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Dysphagia management policy

Contents

  1. Policy summary
  2. Introduction
  3. Purpose
  4. Scope
  5. Procedure or implementation
  6. Training implications
  7. Equality impact assessment screening
  8. Links to any other associated documents
  9. References
  10. Appendices

1 Policy summary

The dysphagia management policy is a clinical policy to assist and guide staff with respect to the safe management of patients who have or present with eating, drinking or swallowing difficulties (dysphagia).

It outlines what dysphagia is, who it can affect and how dysphagia may present in service users or patients. The clinical signs and symptoms of dysphagia are identified along with the subsequent risks to health that may be experienced as a consequence of dysphagia. Thus, highlighting the need for effective and safe management of this condition.

In addition, the policy details how to refer someone with a swallowing difficulty to the speech and language therapy service and how the potential risks associated with swallowing difficulties can be safely and appropriately managed.

2 Introduction

The trust is committed to providing a high standard of care to all patients. As part of that care, procedures must be in place for the identification, assessment and management of patients at risk of dysphagia (eating, drinking and swallowing difficulties) whether this is on an emergency basis or part of a long term problem.

Disruption of swallowing can have serious medical implications, increasing risk of malnutrition, dehydration, weight loss, pulmonary aspiration (fluid or food going into the lungs) and choking. It is associated with increased morbidity, mortality and a reduced quality of life due to the emotional, psychological and social issues that occur as a consequence of not being able to eat a regular diet and, or drink regular fluids.

Nutrition is a vitally important aspect of our lives. All staff have an important role to play to ensure that food provided is nutritious and well presented, and that patients find eating an enjoyable and pleasant experience.

It is important that patients with known swallowing difficulties or those with behaviours that could affect the safety of the swallowing process receive the recommended modified diet or fluid consistency to reduce the possible risk of aspiration (food or fluids entering the lungs) and choking.

Choking has several causes, but it is often the result of either a foreign object, such as food lodged in the windpipe or in some adults there may be no problem with the swallow physiology. Instead, cognitive or behavioural problems, such as issues around eating, over filling mouth, taking and hiding food or self-harm by occluding the airway could be the cause.

When a person chokes, key signs are redness of face, inability to breathe, inability to speak, inability to cough and clutching of the throat. Recognition and emergency action to take if a patient is choking is outlined in the trust life support training.

Swallowing problems (dysphagia) are seen in people with a variety of diagnoses, for example dementia, stroke or progressive neurological conditions such as Huntington’s Chorea, Parkinson’s Disease or Progressive Supranuclear Palsy.

People with learning disabilities experience a higher incidence of health problems than the general population and dysphagia is an important area of risk for people with learning disabilities.

In some patients there may be no problem with the swallow physiology. Instead, cognitive and behavioural problems may result in disorganised feeding or drinking; eating too much too fast without attention to safety; spitting out foods or fluids, prolonged chewing and holding food or fluid in the mouth.

Some patients may also have an increased risk of swallowing difficulties due to the long-term side effects of some medications, such as benzodiazepines, that might alter neuromuscular function.

A holistic approach to patient care, considering the patient’s physical needs as well as mental health needs, is essential to improve the safety of individuals with swallowing difficulties. Introducing individualised care management guidelines is good practice to ensure the safety of individuals with eating, drinking and swallowing difficulties and therefore reduce the risk of ill health associated with dysphagia like aspiration and choking.

3 Purpose

The purpose of this policy is to assist staff in identifying patients with Dysphagia and associated risks and ensuring appropriate management. It applies to all clinical areas where food and drink is provided. This policy links to the resuscitation manual and the recommendations from NHS improvement.

RDaSH fully adopts the International dysphagia diet standardisation initiative (IDDSI); the globally standardised descriptors of texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and all cultures (International dysphagia diet standardisation initiative (opens in new window)).

The final framework consists of a continuum of 8 levels (0 to 7). Levels are identified by numbers, text labels and colour codes (see appendix D). Drinks are measured levels 0 to 4, and food measured levels 3 to 7.

