CNTW(C)26 · CNTW(C)26 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)26 – Management of Dysphagia Policy-V03.4-Oct 19 3 2.8 Nutrition is a vitally important

CNTW(C)26

Executive Policy Title Policy for the Multi-disciplinary management of eating,

drinking and swallowing difficulties (Dysphagia)

Policy Reference Number

CNTW(C)26

Lead Officer Executive Director of Nursing and Operations

Author(s) Fiona Johnstone – Speech and Language Therapist

Ratified By Trust-wide Policy Group

Date Ratified April 2015

Implementation date May 2015

Date of full implementation

May 2015

Review date Oct 2019

Version Number V03.4

Review and Amendment Log

Version Type of change

Date Description of change

V03.2 Extension Oct 18 Extension in review, transformation work

V03.3 Extension April 19 Extension in review

V03.4 Extension Oct 19 Extension in review till Apr 20 and governance changes

This policy supersedes:

Reference Number Title

CNTW(C)26 – V03.2 Dysphagia Policy

CNTW(C)26

Management of Dysphagia

Section Contents Page No:

1 Introduction 1

2 Purpose 1

3 Duties and Accountabilities 3

4 Quality Assurance 6

5 Resource Requirements 6

6 Safety and Legal Issues 8

7 Consent 9

8 Identification of Stakeholders 11

9 Implementation 11

10 Equality Impact Assessment 11

11 Standard Key Performance Indicators 12

12 Monitoring Compliance 12

13 Training 12

14 Fair Blame 12

15 Associated Documentation 13

Standard appendices attached to policy

A Equality and Diversity Impact Assessment 14

B Training and Communication Checklist 16

C Audit and Monitoring Tool 18

D Policy Notification Record Sheet - click here

https://www.ntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

CNTW(C)26

Appendices – listed separate to policy

Management of Dysphagia = MoD

Appendix No:

Description

Appendix 1 MoD in Children with a Learning Disability (Newcastle)

Appendix 2 MoD in Adults with a Learning Disability in Community (Newcastle and Sunderland)

Appendix 3 MoD in Adults with Acquired Brain Injury (Walkergate Park)

Appendix 4 MoD in Inpatient areas excluding adult with acquired brain injury

Practice Guidance Note – listed separate to policy

PGN No: Description

DP-PGN-01 Speech and Language Therapists–LD-Dysphagia referral checklist

1 INTRODUCTION 1.1 Cumbria Northumberland Tyne and Wear NHS Foundation Trust (The

Trust/CNTW) is committed to providing the highest standards of healthcare for all service users. This policy is intended to ensure the high standards of care maintained by the Trust.

1.2 Whilst the clinical process may differ depending on the service user group

and the setting in which they receive their care, the core principles are the same (see separate appendices for specific service user services Section 2.8). The key objective is to ensure the safety of individuals who have eating, drinking and swallowing disorders.

2 PURPOSE

2.1 CNTW is committed to providing the highest standards of care to all service

users. As part of that care, staff must be able to recognise and care for a service user who has swallowing difficulties, from a sudden onset or as part of a long-term problem.

2.2 This policy provides clinical guidance to ensure the health and safety of

service users with dysphagia of CNTW inpatient wards and CNTW Sunderland and Newcastle Community Team LD).

2.3 Some service users with dysphagia are supported in the residential settings by CNTW staff. In these cases, CNTW staff should work within the framework of this protocol. The CNTW staff should be instrumental in identifying dysphagia and referring to appropriate community agencies.

2.4 Disruption of swallowing can have serious effects impacting on physical health, with complications such as malnutrition, pulmonary aspiration (fluid or food going into the lungs), and the emotional and psychological problems associated with not being able to eat normally. If not recognised and managed correctly, dysphagia can be fatal.

2.5 The term dysphagia is used to refer to eating, drinking and swallowing

problems arising from a wide range of acquired and congenital causes. These problems include: orophanyngeal structural problems, motor processing difficulties, problems arising from the effects of medication, neurological disorders, phanyngo-oesophageal problems, poor oral health, mental health problems and psychological conditions (includes information from NPSA 2006)

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Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)26 – Management of Dysphagia Policy-V03.4-Oct 19

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2.6 Implications of dysphagia 2.6.1 If not managed properly, swallowing problems can lead to:

Malnutrition

Dehydration

Poor oral health

Poor healing of wounds

Increased fatigue

Decreased concentration

Reduced development and growth

Increased risk of social isolation

Reduced quality of life

Distress

Choking

Chest infections/pneumonia

Premature death

2.7 Aims of a multidisciplinary approach to managing eating, drinking and swallowing difficulties service are:

To provide a comprehensive, evidence based and responsive service to people presenting with swallowing disorders, including taking a central role in the promotion of health and well-being

To assess, diagnose, request and interpret diagnostic tests, to refer to other agencies as appropriate, provide a management plan and to discharge

To be a first point of contact for patient care, including single assessment (where indicated.)

To facilitate intervention by the multi-disciplinary team extending and improving collaboration with other professions and services

To engage in MDT discussion and decision making, along with service users, carers and families as appropriate, regarding quality of life, service user wishes and Best Interest Decisions in complex risk management cases. This includes when a service user is risk feeding (unsafe on all oral consistencies), end of life or risk feeding protocols where appropriate

To take an active role in strategic planning and policy development for services to clients presenting with swallowing disorders

To provide training and education for, professionals and carers involved in the care of clients with dysphagia

To develop and apply the best available research evidence and evaluative thinking in all areas of practice

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2.8 Nutrition is a vitally important aspect of our lives. Nursing staff have an

important role to play to ensure that food provided is nutritious and well presented, as well as the appropriate consistency and that service users find eating/drinking safe as well as an enjoyable and pleasant experience.

2.9 It is important that service users with known swallowing difficulties and/or those with known behaviours that could affect the safety of the swallowing process, receive appropriate management for their difficulties to reduce the risk of complications. This includes being offered the recommended texture modified diet/consistency to reduce the possible risks.

2.10 This policy applies to all staff employed by or working in the Trust. The policy will apply wherever care is given; this may be hospital premises, CNTW residential settings, the client’s home, or another designated area.

2.11 The policy for the Multi-disciplinary management of eating, drinking and

swallowing difficulties (Dysphagia) includes the following appendices relating to specific service areas -

Management of Dysphagia in Children with a Learning Disability (Newcastle)

Management of Dysphagia in Adults with a Learning Disability in Community (Sunderland and Newcastle)

Management of Dysphagia in Adults with Acquired Brain Injury (Walkergate Park)

Management of Dysphagia in individuals on inpatient wards (excluding acquired brain injury)

3. Duties and Accountabilities

3.1 The Senior Management Team are accountable to the Trust Board for

ensuring the Trust-wide compliance with Policy. 3.2 Locality, Associate Directors and Corporate managers are responsible for the

application and compliance of staff within their services with the Policy. 3.3 Inpatient/Residential Associate Directors:

Associate Directors are responsible for staff, within their areas of responsibility, having an awareness of recognising and managing service users who are at risk of dysphagia and choking

Referring the service user to the appropriate member(s) of the Multi-Disciplinary Team (MDT) for further assessment and advice

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Reporting choking incidents using the Trust’s Safeguard Incident Reporting System and investigates, involving the multidisciplinary team

3.4 Inpatient/Residential Services Clinical Staff

It is the responsibility of clinical staff to be aware of service users who may be at risk of eating and drinking difficulties by completing a risk assessment and taking appropriate action to reduce the risks whilst meeting the nutritional and hydration needs of the individual

Referring the service user to the appropriate member(s) of the MDT for further assessment and advice

Reporting of choking/ eating and drinking incidents and contributing to the investigation of incidents

