Supporting Residents with Dysphagia Sheffield Care Home Conference 19 September 2019 Elizabeth Barnett, Speech and Language Therapist - Care Homes Liaison STHFT
Plan of session • What is Dysphagia ? • Management of Dysphagia in a care home setting • International Dysphagia Diet Standardisation Initiative IDDSI - Descriptors for diet and fluids • Sharing ideas - Finding solutions – workshop • Questions
Dysphagia / Swallowing Problems • What is dysphagia / What isn’t dysphagia ? • Common issue • Impacts on health and well-being • Context • An ‘avoidable harm’
Management of Dysphagia ▪ Relatively simple strategies if consistently practiced make a huge difference to someone’s experience and safety Environment , positioning , equipment , Assistance , diet and drink texture modification ▪ Key role of care and kitchen staff ▪ Whole systems approach ▪ Partnership ▪ Meeting the challenges
Guidance Available • CQC Outcome 5 - Meeting Nutritional Needs • Skills for Care - Induction • NHS England Patient Safety Alert June 2018 • International dysphagia descriptors Initiative Frame work, 2018 http://iddsi.org/ • Inter-Professional Dysphagia Competency Framework, Boden 2006 • RCSLT Guidance on the Management of Dysphagia in Care Homes, 2018 • Royal College of Physicians Jan 2010, Oral Feeding Difficulties and Dilemmas – A guide to practical care, particularly towards the end of life Report of a working party. National End of Life Care Strategy , DoH 2008
Managing dysphagia in a care home setting - Barriers and facilitators Research Study – Funded by Abbeyfield Foundation IRAS Project ID 215697 ‘A literature and consensus based approach to the development of a dysphagia management protocol in the care home setting’ Publication Pownall, S., Barnett, E., Skilbeck, J., Jimenez-Aranda, A., Fowler-Davis, S. (2019) The Development of a Digital Dysphagia Guide with Care Homes: Co-production and Evaluation of a Nutrition Support Tool . Geriatrics, 4(3), 48: https://doi.org/10.3390/geriatrics4030048 Participating Homes HC- One – Ascot Lodge Sheffcare – Castelayn Palmsrow – Westbourne Scarsdale Grange LLP – Scarsdale Grange
Key Themes ▪ Training ▪ Food Production & Presentation ▪ Quality & Safety ▪ Workforce ▪ Themes cut across all 3 levels of the organisation ▪ Resident level - Resident experience of care / food ▪ Care Home level - Care home operational planning ▪ Organisational level - Policy/Strategy ▪ All interlinked requiring systems approach
‘ ‘ Whereas if you’ve got to physically make a drink for somebody, you’ve got to do a fork-mashable diet, you’re going to remember When we’re buddying people or introducing that more than you’re going to remember them to the job, we do, specifically when we’re reading something ‘ giving out meals, we’re saying to people, you Focus Group know, you don’t just slop food on somebody’s plate; it must look presentable and nice because ‘ They talk about us as if we’re proper chefs. you’re giving it to somebody to eat. I wouldn’t Everything I do is self- taught , which was enough eat that! You don’t do that in your own home. So when it was a basic care home , but now they are we do train people to be aware of these things. going up the ladder, I don’t feel I’ve got that Focus group qualification’ Focus Group
‘What’s this, what I'm eating now? Don’t you know? I said if I'd have known I wouldn't have asked you. She said it's trout .’ Resident : Interview ‘Basically it looks as though someone’s got either a decent-sized ladle [unclear] food or a ladle, and put it out and it’s just sort of settled into different sort of round-ish, oval-ish shapes.’ Focus Group
‘From what I've seen, you know, there’ve been times when things have been very similar and there’s not been much of a choice’. Focus Group ‘ it’s hard to find snacks and I was just wondering: is that a situation in - It’s hard— isn't it? — if somebody's not able to eat cake or bread or a bun or biscuit’ Focus Group ‘ it would be nice to have good recipes for you guys, I mean we’ve got good cooks here, but I mean as in ways of doing things that you might not thought of doing’ Focus Group ’
‘We will monitor them, not for too long, and probably we will try a little bit of adjustments with the initial sort of diet and drinks to see, I know it’s not a quick fix but sometimes it seems to take weeks to see the SALT, and in those weeks there’s more weight loss. We can't give a soft diet unless we’re told to give a soft diet so sometimes some people will be struggling and then they’ll be struggling for a while and then your referral goes in. Then, as you know, it can take up to three or four weeks to get a speech therapist out’ Focus Group