The imprecise term soft diet must no longer be used as a texture descriptor. A review of the national reporting and learning system (NRLS) highlighted seven occasions where patients appear to have come to significant harm over a two-year period including two patient deaths due to confusion about the meaning of the imprecise term ‘soft diet’. These incidents ranged from coughing to choking with support being required from an emergency team, and aspiration pneumonia (patient safety alert June 2018).

3.1 Definition or explanation of terms used

  • Dysphagia is the medical term used to describe eating and drinking disorders. Difficulties may occur in the oral, pharyngeal or oesophageal stages of the swallow. Speech and language therapists assess and manage dysphagia in all but the oesophageal stage of the swallow. Dysphagia can result in, or contribute to, critical negative life conditions including weight loss, malnutrition, dehydration, choking, aspiration pneumonia and a reduced quality of life
  • Aspiration is defined as the inhalation of food or drink particles into the lungs. This can be either acute or chronic in presentation. Aspiration can cause serious pulmonary complications including aspiration pneumonia
  • Choking is defined as the accidental introduction of a foreign object into the airway, which becomes lodged in the airway and reduces or obstructs the air flow into the lungs. This can be a consequence of dysphagia
  • The ability to swallow safely can be influenced by a number of factors which can include coordination and strength of the musculature, posture, bolus size, texture of bolus, and disuse of swallow due to pain, illness, change in taste, nausea, ageing, cognition, respiratory, and cardiac problems.

4 Scope

This policy applies to trust staff who are involved in caring for adults in all inpatient areas across the trust and RDaSH learning disability day services across Rotherham, Doncaster and North Lincolnshire.

RDaSH speech and Language Therapy services accept referrals from the following areas:

  • Doncaster physical health services
  • Doncaster learning disability services
  • Rotherham learning disability services
  • North Lincolnshire learning disability services

In addition, RDaSH have a service level agreement with The Rotherham Foundation Trust (TRFT) adult speech and language therapy service to provide speech and language therapy (including dysphagia management) to patients at the RDaSH Woodlands Unit and to community patients under the RDaSH older people mental health service (OPMHS) in Rotherham. Please see contact details on the referral form located in appendix E8.

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

5 Procedure or implementation

5.1 Quick guide

5.1.1 Identify dysphagia

  • Be aware of the clinical signs or symptoms indicating possible dysphagia.
  • Consider patients and service users who may be at greater risk of swallowing difficulties due to medical conditions, general health and wellbeing or behaviours displayed.
  • Clearly document any observed or reported swallowing difficulties or adverse signs.

5.1.2 associated risks

  • Be aware of the potential negative effects to health as a result of dysphagia and take any appropriate action for example, ensure any safe swallow strategies are being followed. Speak to you speech and language therapist for further details.

5.1.3 Referral

  • Referrals should be made to the speech and language therapy service in a timely manner.
  • Referrals should be made to the relevant service within each care group.

5.1.4 Management

  • Ensure all staff involved in the patient or service user care are made aware of any recommendations regarding diet and, or fluid medication and any relevant strategies or techniques to aid safe swallowing.
  • All food or fluids provided for the patient or service user should be of the recommended consistency.
  • Where thickening agent is required for fluids, this should be safely stored away when not in use.

5.1.5 Incidents

  • Any choking incidents or incidents of concern (such as non-adherence to recommendations) should be reported using the trust reporting system.

5.2 Identifying dysphagia

The severity of dysphagia can vary from individuals having difficulties with certain consistencies of food, liquids, fluids or saliva to being completely unable to swallow. These difficulties may be caused by mechanical (physical), neurological or behavioural problems. Some people may also complain of pain or discomfort while swallowing.