3.5 Dysphagia Qualified Practitioner (Dysphagia Trained Speech and

Language Therapists and/or dysphagia trained nurses)

When required, these Dysphagia Qualified Practitioner will complete a comprehensive assessment of a service user’s eating, drinking and swallowing skills and advise staff on the service user’s requirements and safe swallowing management

They will also assess the risk from any cognitive factors that could compromise the safety of the swallowing process

They will provide training for clinical and non-clinical staff as identified

o They will refer the service user to the appropriate

member(s) of the MDT for further assessment and advice

3.6 Dietitian

‘If the completed nutrition screening tool indicates, a referral to dietetics is made and the Dietitian will assess, advise and monitor the individual’s diet, in order to meet nutritional needs’

They will refer the service user to the appropriate member(s) of the MDT for further assessment and advice as required

3.7 Physical Health Nurse

The Physical Health nurse will advise about the impact of any physical health difficulties on swallowing, eating and drinking

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and provide specific and supporting information in relation to the service user’s medical treatment

They will refer the service user to the appropriate member(s) of the MDT for further assessment and advice as required

3.8 Estates and Facilities staff for inpatients

Estates and Facilities staff will ensure that appropriate meals are available for service user’s with swallowing difficulties in the appropriate textures, including snacks and finger foods

They will ensure that additional items recommended by Dysphagia Qualified Practitioner, and dietetics, are ordered

The Dysphagia Practitioner would liaise with the person who orders meals/snacks for the ward to ensure the appropriate food consistencies were ordered for service users

3.9 Pharmacy

Will ensure that an appropriate range (different stages and flavours) of pre-thickened drinks, thickener and liquid medications are available and easily accessible within inpatient services within the Trust.

Will provide pharmaceutical advice on presentations/formulations of medicines for people with dysphagia and prescription of thickeners

Will provide access to advice and information about medicines which may increase the risk of dysphagia

3.10 Physiotherapist

The Physiotherapist will assess, advise and monitor the service user’s posture, seating and chest care, in order to meet nutritional needs and dysphagia management.

They will refer the service user to the appropriate member(s) of the MDT for further assessment and advice

3.11 Occupational Therapist

The Occupational therapist will assess, advise and monitor the service user’s daily living skills around mealtimes and snacks, including utensil use and appropriateness, in order to meet nutritional needs and swallowing problems.

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3.12 Medic

Medics will assess overall health needs of the service user and continue to monitor

They will prescribe thickener when needed, and refer the service user for further assessments as required, for example, for videofluoroscopy, to gastroenterology. They will also consider medication use and review within the MDT in consideration of swallowing difficulties following assessment and advice from Speech and Language Therapist (Dysphagia Qualified Practitioner)


4 QUALITY ASSURANCE

4.1 All Dysphagia Qualified Practitioners will be registered Speech and Language

Therapists or Qualified Nurses who have undertaken further dysphagia training.

4.2 There is a minimum requirement of a post-graduate dysphagia course or

equivalent training with supervision from a competent Dysphagia Qualified Practitioner prior to working independently with dysphagic clients.

4.3 Advanced skills training are required prior to working with more complex

cases. This may be achieved through a recognised course, e.g. MSc, Advanced Practitioner Courses or Portfolio of relevant and up to date CPD activity.

4.4 Dysphagia Qualified Practitioners are required to provide evidence of

Continuing Professional Development in relation to dysphagia management via further training courses, special interest groups, knowledge and evaluation of recent research and peer review. Evidence of this will be demonstrated in Personal Development Plans and Continuing Professional Development Logs.

4.5 Clinicians in the process of training in Dysphagia should be working under the

direct supervision of a competent Dysphagia Practitioner. New Graduates/Post Graduates with introductory dysphagia knowledge should work under the direct supervision of a competent Dysphagia Qualified Practitioner to gain their next stage of competence.

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4.6 Students may take part in observation as part of assessment with prior

client/carer consent, under direct supervision of a competent Dysphagia Qualified Practitioner.

5 RESOURCE REQUIREMENTS

5.1 Medical notes for service users should be available when seen in the acute

setting. A brief summary of background and medical history is necessary for an outpatient/community referral. If the service user is known to CNTW, such information should be available on RiO for reviewing by the Dysphagia Qualified Practitioner.

5.2 Relevant testing materials should be available, to include food/fluids and

clinical supplies

5.3 A more experienced dysphagia practitioner will be available for second

opinions/support for therapists with less experience 5.4 Compliance of ward staff/ community staff in assessment and following care

plans is vital to ensure the needs of the service users are met and to ensure risks are kept to a minimum as well as eating/drinking being an enjoyable and pleasant experience.

5.5 Access to Videofluoroscopy Clinics would either be through Service Level

Agreement (SLA) or on a cost per case basis depending on the service agreements and requirements.

5.6 Access to high quality video playing equipment to facilitate reading of

VFSS and FEES examination tapes

5.7 Adapted utensils – assessment for adapted utensils may be carried out by

Occupational Therapists (see Section 3.11) for in-patients and community as well as dysphagia qualified practitioners.

5.7.1 An item may be trialled for appropriate use and then purchased for the

service user. Details of the item should be recorded in the service user’s notes and disseminated to staff and carers for future reference and purchasing.

5.8 Dysphagia posters/information – information regarding swallowing

problems, signs and symptoms to look for, high risk foods, high risk behaviours, making mealtimes safe and different food and drink consistencies are available.

5.9 Thickener from pharmacy – see section 3.9 for further information relating

to in-patients. In the community, the dysphagia qualified practitioner will contact the GP to request thickener for service users as required.

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5.10 Modified texture meals – see section 3.8 for Estates and Facilities

information. National descriptors are used for meal ordering and preparing appropriate meals on wards and in the community.

5.11 Mealtime plans - care plans will be completed on RiO for CNTW inpatient

service users. Specific mealtime plans will be completed for other staff, carers, families in the Community. The content of these plans will be discussed with key people and disseminated to other staff, carers, family members as well as those in the MDT.

5.12 E-learning – Awareness training on dysphagia will be available via E-learning

and is recommended training for all in-patient registered nurses and non-registered staff. See Section 13 – ‘Training’, as well as ‘Appendix B’ – Communication and Training Checklist including ‘Needs Analysis’.

6 SAFETY AND LEGAL ISSUES 6.1 The Dysphagia Qualified Practitioner must ensure that recommendations

follow good practice and maximise the safety of the service user with all food and drink.

6.2 Health and Safety Guidelines in specific environments should be followed at

all times, particularly regarding prevention of cross infection by the Dysphagia Qualified Practitioner.

(a) Immunisation

Dysphagia qualified professionals working with service users with dysphagia are advised to undergo immunisation for Hepatitis B

Individuals are personally responsible for ensuring that their boosters are kept up to date. This can be done through the Occupational Health Department – Team Prevent.

(b) Infection Control

Dysphagia qualified professionals need to follow the Trust’s Infection, Prevention and Control Policy, CNTW(C)23

(i) Sterilisation and storage of equipment should adhere to

the above policy to avoid cross infection of both patients and staff involved in the clinic.

(ii) Staff must wear disposable gloves and other

appropriate protective clothing (e.g. aprons, glasses) during oral examination.

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(i) Staff must adhere to the Trust’s policy CNTW(C)23 Infection, Prevention and Control, practice guidance note IPC-PGN-04.1-Hand Hygiene and use of alcohol hand rub for cleaning hands before and after seeing a patient.

(ii) Staff must be aware and comply with the Trust’s policy

CNTW(C)23 Infection, Prevention and Control, practice guidance note IPC-PGN-21, Management of MRSA in Hospitals.

