independent Mental Capacity Advocate (IMCA) □ yes □ no

RISK REDUCING RECOMMENDATIONS (to be completed by Speech & Language Therapist)



Fluids

Thin fluids

(normal)

Naturally Thick fluids

Stage 1 fluids

Stage 2 fluids

Stage 3 fluids

Food

Puree

Soft moist

Soft

Normal

Strategies

SpR/Consultant: _________________________________ Signature: _______________________

Speech and Language Therapist: _____________________ Signature: _______________________

Please contact Speech and Language Therapy if the management plan or risk feeding decision changes.

Guidelines for use of Risk Feeding Form

The medical team may decide that risk feeding is the preferred option prior to a

SALT assessment. The protocol needs to be printed from the intranet. A referral will

need to be made to SLT.

The SLT or Medical Team member is responsible for conducting a capacity

assessment for establishing a method of nutrition. The aspects within establishing

capacity, listed on the risk feeding form needs to be assessed. When SLT are

conducting the capacity assessment appropriate communication aids should be

used.

The SLT will need to discuss the capacity status and swallow assessment findings

with a member of the Medical Team (SpR or Consultant) before a risk feeding

decision is documented. If it’s a best interest decision, it is essential that this is

signed by a consultant.

An entry on the decision needs to be documented clearly in the progress notes with

the form filed in the report section on RIO.

If a patient is going to be risk fed the SLT will need to inform the Physiotherapist so

that chest intervention can then be discussed with the Medical Team.

It is essential that the decision is communicated to the patient/family/carers/

significant others. This can be done via the Medical or SLT Teams.



References Finucane TE, Christmas C, Colleen TK. (1999). Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 282(14) 1365-1370. Gillick MR. (2000).Rethinking the role of tube feeding in patients with advanced dementia. The New England Journal of Medicine 342: 206-210. GMC (2000) Withholding and withdrawing life prolonging treatments – good practice in decision-making. Ina L (2002).Feeding tubes in patients with severe dementia. American Family Physician Kim Y (2001). To feed or not to feed: tube feeding in patients with advanced dementia. Nutrition Reviews 5913; 86. Lennard-Jones JE (2000).Ethical and legal aspects of clinical hydration and nutritional support. BMJ 85(40) 398-403. Mental Capacity Act (2005) Mitchell S, Kiely DK, Lipsitz LA. (1997).The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Archives of Internal Medicine 157(3) 327-332. NICE (2006) Guidelines o palliative care and dementia. RCP (2010) Guidelines on oral feeding difficulties and dilemmas. Sherman FT (2003).Nutrition in advanced dementia. Tube feeding or hand feeding until death? Editorial. Geriatrics 58, 11: 10. Skelly RH (2002).Are we using percutaneous endoscopic gastrostomy appropriately in the elderly? Current Opinion in Clinical Nutrition and Metabolic Care. 5(1) 35-42.



Appendix 17: Modified texture food/fluids and thickening products: Selection, ordering and monitoring procedure

Ward team perform dysphagia screening and it indicates possible swallowing problem

Ward team refers to SLT for swallowing assessment

Ward team identify a nutritional problem

Ward team refers to dietitian for assessment

SLT completes swallowing assessment

and dysphagia care plan devised as appropriate

Dietetic assessment and nutrition care plan devised as

appropriate

And/or

SLT selects appropriate thickener/pre-thickened

drink/texture modified diet as appropriate

Dietitian completes nutritional assessment and devises nutrition

care plan, selecting supplements as appropriate

SLT to liaise with dietetics if there are nutritional considerations with the dysphagia

care plan.

SLT to notify dietetics if the patient has a diagnosis of diabetes or kidney difficulties.

NB: This can take place at any point in this process

Dietitian (PGD trained)

or qualified prescriber (consulting with dietitian) adds supplements

to prescription chart

Dietitian orders supplements from Pharmacy and monitors patient’s nutrition

Dietetics to liaise with SLT if there are concerns re: swallowing.

NB: This can take place at any point in this process

Ward team alerts dietitian if supplements stock run low and dietitians reorder from

Pharmacy

NB: The Limes can directly reorder from pharmacy

Ward staff monitor the dysphagia care plan and liaises with SLT if there is a change to the patient’s presentation or the

team need further advice or support.

Initial Ordering of Thickener

Ward staff order and copy SLT in. Pharmacy will only respond to new

orders if the SLT is copied in

Ordering texture modified diets or pre-thickened drinks:

Downgrading texture modified meals: Either

SLT, a dietitian or ward staff can order. If ward staff are ordering they must copy SLT in

Upgrading texture modified meals: Only to be

ordered by SLT

Pre-thickened drinks: Only to be ordered by SLT