The following are signs and symptoms that staff may notice which are indicative of a possible dysphagia:

  • individual’s inability to recognise food
  • prolonged chewing time or taking a long time to finish meals
  • pocketing or storing of food, or food residue remaining in the patient’s mouth
  • difficulties with chewing and manipulating food in the mouth
  • poor lip closure or difficulties in controlling foods, fluid or saliva in the mouth
  • dribbling or drooling after drinking
  • gurgling sound (wet voice) after liquids
  • inability to cough or a weak ineffective cough when eating
  • coughing during or immediately after eating or drinking
  • history of recurrent chest infections and, or deterioration in chest status
  • regurgitation of food or nasal regurgitation
  • poor oral hygiene (please see mouth care matters (opens in new window))
  • slurred speech and, or facial weakness

The following are examples of possible behaviours that may cause disorganised feeding and drinking and thus increase the risk of aspiration and choking:

  • lack of interest or attention to food and drink and the feeding environment
  • cramming or overloading of food into mouth
  • will overload their mouth having taken food from others or from available sources such as fruit bowls.
  • holding food or drink in the mouth
  • will accept or put any item into the mouth
  • swallowing without chewing
  • has issues around eating with others
  • speed of eating
  • pacing and agitation whilst eating
  • mood levels
  • levels of alertness

Difficulties with swallowing means that if food and drink penetrate the patient’s airway or enters the lungs this will manifest itself acutely as choking, coughing, wheezing and respiratory distress. Please refer to the trust life support training for management of choking (please see section 5.5 below). A serious and possible fatal lung infection such as aspiration pneumonia may result. In some patients who have no cough reflex there may be no sign of aspiration (silent aspiration) or if this is a slow, ongoing problem, as opposed to an acute one, the patient may have chronic symptoms.

5.2.1 Signs of acute aspiration

  • Pyrexia.
  • Coughing and choking.
  • Change of colour of face and, or lips.
  • Sounds of respiratory distress.
  • Loss of voice or changes in voice quality.
  • Gasping.
  • Rapid heart rate.

5.2.2 Signs of chronic aspiration

  • Loss of weight.
  • Repeated chest infections.
  • Hunger.
  • Excess or changes in oral secretions.
  • Respiratory problems.
  • Coughing and choking history.
  • Refusal to eat.

5.3 Referring to speech and language therapy

Each care group and, or service area within RDaSH has their own referral pathway (see appendix E1 to E8).

5.4 Managing dysphagia

All staff and carers need to be aware of the patient’s individual requirements in order to maintain their nutritional needs and to minimise the risk of aspiration and choking. Nursing presence at mealtimes is a good time to build on relationships with patients and to observe and assess for any difficulties highlighted above. If recording of food and, or fluid intake is required, the nurse is the health professional best situated to perform this task.

There must be robust procedures in place to ensure that all staff are aware that a patient is on a modified diet and, or fluid consistency and this must be communicated to all staff involved in that patient’s care on a daily basis as per ward procedure. Patients on a recognised modified texture diet or fluid consistency must be given only the correct diet or fluid consistency and this includes snacks or foods or drinks given outside meal times and across all settings.

Staff should ensure that food and any fluids are well presented, served at the right temperature, and at the right consistency recommended for any patient who has been assessed by a dysphagia trained practitioner. For patients whom require thickened fluids, staff should ensure that the thickening agent or powder is stored away appropriately (see appendix C). This follows nationally identified patient safety incidents where harm has been caused by the accidental swallowing of the thickening powder when it had not been properly stored out of reach (Patient safety Alert, 2015). The dietitian and speech and language therapist can provide advice regarding individual’s needs, and all requirements should be accurately documented in care plans and, or the electronic patient record. Contact details for speech and language therapy are attached (see appendix F).

Dehydration and malnutrition can also result from dysphagia. Clinical staff must assess patients for possible signs of these and personalise and implement an appropriate care plan.

If an individual has an identified dysphagia this may impact upon safe management of oral medications. In such cases, advice should be sought from the general practitioner, consultant or appropriate prescribing professional.

Referrals made to speech and language therapy for problems or difficulties taking medications only (in the absence of signs of dysphagia) will not be accepted.

5.5 Choking action

Any choking incidents must be reported on the trust’s Safeguard incident reporting system.

Please refer to the trust life support training sessions and policy for recognition and emergency actions to take if a patient is choking (resuscitation manual).

6 Training implications

Staff should receive basic dysphagia awareness training where appropriate, for example, if required in relation to their working environment. Texture modified diet and fluid consistency advice booklets are available from all the speech and language therapy departments.

All staff should be compliant with trust mandatory and statutory training including life support training and choking.

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

No issues have been identified in relation to this policy.