Related reading: Trust policy CNTW(C)23, Infection, Prevention and Control

(c) Food Handling

Staff must be aware of and adhere to the Trust’s policy CNTW(O)53 – Food Hygiene regarding storage and transportation of food and drink.

(d) Staff must be aware of and adhere to the following policies and

practice guidance notes:

CNTW(O)27 - Nutrition Policy

CNTW(O)53 - Food Hygiene Policy

CNTW(O)70 - Catering Service Policy

CNTW(C)17 – Medicine Policy, practice guidance note:

o UHM-PGN-26 - Dietary Products

CNTW(C)29 – Trust Standard for the Assessment and Management of Physical Health

(e) Cardiac Pulmonary Resuscitation

Staff are responsible for attending regular CPR training. This is available through the Trust and should be renewed annually

6.3 If recommendations are not being followed, the Dysphagia Qualified

Practitioner should clearly state this in the client’s notes and discuss the reasons with the service user and team members, as appropriate. It will be necessary to also raise the issue(s) with ward managers/team leads.

6.4 Further discussion would be required regarding further input for the service

user by the Dysphagia Qualified Practitioner. If recommendations continue not to be followed, the clinician may need to complete a Safeguarding alert.

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7 CONSENT 7.1 Clinicians should refer to the Trust’s policy, CNTW(C)05 – Consent to

Examination or Treatment.

7.2 (a) General

Client consent should be sought in line with DOH guidance www.doh.gov.uk/consent

Consent should be sought prior to assessment in all cases and re-sought with any significant changes in treatment / management

“For consent to be valid, it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question. Consent must be given voluntarily and freely. The individual needs to understand, in broad terms, the nature and purpose of the procedure. It is advisable to inform the individual of any ‘material’ or ‘significant’ risks in the proposed treatment, any alternatives to it and the risks incurred in doing nothing”

It is the responsibility of the Dysphagia qualified professional, working within the multidisciplinary team, to ensure this

Translation services will be sought, as appropriate, where the service user/service user’s relatives have English as a second language

7.3 (b) Where the client is unable to consent:

Parents, relatives or members of the healthcare team cannot consent on behalf of an adult who is unable to give consent for him or herself

When an individual is unable to give consent a key principle is that of the person’s best interests. Best interests are not confined to best medical interests. Case law has established that other factors, which may need to be taken into account, include the service user’s values and preferences when competent, relationships with relatives or carers, spiritual or religious beliefs, for example. It is good practice for the healthcare team to involve those close to the service user in order to find out the service user’s values and preferences before loss of capacity

Consideration should be given to obtaining consent in writing where there is judged to be significant risk to the service user. See the Trust’s CNTW(O)05, Consent to Examination or Treatment Policy

http://www.doh.gov.uk/consent

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7.4 (c) Adults capable of giving consent who have communication difficulties:

Verbal consent can be gained from the service user prior to assessment, treatment and management. Where there are significant communication difficulties, every attempt will be made to inform the service user non-verbally about these procedures, using alternative/augmentative strategies e.g. photographs, symbols, signing

Verbal consent is acceptable as for any other aspect of Speech and Language Therapy with this group. If the service user has severe language and communication impairment (either expressive or receptive) consent may be sought via non- verbal communication methods (see above)

How consent has been given should be clearly documented in service user’s notes on RiO

Where the service user lacks the ability to consent to a particular course of treatment this should be clearly documented. In these cases a multi-disciplinary team decision may be made, in consultation with the family/carers/advocate, about the service users’ best interests

Wherever possible it is good practice through the use of non-verbal methods, to gain as much information from the client as to their wishes and preferences in relation to a particular treatment

7.5 (d) Video and photographic consent:

This should be sought in accordance with the Trust’s CNTW(O)45, Visual Imaging and Audio; CNTW(O)05, Consent to Examination or Treatment policies, regarding consent for clinical photography and conventional or digital video recordings

7.6 Consent agreement and discussions must be documented in the service

user’s notes on RiO. Written and signed consent forms should be uploaded onto RiO and copies given to the service user and carer’s as appropriate. This also applies for MCA forms.

8 IDENTIFICATION OF STAKEHOLDERS 8.1 This is an existing policy under review which has been circulated to the

following for a four week Trust wide consultation period:

North Locality Care Group

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Central Locality Care Group

South Locality Care Group

North Cumbria Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

9 IMPLEMENTATION

9.1 This policy will meet the target date of 12 months from the date of ratification to be implemented across the Trust. If this target date cannot be met, then the Physical Health Group will be responsible for developing an action plan.

10 EQUALITY IMPACT ASSESSMENT 10.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has

undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner.

11 STANDARD/KEY PERFORMANCE INDICATORS 11.1 The Healthcare Commission and the Mental Health Act Commission require

assurance and information relating to the management of dysphagia within the Trust. Information maybe considered by the NHS Litigation Authority. Key performance indicators within service specifications maybe outlined relating to the use of dysphagia. It is therefore required that records/procedures must be maintained as specified within the dysphagia policy.

12 MONITORING AND COMPLIANCE – see Appendix C 12.1 To monitor all Dysphagia qualified practitioners are registered SALT or Nurse 12.2 To ensure clinician has successfully completed an accredited postgraduate

training programme within Dysphagia or recognised training course to be able to work unsupervised.

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12.3 To ensure that CPD is in accordance with profressional body. 13 TRAINING – See Appendix B 13.1 Awareness training on dysphagia will be available via E-learning and is

recommended training for all in-patient registered nurses and non-registered staff. Further training will be provided by Dysphagia Trained Practitioners alongside members of the MDT as needs arise, focussing on more specific issues related to specific client groups and areas within The Trust.

13.2 The Trust will ensure that all identified staff has access to appropriate levels

of training, and it is the responsibility of each Director to ensure staff attend. 13.3 Levels of training are identified in the training needs analysis (see Appendix B

of policy) and are included within the Essential Training Guide which forms part of CNTW(HR)09 – Staff Appraisal Policy.

13.4 All Trust staff are recommended to complete E-learning awareness training

with a focus on signs and symptoms of dysphagia and what to do if these are observed.

14 FAIR BLAME

14.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

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15 ASSOCIATED DOCUMENTATION 1. Clinical Guidelines in Dysphagia Management 2003 RCSLT

2. Communicating Quality 3 RCSLT. Professional Standards for Speech and

Language Therapists 2006

3. Hickman, J, and Jenner, L, 1997 ALD and dysphagia: issues and practice, Speech and Language Therapy in Practice, Autumn 8-11

4. Langmore, S.E., 1999 Issues in the Management of Dysphagia. Folia

Phoniatrica et Logopaedia, 51, 220-230 5. The Ionising Radiation (Medical Exposure) Regulations 2000

6. Protocol for VFSS and FEES, Sunderland Speech and Language Therapy Service 2004

7. Reference Guide to Consent for Examination or Treatment

www.doh.gov.uk/consent 8. Ten Key Roles for Allied Health Professionals, Department of Health 9. Trust policies in relation to:

CNTW(C)04 - Safeguarding Children Policy

CNTW(O)05 – Consent to Examination of Treatment Policy

CNTW(O)27 – Nutrition Policy

CNTW(O)45 – Visual imaging and Audio Policy

CNTW(O)53 – Food Hygiene Policy

CNTW(O)70 - Catering Service Policy

CNTW(C)17 – Medicine Policy, practice guidance note:

o UHM-PGN-26 - Dietary Products

CNTW(C)29 – Trust Standard for the Assessment and Management of Physical Health

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area /Locality

Fiona Johnstone November 2014 March 2018

Policy to be analysed Is this policy new or existing?