‘The problem isn't knowing what stage one, what stage two, what stage three is; the problem is being sure who’s on what stage. That can be the issue. Particularly, you know, if you’ve got a rota where there’s a lot of newer people on ‘ Focus Group ‘This is why I think if you’ve got something that’s a clear visual chart that’s easy to update and that people can look at at a glance’. Focus Group
‘ ‘For them, it’s not about so much how to do it, - It's more about giving them the time to go and do it ’ Manager : Interview ‘ It’s having the time to – I mean if you’re in the kitchen on your own… cooking 50 odd meals, and to actually stop and do a blending from start to finish can take you an hour out of your day ‘ Focus Group ‘ Having on of those blenders would be an amazing thing. You could do it’ Focus Group
Texture Modified Diets and Drinks ▪ How does altering the texture help ? ▪ Diet – Reduces the need to chew as much ▪ Drinks – Gives the body more time to swallow safely ▪ Pros and cons
Why do we need standardised terms to describe texture modified diet and fluids ? Patient Safety Alert NHS/PSA/2018/004 June 2018 Over a 2 year period – confusion over the meaning of the term ‘soft diet’ caused 7 incidents of significant harm including choking and aspiration pneumonia and resulting in 2 deaths Actions: ❑ All organisations providing NHS funded care to eliminate use of imprecise terminology including ‘ soft diet’ ❑ Transition to IDDSI Terminology by April 2019
Examples of texture modified diets served ‘ Soft Diet ’ ‘Pureed Diet ‘
What is IDDSI ? The International Dysphagia Diet Standardisation Initiative ( IDDSI) is a global standardised terminology and definitions to describe texture modified foods and thickened liquids for individuals of all ages in all care settings , and all cultures It is to be used world wide by April 2019 IDDSI Fluid & Diet Descriptors Official IDDSI website https://iddsi.org/
IDDSI Tests • Syringe test • Fork Pressure Test • Spoon tilt test
Thin Fluid -Level • Flows like water • Fast flow ❑ Water, squash, tea, coffee
Slightly Thick /- Level • Thicker than water / milk • Flows through a straw • IDDSI Flow Test ➢ leaves 1- 4 ml after 10 secs • Smoothies , milk shakes
Mildly Thick – Level • Flows off a spoon. • Pours quickly from a spoon, but slower than thin drinks. • Effort needed to drink through standard bore straw ( 5.3 mm diameter) • IDDSI Flow Test ➢ leaves 4 - 8ml after 10secs ❑ Thick smoothies, milkshakes
Moderately Thick – Level • Can be drunk from a cup or a spoon. • Some effort needed to suck through straw – standard or wide bore 5.3 / 6.9mm • IDDSI Flow Test : ➢ leaves > 8 ml after 10 secs ➢ Same texture as Diet - Liquidised / Level 3 ❑ Thick smooth soups
Extremely Thick - Level • Cannot be poured from a cup, or sucked through a straw. • Use a spoon • Same texture as Pureed / Level 4
Diet : Liquidised - Level • Completely smooth texture • Drips through prongs of fork • Spreads on plate. • Can be drunk from mug • No chewing / oral processing required. Can be swallowed directly ❑ Thick smooth soups , runny yogurts
Diet : Pureed - Level • Completely smooth texture • Cohesive to hold shape on spoon. • Can be piped, layered, or moulded. Prongs of fork make clear pattern on surface. • Not sticky- should fall from tilted spoon. • Liquid must not separate from solid. • Gravy / sauces can be used – ( Levels 2 - 3 ) Ask SLT to specify • No biting or chewing required
Diet: Minced & Moist – Level • Can be eaten with a fork or spoon • Can be scooped and shaped on plate • Soft and moist with no separated thin fluid – Serve with gravy or sauce ( Level 2 – 3 ) – Ask SLT to specify • Easy to squash on the tongue • Minimal chewing required • Food particles should be no bigger than 4mm • If pressed with a fork – food should be able to go through prongs ❑ Bread – Only if soaked ( e.g in soup )
Diet: Soft& Bite-sized – Level • Soft tender and moist throughout. • Can be eaten with a fork, spoon , or chopsticks • Pre - cut into 1.5 cm piece – size of thumb nail • Can be mashed / broken down with pressure from fork / spoon • SLT to assess individual ability for gravy’s , sauces or for foods with high water content (liquid separates when chewing) ❑ No bread unless soaked or advised by SLT
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