7.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

8 Links to any other associated documents

9 References

10 Appendices

10.1 Appendix A Responsibilities, accountabilities and duties

10.1.1 Board of directors

Board of directors are responsible for the trust having policies and procedures in place, based on good practice. The lead director for this policy is the executive director of nursing and allied health professionals.

10.1.2 Inpatient services managers

Inpatient services managers are responsible for the following:

  • ensuring that staff within their areas of responsibility have an awareness of recognising and managing patients who are at risk of dysphagia
  • reporting choking incidents and incidents of concern such as non compliance with recommendations using the trust’s Safeguard incident reporting system and investigating such incidents, involving the multidisciplinary team

10.1.3 Inpatient clinical staff

Inpatient clinical staff are responsible for are responsible for the following:

  • identifying and appropriately reporting adverse signs in a timely manner
  • making appropriate, thorough and timely referrals to the speech and language therapy service
  • following recommendations made by a dysphagia trained practitioner to reduce the risk of aspiration and choking whilst meeting the nutritional and hydration needs of the individual
  • to be aware of the safe storage of thickening agents (appendix C)
  • reporting of choking incidents and incidents of concern, and contributing to the investigation of such incidents.
  • ensuring that any food or fluids brought into the ward or other settings by carer’s and relatives are appropriate for the consistency recommended for the individual patient (appendix D)
  • ensuring a regular mouth care routine is completed appropriately

10.1.4 Speech and language therapist or dysphagia trained practitioner

Speech and language therapists or dysphagia trained practitioner will, when required, complete a comprehensive assessment of an individual’s eating, drinking and swallowing skills and advise staff on the individual’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. The assessment and management will also take into account an individual’s preferences and beliefs as well as best interest and quality of life issues.

10.1.5 Dietitians

Dietitians interpret the science of nutrition to improve health and treat diseases or conditions by educating and giving practical, personalised advice to clients, patients, carers and colleagues. The dietitian will advise on the individual’s diet, taking in to consideration the person’s swallowing difficulties whilst ensuring they meet their nutrition and hydration needs. A nutritional screening assessment, for example, must, can be completed as referred to in the trust’s nutrition policy (promoting good nutrition for patients) and referral to a dietitian made where appropriate.

10.2 Appendix B Monitoring arrangements

10.1 Incidents of choking

  • How: IR1 Reporting system.
  • Who by: Staff member involved in the incident.
  • Reported to:
    • resuscitation
    • officer
    • matrons or service
    • managers
    • speech and language therapy (SALT) area
    • leads
  • Frequency: As and when incidents occur.

10.2 Incidents of choking

  • How: Annual audit.
  • Who by: Resuscitation officer.
  • Reported to: Resuscitation committee.
  • Frequency: Annually.

10.3 IR1 reports

  • How: IR1 report reviews.
  • Who by: Resuscitation officer or matrons or service managers or SALT area.
  • Reported to: Relevant care group forum.
  • Frequency: On exception basis.

10.3 Appendix C Guidance for use and storage of thickening agent

10.4 Appendix D International dysphagia diet standardisation initiative (IDDSI)

10.5 Appendix E Referral forms

11.5.1 Appendix E1 Referral Doncaster GP and non-care home

10.5.2 Appendix E2 Referral Doncaster care home

10.5.3 Appendix E3 Doncaster care home dysphagia monitoring chart diet

10.5.4 Appendix E4 Doncaster care home dysphagia monitoring chart fluids

10.5.5 Appendix E5 Referral Doncaster learning disability service

10.5.6 Appendix E6 Referral Rotherham learning disability service

10.5.6.1 Eligibility criteria

The learning disability community health team service is available to people with learning disabilities where learning disability is defined by the presence of three criteria.