CNTW(C)26 – Dysphagia Policy Existing with new training requirements

What are the intended outcomes of this work? Include outline of objectives and function aims

Ensuring safe working practise

Who will be affected? e.g. staff, service users, carers, wider public etc.

Staff and Service Users

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability Yes – positive impact to ensure safe drinking and eating

Sex N / A

Race N / A

Age Yes – positive impact to ensure safe drinking and eating

Gender reassignment

(including transgender)

N / A

Sexual orientation. N / A

Religion or belief N / A

Marriage and Civil Partnership

N / A

Pregnancy and maternity

N / A

Carers N / A

Other identified groups No

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Through standard policy process procedures

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How have you engaged stakeholders in testing the policy or programme proposals?

Through standard policy process procedures

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

Appropriate policy review by author/team

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

Positive impact to ensure safe eating and drinking for service users across CNTW

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

N / A

Advance equality of opportunity N / A

Promote good relations between groups N / A

What is the overall impact? Ensuring safe working practise

Addressing the impact on equalities N / A

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010?

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Fiona Johnstone Date: April 2015

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Appendix B

Communication and Training Check list for policies Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

Existing with additional training requirements from previous policy

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below

Required competencies for working in dysphagia as laid out in clinical guidelines & recognised training courses.

Agreement made at MDT planning workshops in January 2014 regarding training needs.

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolution etc.

Please identify the risks if training does not occur

Awareness training considered best practise

Ensure staff working in the management of dysphagia have the required competencies and access to supervision

Risks of not having the training: See Section 2 & 4.2 of the policy

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

E-learning awareness training from National Skills Academy

Is there a staff group that should be prioritised for this training / awareness?

Awareness and adherence to policy which mirrors clinical guidelines

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session E Learning

Team brief to raise awareness of the policy Ensure clinicians working with dysphagia receive their own copy through management cascade E-learning or taught session in situ

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

Awareness training already on e-learning: 000dysphagia:nutrition & hydration

National Skills Academy

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Appendix B – continued

Staff/Professional Group Type of training Duration of

Training

Frequency of Training

In-patient/residential ward

LD community staff

e-learning

000dysphagia:nutrition & hydration

National Skills Academy

20 minutes Bi-annually

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Appendix C Monitoring Tool

Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

CNTW(C)26 – Management of Dysphagia - Monitoring Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any Associate Action Plan will be reported to, implemented and monitored; (this will usually be via the relevant Governance Group).

1. All Dysphagia Qualified Practioners will be a registered SALT or Nurse

Registration to profession will be checked on recruitment by appointing officers.

Record made on departmental register by manager

Departmental register checked and updated annually by manager Annual Report to Physical Health Group

2. To work unsupervised in dysphagia management, the clinician should have successfully completed an accredited postgraduate training programme in dysphagia, or recognised training course

Departmental register will be updated either on recruitment by manager or on completion of training by supervising dysphagia qualified clinician

Departmental register checked and updated annually by manager Annual Report to Physical Health Group

3. CPD is in accordance with professional bodies

Regular clinical supervision by supervising dysphagia qualified clinician

Departmental register will be updated by supervising dysphagia qualified clinician

Departmental register checked and updated annually by supervising dysphagia qualified clinician Annual Report to Physical Health Group

The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out.

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Appendix 1

Community Team – Learning Disability

Department of Communication

Management of Dysphagia in Children

with a Learning Disability in the Community

(Newcastle)

This document describes the current policies in place for the Department of Communication Dysphagia Service and follows guidelines set down in Communication Quality (RCSLT, 2006).

Fiona Johnstone Gillian Welsher

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Management of Dysphagia in Children with a Learning Disability in

the Community (Newcastle)

1. DEFINITION OF CLIENT GROUP 1.1 The Department of Communication is part of the Community Team for

Learning Disability (CTLD) and offers communication and dysphagia services to any adult or child who is resident or attends a day placement in Newcastle upon Tyne and has a recognised learning disability. The Department also offers a dysphagia service to client’s resident at Prudhoe and Northgate hospital on specific wards. The dysphagia service adheres to the objectives of the Department of Communication:

To promote best practice in Speech and Language Therapy within CTLD and for service users who have a learning disability in the city in order to enhance the communication and eating/drinking potential of the clients of the service

To provide high quality, holistic services to meet individual needs within a multidisciplinary service

To develop services to meet existing and anticipated needs within the context of CTLD

To provide teaching and training on communication and dysphagia

To support staff and to develop all staff’s skills

To advise colleagues within and without CTLD regarding developments from the profession

To increase general public awareness of the communication and or eating and drinking needs of people who have a learning disability

To provide clinical teaching placements for the undergraduate and postgraduate speech and language therapy students

2. AIMS OF DYSPHAGIA SERVICE

To provide a comprehensive assessment of service users who present with an eating/drinking and/or swallowing difficulty

To work as part of a multi-disciplinary team in the delivery of the service and ensure all management decisions are discussed and clearly documented

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To provide intervention that promotes optimal safety and nutrition for clients, and where possible, allows for the client to maintain or develop their oral skills

To provide training to family and carers that is specific to the needs of an individual service user where this is felt to be appropriate and forms part of intervention. This is to assist in the understanding and implementation of any recommendations

To provide general training to family, carers, mealtime assistants and other relevant individuals to enable a general awareness and understanding of eating, drinking and swallowing and potential problems. This is of general information, not specific to any client

To work with staff in schools and family homes in an advisory capacity to investigate and identify appropriate referrals to the service

3. TEAM MEMBERS 3.1 The Speech and Language Therapist will work as a core member of the multi

or interdisciplinary team. The composition of the team may vary depending on the setting

3.2 The multi-disciplinary management of individuals with dysphagia ensures a

timely efficient integrated and holistic period of care. 3.3 Care team members:

The service user

Parents/carers

Speech and Language Therapist

Key workers

GP

Medical Consultants

Lunchtime Co-ordinators and Lunchtime Assistants

Ward staff

Respite Carers

CTLD team members currently involved with the client e.g. community nurse, physiotherapist, clinical psychologist

Occupational Therapist

3.4 A referral may be made to other agencies as required and they will form part

of the core team for that service user.

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3.5 Other agencies:

Consultant Radiologist

Gastroenterologist

Respiratory Physician

Dietician

Social Worker

Dentist

4. FEEDING CLINICS 4.1 These are run in Hadrian, Sir Charles Parsons and Thomas Bewick schools on a

termly or half termly basis. The SALT attends the clinic as part of a multi-disciplinary team with members of the care team, including parents/carers, dietician and paediatrician (in Hadrian and Sir Charles Parsons Schools) and with Occupational therapist and clinical psychologist (Thomas Bewick school). School staff may attend and other care team members may be invited as appropriate.

4.2 All children attending a clinic at Hadrian and Sir Charles Parsons Schools are

weighed and measured and this is recorded. This clinic aims to monitor all children in school who have feeding issues whether they are currently undergoing intervention or have received intervention in the past. A clinic summary letter is written after each clinic. Information is passed from one school to the next via care team members.

4.3 Parents/Carers of children attending Thomas Bewick school, are invited to a

group clinic where specific issues around feeding are discussed pertinent to the children. Suggestions are discussed with members of the MDT at the clinic and the parents attending – this will include possible reasons for the issue(s), next step(s) to move onto, activities that could be used to move onto the next step(s) and a target for the family. Written feedback from the clinic is sent out to the parents/carers following the clinic.

5. REFERRAL PROCEDURE 5.1 The Department of Communication operates an open referral system. 5.2 Requests for a referral can be made to CTLD via e-mail, phone call or direct

to a Speech and Language Therapist. The Speech and Language Therapist will ask screening questions or may observe a mealtime in order to establish it is an appropriate referral. Following this a referral form needs to be completed and consent for the referral gained. The Department of Communication is usually notified immediately on receipt of a dysphagia referral if not received directly.

