Dysphagia Sheffield Care Home Conference 19 September 2019 - - PowerPoint PPT Presentation

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

• f 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

When we’re buddying people or introducing them to the job, we do, specifically when we’re giving out meals, we’re saying to people, you know, you don’t just slop food on somebody’s plate; it must look presentable and nice because you’re giving it to somebody to eat. I wouldn’t eat that! You don’t do that in your own home. So we do train people to be aware of these things. Focus group ‘ ‘ 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 that more than you’re going to remember reading something ‘ Focus Group ‘ They talk about us as if we’re proper chefs. Everything I do is self- taught , which was enough when it was a basic care home , but now they are going up the ladder, I don’t feel I’ve got that 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 ?

IDDSI Fluid & Diet Descriptors 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 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

Diet: Regular Level -Easy Chew

• Normal everyday foods of

soft / tender texture

• Often softened with gravy /

sauce .

• Can cut with side of fork

and apply Fork Pressure Test

• Avoid hard, tough, chewy,

fibrous , stringy , gristle or stones

• No size restriction.

Foods to Avoid – Regular Level -Easy Chew

Avoid foods that are ▪ Hard or dry ▪ Tough / fibrous ▪ Crispy / Crunchy ▪ Sharp / Spiky ▪ Bone / Gristle ▪ Pips / seeds ▪ Sticky / gummy ▪ Stringy

Diet: Regular – Level

• Normal everyday foods of

varying textures

• Ability needed to bite off

pieces of food alongside the ability to chew hard and soft foods , without tiring

Diet : Transitional Foods

• Food changes to

another texture when moistened ( wafer) or heated ( ice - cream )

• Use Fork Pressure Test
• Minimal chew required
• Can be used alongside

Level 5 - 7 - Easy chew

Things to remember

• You need to know both diet and fluid Levels re: gravies , sauces ,

nutritious drinks and soups

• SLT Diet recommendations are generally ‘up to and including’
• Level 4 = Level 3 & 4 ( and maybe 0 – 2 – check fluid advice )
• Level 5 = Level 3, 4 & 5 ( and maybe 0- 2)
• Level 6 = Level – 5 ( and maybe 0-2)
• Check with the SLT if you are in doubt whether someone can have a

specific item of food fits outside the IDDSI level

• Can they manage any Transitional foods ?
• Try and incorporate as much variety as possible in terms of

appearance , flavour , temperature and texture within your limits .

Pureed Meal / Level 4 – Using Mould

Wilshire Farm Foods

Pureed Meal / Level 4 Using Mould

www.acticare.com

Workshop/ discussion

• How can we improve our management of

dysphagia to improve QOL and safety at each level of the organisation

• Sharing ideas - Finding solutions

Care Home Dysphagia Guide

https://vimeo.com/288403121 Password: watchfilm