  1. The person has a mental ability that is significantly below average. This is generally measured by a standardized test of intelligence that gives a score (IQ) according to how far an individual is from the average of the population. Deficits in intellectual functioning may be demonstrated by delays in acquisition of or decline in acquired cognitive functions like comprehension (understanding), expression (verbal and non-verbal language), memory, academic learning, learning from experience, reasoning, problem-solving, planning, judgement and abstract thinking.
  2. There are also difficulties in adaptive functioning. In other words, the person struggles to cope with everyday life age-appropriate adaptive functioning is the ability to function to meet the demands of everyday life, necessary for independent living, for a person that age. These include:
    • toileting
    • washing
    • cleaning
    • brushing teeth
    • shaving beard
    • bathing or showering
    • dressing
    • eating
    • cooking
    • operating home appliances safely
    • shopping
    • negotiating traffic
    • reading time
    • handling or managing money
    • travelling
    • employment and social functioning etc.
  3. The difficulties began before the age of 18. Joint work can start with those with learning disability, who are under the care of CAMHS, at 17 years of age. However formal transfer of care takes place at or after 18th birthday. There are some important assumptions here:
    • the team works within a social model of disability (WHO, 2001) where disability is understood as an interaction between the person, their environment and the support they receive
    • all assessments consider the culture and background of the person
    • assessments are only carried out if they are expected to benefit the person
    • where an IQ assessment is completed, single IQ scores will not be given, the results may be given as a range of scores and the extent to which we can be confident in the results
    • the learning disability must be the primary need or the origins of the presenting difficulty must be as a result of their learning disability
    • the final assessment of eligibility to the learning disability service is a matter of clinical judgement on the basis of standardised assessments and presenting need
    • presenting needs can change depending on social and socioeconomic circumstances, mental health and physical health. Therefore with each new referral to the service, consideration will be given to whether the learning disability service is the best service to meet their needs.
10.5.6.2 Assessment process

When a referral is made, there are three possible levels of assessment:

  1. fact finding, sometimes we will contact the referrer to gain some further information about the person and the circumstances of the referral. This is likely to be a ‘phone conversation with a community team worker
  2. initial screen. here a community team worker will go through an assessment known as the LDSQ and an initial assessment protocol. This will usually be a visit and a conversation with the person, a family member and, or support staff. For most people this will be sufficient to identify whether the person has difficulties or needs that are consistent with a global learning disability and is eligible for the service. If there is still some element of doubt, the third level of assessment may be needed
  3. full assessment, here a member of the clinical psychology service will undertake a full assessment using formal standardised assessments of intellectual ability and adaptive functioning

Exclusion criteria:

  • developmental disorders not associated with a learning disability, for example, Asperger’s Syndrome, ADHD (unless IQ less than 70)
  • specific learning difficulties, for example, dyslexia, dyspraxia unless associated with a global learning disability
  • problems arising from social exclusion issues that require social care rather than health care

Problems arising from acquired global cognitive and functional decline after the age of 18 that is not associated with a learning disability, for example:

  • acquired brain injury
  • cerebrovascular accident
  • brain hypoxia
  • cerebral infection or inflammation or tumour
  • uncontrolled epilepsy
  • dementia and other brain degenerative disorders references

AAID Ad Hoc Committee on Terminology and Classification (2010). Intellectual Disability: definition, classification and systems of supports 11th edition. American Association on Intellectual and Developmental Disabilities: Washington WHO (2001) (opens in new window).

Referrals are made via the care coordination centre on 01709 426600.

Referrals are then discussed during the health referral meeting every Wednesday which takes place at the learning disability service.

10.5.6.3 Contact details

Rotherham learning disability service:

10.5.7 Appendix E7 Referral North Lincolnshire learning disability service

10.5.8 Appendix E8 Speech and language therapy referral form

10.6 Appendix F RDaSH speech and language therapy contact details

10.6.1 Doncaster care group

Doncaster physical health service:

Learning disability service:

10.6.2 North Lincolnshire care group

Learning disability service:

10.6.3 Rotherham care group

Learning disability service:

Older people’s mental health service:

Document control

  • Version: 10.1.
  • Unique reference number: 381.
  • Approved by: Clinical policy review and approval group.
  • Date approved: 20 February 2024.
  • Name of originator or author: Clinical lead, speech and language therapist.
  • Name of responsible individual: Executive director of nursing and allied health professionals.
  • Date issued: 27 February 2024.
  • Review date: 28 February 2026.
  • Target audience: All staff in inpatient, residential or day service settings.

Page last reviewed: November 14, 2024
Next review due: November 14, 2025

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