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5.3 Following receipt of a referral a Speech and Language therapist qualified to work

with dysphagia is allocated and initial contact is made with referrer and/or carers within 3 working days to ascertain the severity of the problem. Most referrals to the Department of Communication are non-acute and do not require an assessment visit within 2 working days, but will be seen within 2 weeks as stated in Communicating Quality (1996)

5.4 Clients with behavioural issues relating to their eating and drinking e.g. restricted diets, only eating puree food, can be referred for parents/carers to attend a Feeding clinic where issues can be discussed e.g. at Thomas Bewick school in group setting. Should further assessment/intervention be required, the SALT would arrange to carry out a full assessment as outlined below.

6. ASSESSMENT PROCEDURE

6.1 An assessment will always start with gathering information from appropriate sources to inform further assessment and to determine if assessment/intervention is appropriate.

6.2 An assessment of the service user’s ability to eat, drink and swallow will be carried out in order to determine the safety and efficiency of the service user’s eating and drinking skills.

6.3 Assessment includes:

Case history of service user and their presenting difficulties

Description given by carers and other relevant parties of eating, drinking and / or swallowing problems

SALT’s observation of condition of oral structures

SALT’s observation of service users oral skills (including oral hygiene and dental health, medication)

SALT’s observation of service users difficulties observed during mealtime assessment in relevant environments

Assessment of position for eating and drinking in consultation with the clients physiotherapist as appropriate (including general motor skills)

Input from team members regarding the clients safety at mealtimes and nutritional status

service users /carers perception of difficulties – as appropriate

Information from recording sheets/food dairies completed by carers etc

service users communication skills

Respiratory status

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Management of secretions

Cognitive levels

Levels of alertness 6.4 A “Department of Communication” dysphagia assessment form is available

for SALTs to use. To gather detailed information, several assessment visits may be needed to see the service user in all relevant situations, e.g. home, day centre, respite care, observing different mealtimes as appropriate.

6.4 Further assessments

6.4.1 A full case history and observational assessment may suggest further

investigation is required to inform case management. e.g. a referral to the Feeding Clinic.

6.4.2 A letter or report detailing findings is written and sent to those involved with

the client. Further medical information may be requested from the GP/consultant as necessary.

6.4.3 Referrals to other agencies may also be made at this point, e.g.

physiotherapy, dietician, if not already involved in initial assessment following discussion with all these involved).

6.4.4 A referral for videofluoroscopy assessment may be necessary. Possible

reasons for requesting a videofluoroscopy assessment include:

To further visualise the structure and function, and to gain a dynamic view of the upper aerodigestive tract

To assess presence and cause of aspiration and residue

To facilitate techniques which alleviate aspiration and residue and improve swallow efficiency

To compare baseline and post intervention function

Identify and direct specific therapeutic strategies and regimes

6.4.6 Contact is made with the SALT department at the RVI for referral to a videofluoroscopy clinic. An x-ray request form must be completed by a medical practitioner and sent to the x-ray department. Discussion with carers and client about the videofluoroscopy procedure will be made prior to the referral and assessment. The SALT will inform carers on appropriate food, drinks and feeding equipment to be brought by the service users to the clinic.

6.4.7 A videofluoroscopy clinic is run by the SALT from the hospital department and

the radiology team. The Community SALT (i.e. CTLD SALT) attends. The team will plan the procedure, ensure sufficient information is obtained, and interpret the findings.

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6.4.8 A report of the assessment is written by the hospital SALT and countersigned by the consultant radiologist. Following the assessment the CTLD SALT will make recommendations and disseminate to the team involved.

7. MANAGEMENT 7.1 It is essential that all decisions regarding the individual’s management are

agreed within the multidisciplinary team and with the family/carers and significant others in order to:

Identify and agree which interventions receive priority at any stage in time

Identify any factors that may negatively impact upon the individual’s health status and well-being

7.2 Intervention should follow recommendations resulting from assessment i.e.

observational, Cervical Auscultation and / videofluoroscopy findings (where appropriate).

7.3 This should be discussed and agreed within the team. Recommendations

should be clearly documented, explained and demonstrated by the SALT to all relevant parties. Particular emphasis should be placed on informing those carers involved in assisting the service users with meals and drinks.

7.4 Intervention may include:

Working directly with the individual

Preparation for oral intake

Presentation of food and drink (bolus)

Type of food or liquid given – including modification of consistencies

Compensatory strategies

Body position during swallowing – in conjunction with physiotherapist/OT

Stimulation and range of movement exercises

Modification of the environment

Education and training for caregivers

Education of the individual or individual’s caregiver

Oral stimulation

Teaching and training

Feeding Plans

Service users and/or Parent/Carers attendance at a Feeding Clinic

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7.5 Management in school may be recorded through a feeding plan. These can be available, with parental consent, for other agencies of care. These are reviewed 6 monthly or sooner if a query is made.

7.7 Non-oral Nutrition

7.7.1 The Speech and Language Therapist will contribute to the multi-disciplinary decision regarding the potential need for non-oral nutrition and hydration.

7.7.2 Partial or total provision of nutrition and hydration by a non-oral route may be

necessary where the daily intake requirements are not being met safely by the oral route. This decision is arrived at by the multidisciplinary team, including the dysphagic individual and their significant carers. The Speech and Language Therapist’s role in this decision will be to contribute information regarding safety and efficiency of oral intake and the prognostic indicators for improvement. The SALT remains involved if some oral feeding is maintained following decision to use non-oral feeding.

8. TRANSITION 8.1 Information regarding the service user eating and drinking skills requiring

current intervention/monitoring will be passed to the appropriate SALT working where the client moves to, e.g. secondary school, day centre.

9. DISCHARGE PROCEDURE

9.1 The service user may be discharged from the Department of Communication

once members of the team agree that safety and nutritional levels are satisfactory for the service user. A re-referral can be made following the same referral procedure stated above.

REFERENCES RCSLT Clinical Guidelines 2006

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Appendix 2

Sunderland and Newcastle

Speech and Language Therapy Services

The Management of Dysphagia in Adults

With Learning Disabilities

Rachel McMurray and Fiona Johnstone

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)26 – Management of Dysphagia Policy-V03.3-Apr 19

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The Management of Dysphagia of in Adults with Learning Disabilities (LD)

1. INTRODUCTION: 1.1 The Sunderland and Newcastle Dysphagia Teams provide an inpatient and

outpatient service to adults with learning disabilities with dysphagia (developmental, and/or acquired or progressive).

1.2 The term dysphagia is used to describe swallowing difficulties characterised by

difficulty in oral preparation, oral, pharyngeal and oesophageal phases of the swallow, that is, the transportation of a bolus from the mouth to the stomach. Subsumed in this definition are developmental, neurological, psychological and structural conditions.

1.3 Adults with learning disabilities and dysphagia who are admitted to an acute

hospital will normally primarily be seen by the Speech and Language Therapy team based at the hospital. However, liaison and support will be facilitated between the hospital and community teams.

2. TEAM MEMBERS 2.1 The Sunderland team comprises of four Speech and Language Therapists and

two nurses, who have all completed recognised post qualification dysphagia courses (Langmore 1999).

2.2 The Newcastle team comprises of five Speech and Language Therapists who have all completed recognised post qualification dysphagia courses (Langmore 1999).

2.3 For the purpose of this document, all team members will be referred to as ‘Dysphagia Qualified Practitioners’.

3. THE AIMS OF A DYSPHAGIA SERVICE ARE:

To provide a comprehensive, evidence based and responsive service to Adults with Learning Disabilities presenting with swallowing disorders, including taking a central role in the promotion of health and well-being

To assess, diagnose, request and interpret diagnostic tests, to refer to other agencies as appropriate, provide a management plan and to discharge

To be a first point of contact for patient care, including single assessment (where indicated.)

To facilitate intervention by the multi disciplinary team extending and improving collaboration with other professions and services

To take an active role in strategic planning and policy development for services to service users presenting with swallowing and communication disorders


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To provide training and education for Speech and Language Therapists, professionals and carers involved in the care of service users with dysphagia

To develop and apply the best available research evidence and evaluative thinking in all areas of practice

4. REFERRALS 4.1 New referrals:

An open referral system is available for service users with dysphagia

All referrals are made through the Single Point of Access system between 9am and 5pm, Monday to Friday

It is the responsibility of the referrer to ensure consent is given for the referral

If the service user is unable to consent, a multi-disciplinary discussion should occur to assess the client in their best interests

4.2 It is good practice to inform / involve other members of a multi-professional team

at the point of referral:

To discuss with the other professionals the current issues that may relate to dysphagia assessment and management

To facilitate appropriate multi-disciplinary involvement to consider the multifaceted nature of complex swallowing disorders

To seek relevant current medical information

To facilitate any action of a medical nature and shared responsibility for risk management when drawing up management plans

4.3 Prioritisation 4.3.1 All referrals are passed to an allocated Dysphagia Qualified Practitioner who then

contacts the referrer/carer for more information about the referral. This may include administering the ‘Dysphagia Referral Checklist over the telephone. This initial contact happens within 2 working days of receipt of the referral.

4.3.2. The Dysphagia Qualified Practitioner makes a clinical decision on the urgency of

the referral. If the referral is deemed to be ‘urgent’, provision is made for an initial assessment within 5 working days of referral. The referrer is also advised at this point to access primary healthcare services should they require more immediate support.


31

4.3.3 Routine/non urgent referrals are seen within 10 working days of referral, within service resources.

4.3.4 There is no service at weekends or on Bank Holidays.

4.5 Locations

The service may be carried out in different locations and settings e.g.

o Community Settings

o Home

o Nursing Homes

o Social Services Premises

o LD Inpatient Services

5. ASSESSMENT 5.1 General:

(a) Some service users may receive a uni-disciplinary Dysphagia Team assessment. However, in cases where more complex interacting factors are involved, an essential part of the assessment process is close liaison with the relevant multi-disciplinary team in order to gain the necessary information regarding the service user and presenting disorder.

(b) Effective assessment, treatment and management of service users with

dysphagia requires expertise from a number of different professions. Dysphagia Qualified Practitioners working with dysphagic service users should function as part of a multi-disciplinary team and this should include service users / carers/ parents.

(c) Dysphagia Qualified Practitioners should have a clear understanding of the

roles of other professions involved and should respect skill boundaries whilst having shared working practices and tools.

(d) Dysphagia Qualified Practitioners will examine the nature of the client's difficulty using a variety of methods.

Case history including:

o the service users / carer's view of the problem/s

o medical background including diagnosis/aetiology


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o neurology

o weight history

o medication and possible implications

o nutritional intake: current method / quantity

o previous interventions and outcomes

o respiratory history

o gastroenterology history

Examination: for example;-

o Through observation and discussion of the usual situation surrounding eating drinking or feeding (including physical, behavioural, sensory, environmental, interactions, cognitive and communication)

o Through observation of simultaneous indicators, for example, response to feeding situation, state, respiration, oral motor skills, reflexes, swallowing coordination, stress signs, indicators of gastroesophageal reflux.

o Of the oromotor structure and function / laryngeal function

o Examination may include the use of cervical auscultation, pulse oximetry, FEES (see below)

(e) The Dysphagia Qualified Practitioner will identify the need for involvement

of other professionals as appropriate and will refer on to these agencies.

(f) The Dysphagia Qualified Practitioner will provide justified recommendations and refer for further investigations of dysphagia, for example:-

Videofluoroscopic swallow study (VFSS) under a Radiology Group Direction (RGD), or,

fibreoptic endoscopic evaluation of swallowing (FEES) as part of the assessment process

The planning of intervention may be limited without such investigations. Dysphagia Qualified Practitioners should not undertake a programme of intervention where there is insufficient


33

information about the underlying swallowing disorder. Liaison with medical staff will take place

(g) The Dysphagia Qualified Practitioner’s assessment of a client with

dysphagia must be fully documented in the case notes. A report will be sent to the referrer and GP responsible for the care of the service user.

(h) Results of investigations, assessment findings and planned management should be discussed fully with the service user and carer and with the multidisciplinary team (MDT) as appropriate.

5.2 Diagnosis

(a) The Dysphagia Qualified Practitioner will analyse the assessment findings within a problem-solving model in order to make a diagnosis of the service users eating and swallowing difficulty.

(b) This should be considered within a 'holistic view' in order consider the prognosis and to predict likely outcomes.

Diagnosis may indicate:

o Level of breakdown in swallowing process and nature and severity of dysfunction

o Prediction of aspiration/qualification of aspiration

o Psychological aetiology

o Nature and consequences of deterioration in function, for example, due to progressive condition or secondary disability

o Indicators of other potential problems/ diagnostic indicators (early identification)

o Ability to achieve desired nutritional status 6. INTERVENTION 6.1 Action Planning: Treatment and Intervention (a) The assessment results, diagnosis, prognosis and action plan should be

discussed with the team and used as a basis for treatment planning in conjunction with other team members’ findings. For example, other medical issues such as gastroesophageal reflux and nutritional status should be considered together with swallowing dysfunction in order to identify the relative risks and facilitate the development of a treatment plan.

(b) All forms of intervention will be fully discussed with the client, carer and team at

the outset and a written care plan formulated. Some options will need a carefully planned approach as some information is of a highly sensitive and emotive nature.


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(c) Where disagreement exists between the service user or carer and the team, every

effort should be made to resolve it through discussion (Communicating Quality 3, 2006). It is important to have full understanding and co-operation for management to be carried out effectively.

(d) The Dysphagia Qualified Practitioner should explain and demonstrate treatment

and or management methods to the service user /carer and assess their learning in relation to these methods. Written instructions relating to feeding programmes and other related interventions should be given to the service user / carer /family where appropriate.

(e) The Dysphagia Qualified Practitioner may delegate therapy tasks to other team

members, the service user or carer. These may include feeding and supervision of oral intake. Training will be given to ensure that tasks are carried out appropriately.

(g) The Dysphagia Qualified Practitioners will review the programme goals in

conjunction with the multidisciplinary team as appropriate;

to ensure progress has been maintained or achieved

to evaluate readiness for intervention or to change intervention

to evaluate any change in status

(h) The frequency of review should be considered carefully. Service users presenting

with degenerative disorders may need regular review over many months (Communicating Quality 3, 2006)

(i) The intervention programme will:

be sensitive to the changing and individual needs and skills of the service user / family / carers, including socially and emotionally and with respect to cultural and religious beliefs

take into account the desires of the service user where these can be ascertained

take place with regard to consent to treatment

ensure that the service user, family and/or carers are actively involved in any treatment plan


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(j) Management of dysphagia may involve

Advice on the potential risk of aspiration and the safety of oral feeding, taking into account the limitations of the assessment process. Advice will usually include approaches to minimise risk: the potential for compensatory and / or alternative feeding methods where the risk is significant

Indirect or compensatory techniques including changing texture, compensatory postures to facilitate a safe swallow, changing feeding procedures, thickening fluids, sensory considerations such as taste, prosthetic devices, feeding aids, utensils and environmental considerations

Training carers in dysphagia management techniques (Hickman & Jenner, 1997)

Direct therapy techniques which include specific exercises, for example, Oral Facial Tract Therapy (OFTT), thermo-tactile stimulation, biofeedback, placement and timing of the bolus

Risk management may specify non-oral feeding as an option and discussion with the service user/family/carers where appropriate

Appropriate ways to take medications (k) All intervention should be clearly and precisely recorded and dated on RIO.

Updates on outcomes of intervention should be provided to referrers and for service users on a regular basis.

(l) At any stage during intervention onward referral may be made with service user

agreement to, for example:

Gastroentrology

Radiology

Videofluoroscopy Clinic

Neurology

Clinical Psychology

ENT

Dietetics

Respiratory Medicine

Physiotherapy


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Other agencies as appropriate

7. DISCHARGE (a) The Dysphagia Qualified Practitioner should make the decision to discharge

including the reason for discharge. All decision-making in this area should involve the service users, carers and the team as appropriate in making the decision to discharge from the caseload.

(b) A written discharge summary will be provided to appropriate personnel including GP. A written report sent to the referrer with a copy to the GP (for community service users).

(c) The procedure for re-referral to the Dysphagia Team should be made clear.


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Speech and Language Therapy Service

Walkergate Park

for NeuroRehabilitation and Neuropsychiatry

Management of Dysphagia in Adults

With Acquired Brain Injury

Author Chris Graeme

V03 - Issue 1 May 2015


38

1 DEFINITION OF CLIENT GROUP 1.1 The speech and language therapy team manage dysphagia in adults with acquired brain

injury within inpatients, in collaboration with all team members. Dysphagia as a consequence of acquired brain injury results not only from disordered swallowing mechanism but from compromised cognitive-communicative skills and behavioural disturbance thus explaining its complex and multi-faceted nature.

1.2 The client group includes a range of aetiologies including: - Traumatic Brain Injury - Hypoxic or Anoxic Brain Injury - Guillain Barre syndrome - Multiple Sclerosis - CVA and in particular Brain Stem stroke - Huntingdon’s Disease - Other acquired neurological conditions

1.3 Typically, as a regional service, service users are referred and admitted from acute

services. Initial dysphagia management and intervention programmes follow the guidelines recommended from the referring clinical team pending review from speech and language therapy. We have capacity to manage up to four service users with tracheostomies within the service. It is not possible to manage service users with nasogastric (NG) feeding within the Centre.

2 TEAM MEMBERS

2.1 The speech and language therapist is a central component of dysphagia management in

the patient with neurological impairment. However, they work in close collaboration with

- the service user

- the service user’s family

- primary nurse

- nursing staff

- the Consultant and other medical staff

- Occupational Therapist

- Physiotherapist

- Social Therapy and Recreational Rehabilitation Team (STARRT)

- Dietician

- Social Worker

- Rehabilitation Assistant

- And others as specifically indicated by the particular patient’s circumstances

2.2. In addition to the core competencies outlined previously, speech and language therapists working with dysphagia in individuals with acquired brain injury have a specific interest in


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facial oral tract therapy (FOTT) as an assessment and treatment technique. Therefore, the department aims to reflect this in its annual educational strategy.

3 AIMS OF SERVICE

3.1 The speech and language therapy service aim to facilitate the service users with

dysphagia to enjoy optimal nutrition and enjoyment from oral intake. Clinicians aim to evaluate and remediate impairments in oral and pharyngeal dysphagia. They also seek to collaboratively devise management plans reflecting compensatory strategies to promote swallowing safety and ongoing general health. Speech and language therapy accept responsibility for training and education about dysphagia in service users with neurological impairment, as part of the core-competencies framework and general induction within the inpatient services, and specific to clinical management of specific service users.

4 REFERRAL PROCEDURE

4.1 All service users admitted to inpatient services will be screened by a speech and

language therapist within the first week of admission. Prior to admission however a pre-admission document will be completed with the transferring service, for example Neurosciences at The Royal Victoria Infirmary, or an outlying district hospital. This document collects information on the individual’s swallowing status, current management plan and contributing factors such as cognitive or behavioural problems.

4.2 For transfers from both within Newcastle upon Tyne and out side of the region, written

letter or telephone transfer of clinical information from the Speech and Language Therapy involved should take place.

5 ASSESSMENT PROCEDURE

The speech and language therapist reviews the handover information from referring services and the pre-admission document. From this point they initiate their own assessment and clinical management, which may take a variety of forms. Frequently service users are nil-by-mouth, and may remain so for some time due to impaired consciousness or very severe dysphagia.

5.1 Assessment of dysphagia in service users with acquired brain injury requires:-

Oral motor examination: to look for signs of oral dysphagia; weakness, sensory impairment, reduced oral movement within the oral cavity, presence of gag, evidence of spontaneous swallowing, voluntary cough.

Clinical examination for signs of pharyngeal dysphagia: reduced saliva management, reduced or absent laryngeal elevation, suggestion of pharyngeal pooling, present voice quality, and altered respiratory presentation.

Evaluation of awareness levels, communication abilities, cognitive awareness and behaviour, for its impact on ability to self-report, ability to use compensatory strategies, compliance, and sufficient alertness to manage oral feeding.


40

Evaluation of physical status: positioning safety for eating and drinking, ability to feed selves.

Information from nursing staff and other team members. 5.2 Information from the assessment is recorded in the patient’s clinical notes. Specific risks

posed by dysphagia particular to the individual; e.g. aspiration, should be included in the relevant care plan under ‘body structure and functions’. Implications for nutritional intake are recorded under ‘nutrition’.

5.3 Additional information about the patient’s swallowing ability may be obtained by using

Videofluoroscopic Evaluation of Swallowing (VFES) and/or Fibre-optic Endoscopic Evaluation of Swallowing (FEES). Both procedures are conducted at a local hospital in conjunction with clinicians who are competent in these procedures, according to RCSLT guidelines. Speech and language therapists working with acquired brain injury will employ these techniques to provide objective information about:

- the structure and function of all mechanisms involved in swallowing

- the presence and severity of penetration, aspiration and residue

- swallow function in relation to a variety of consistencies of food and liquid

- the potential use of management and treatment strategies on swallowing physiology, safety and efficiency

5.4 Possible contra-indications for VFES include:

5.4.1 These are non-exhaustive lists.

• Patient pregnancy

• Medical instability, such as drowsiness and including those conditions where portable ventilation is not possible

• Difficulty maintaining an appropriate stable position

• Difficulty co-operating with the procedure

• Known or suspected adverse reaction to contrast media

• Nil By Mouth for reasons other than dysphagia

• Unnecessary exposure


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5.5 Possible contra-indications for FEES include: 5.5.1 These are non-exhaustive lists.

• Severe movement disorders and/or severe agitation

• Base of skull/facial fracture

• Recent history of severe/life-threatening epistaxis

• Sino-nasal and anterior skull base tumours/surgery

• Nasopharyngeal stenosis

6 MANAGEMENT

6.1 Service Users will remain under the care of a named speech and language therapist for the duration of their admission. Management of their dysphagia may include any or several of the following approaches.

Facial oral tract therapy treatment programme.

Oral trials of prescribed consistency, amount and presentation.

Compensatory strategies, such as modified positioning, use of specific swallowing techniques such as supraglottic swallow.

Modification of environmental aspects such as noise and distractions.

Education of individuals and their family and care staff.

Treatment to improve awareness and minimise fatigue. 6.2 Some interventions will be carried out by other team members, such as rehabilitation

assistants, but remain under the supervision and responsibility of the treating speech and language therapist. Interventions will be recorded in the clinical notes of the patient.

6.3 Service users with severe dysphagia which cannot be managed with oral intake and who do not already have an alternative feeding source in situ will be referred for insertion of PEG feeding (percutaneuous endoscopic gastrostomy).

6.4 This is a team decision led by medical staff and will involve referral back to acute services for this procedure.

7 DISCHARGE

7.1 As discussed, a Service User will remain under a named speech and language therapist for the duration of their admission, even if their swallowing ability has recovered to the point where it falls within normal limits for the general population, or a patient remains entirely reliant on external feeding. On discharge, information is recorded in the extensive discharge pack which accompanies the patient into the community or to another clinical environment.


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7.2 The service user with dysphagia is then transferred to local speech and language therapy services for ongoing management of their dysphagia. A transfer letter is provided for the receiving speech and language therapist, along with the interdisciplinary discharge pack.


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Speech and Language Therapy Service

Inpatient services

Management of Dysphagia in individuals on inpatient wards

(excluding adults with acquired brain injury)

Author(s) Joanna Brackley Amy Foster

V03 – Issue 1 May 2015


50

1 DEFINITION OF CLIENT GROUP 1.1 The speech and language therapy team manage dysphagia in adults on in-patient

wards including service users with dementia in collaboration with all team members. Dysphagia in inpatient populations can arise from disordered swallowing mechanisms, medication effects, compromised cognitive-communicative skills, psychiatric and behavioural disturbance thus explaining its complex and multi-faceted nature.

1.2 The inpatient populations can be divided into two broad groups 1) service users with organic illnesses 2) service users with functional conditions. The age range of this population spans from 18 to end of life. Significantly the older age service user population will typically have co-morbid conditions such as;

COPD

Parkinson’s

Parkinsonism

Stroke

UTI and possible associated delirium

Poor nutrition and hydration

Diabetes

Heart disease

Depression

Psychosis

Paranoia

Delusions

1.2.1 These additional factors impact significantly on the diagnosis, and subsequent

management of dysphagia. 1.3 The service delivers care into all adult inpatient wards within Cumbria

Northumberland, Tyne and Wear NHS Foundation Trust (the Trsut/CNTW).

2 TEAM MEMBERS

2.1 The speech and language therapist is a central component of dysphagia

management team and as such, work in close collaboration with:

the service user

the service user’s family

primary nurse

nursing staff

the Consultant and other medical staff

Occupational Therapist


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Physiotherapist

Social Therapy and Recreational Rehabilitation Team (STARRT)

Dietician

Social Worker

Rehabilitation Assistant

And others as specifically indicated by the particular patient’s circumstances

3 AIMS OF SERVICE

3.1 The speech and language therapy service aim to facilitate the service users with

dysphagia to ensure optimal safety when eating and drinking, optimal nutrition and enjoyment from oral intake. Clinicians aim to evaluate and manage the risks caused by impairments in oral and pharyngeal dysphagia whilst balancing this with quality of life particularly in progressive conditions.

3.2 They also seek to collaboratively devise management plans reflecting the risks

that need to be managed, the environment the service user is in and the service user’s wishes.

3.3. Speech and language therapy accept responsibility for training and education about dysphagia in service users with dementia, as part of the mandatory training for staff working in inpatient dementia wards and specific to clinical management of specific service users.

4 REFERRAL PROCEDURE

4.1 Patients can be referred to inpatient speech and language therapy services by e-

mailing [email protected]. There are specific wards, such as the organic wards, which have a dedicated speech and language therapy service and referrals on these wards may be made through Multi-Disciplinary Team (MDT) meetings on the ward or direct requests from the ward team.

4.2 On some occasions service users are referred for swallowing assessment/ review following transfer from acute hospital settings onto the dementia wards. Referrals in these cases will be telephoned through to speech and language therapy from the acute therapists.

4.3 Referrals made via the e-mail address will be followed up with a telephone

screening questionnaire (see adult LD). This enables clarification of information and prioritisation of the referral.

4.4 Urgent referrals will typically be seen within 2 days of referral as per RCLST

guidance. Less urgent referrals will be seen within 10 working days.

5 ASSESSMENT PROCEDURE

mailto:[email protected]


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5.1 The speech and language therapist reviews the referral information from the ward staff or referring speech and language therapists, checks for relevant information in the core document and any scanned documents in RiO. From this point they initiate their own assessment and clinical management, which may take a variety of forms. Assessment is typically repeated over multiple mealtimes/eating/drinking situations to encompass a variety of foods and fluctuations in the individuals’ presentation.

5.2 Assessment of dysphagia in patients with dementia:-

Oral motor examination: to look for signs of oral dysphagia; weakness, sensory impairment, reduced oral movement within the oral cavity, presence of gag, evidence of spontaneous swallowing, voluntary cough

Clinical examination for signs of pharyngeal dysphagia: reduced saliva management, reduced or absent laryngeal elevation, suggestion of pharyngeal pooling, present voice quality, and altered respiratory presentation

Evaluation of awareness levels, communication abilities, cognitive awareness and behaviour, for its impact on ability to self-report, ability to use compensatory strategies, compliance, and sufficient alertness to manage oral feeding

Evaluation of mealtime environment; factors affecting the preparatory stage of swallow including noise, distractions, communication of mealtime event, table setting, communication, support given by staff

Evaluation of physical status: positioning safety for eating and drinking, ability to feed selves

Information from nursing staff and other team members in relation to psychiatric history and presentation including medication

5.3 Information from the assessment is recorded in the service user’s clinical notes

with risks updated in the face risk assessment form. Care plans are written in the inpatient care plan section – under the heading feeding/eating difficulties by the speech and language therapist assessing. Care plans are written and reviewed by speech and language therapy only.

5.4 Additional information about the service user’s swallowing ability may be obtained

by referring for Videofluoroscopy – this may incur a cost. Due to the nature of the difficulties of this client group VF is not a routine assessment.


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6 MANAGEMENT

6.1 Service users will remain under the care of a named speech and language therapist for the duration of their admission. Management of their dysphagia may include any or several of the following approaches.

Environmental manipulation e.g. being supported to eat in a different room to minimise distractions and enhance attention and safety

Modified diet

Thickened fluids

Oral trials of alternative consistencies

Compensatory strategies, such as modified positioning

Education of the individual (where possible) and staff

Treatment to improve awareness and minimise fatigue

Changes to medication (in liaison with the medical team)

6.2 Some interventions will be carried out by other team members, such as

rehabilitation assistants, but remain under the supervision and responsibility of the treating speech and language therapist. Interventions will be recorded in the clinical notes of the patient.

6.3 Dysphagia risks will be managed within the context of the progressive condition of the patient. Care decisions will be taken within this context and will involve multi disciplinary decision making and involvement of the family and the service user (if capacitated). Non-oral feeding decisions are not typically made in relation to this population but where this is considered- speech and language therapist will liaise with decision maker medical team.

7 DISCHARGE

7.1 As discussed, a service user with a swallowing difficulty will remain under a named speech and language therapist for the duration of their admission whilst their swallowing difficulties are present. Should a swallowing difficulty resolve, the care plan will be closed on RiO.

7.2 On discharge or leave, the care plan will be shared with receiving location (care

home/ family home). 7.3 Should a service user be discharged whilst being assessed, need a review or have

‘unstable’ dysphagia (frequent changes in presentation or additional complicating physical health), the patient will be transferred to the community SALT team via a telephone handover.

7.4 On discharge from hospital, the service user with dysphagia is transferred to local

speech and language therapy services for ongoing management of their dysphagia.

Documents

CNTW(C)26 · CNTW(C)26 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)26 – Management of Dysphagia Policy-V03.4-Oct 19 3 2.8 Nutrition is a vitally important