This policy outlines the duties, roles and responsibilities of all professionals involved in the assessment and management of adults with dysphagia (difficulties with eating, drinking and swallowing) across all NHS Ayrshire and Arran settings. This policy aims to minimise the serious risks to health that dysphagia poses, and to promote the highest quality of person care.

All registered clinical staff and unregistered clinical staff who work with people with swallowing difficulties whilst they are eating/drinking should have awareness of the signs and symptoms of dysphagia.
Acute symptoms of dysphagia include:

• coughing or choking during or immediately after drinking and/or eating
• wet sounding voice during or after eating or drinking
• change of skin colour and/or watering eyes
• refusal of food before or during meal or increased anxiety at drink/meal times
• behavioural difficulties at drink/meal times.

Chronic symptoms of dysphagia include:

• chest infections
• malnutrition as identified by MUST assessment
• significant change to eating or drinking that is not explained by another cause
• dehydration
• fatigue, confusion, weakness.

Speech & Language Therapists (SLTs) are the healthcare professionals who assess, diagnose and make recommendations to minimise the risk of dysphagia in collaboration with the person and the Multidisciplinary Team (MDT). SLTs must have attained the appropriate training and be competent to undertake dysphagia assessment and treatment where this is part of their role. To work autonomously, clinicians should have attained Royal College of Speech and Language Therapists (RCSLT) Dysphagia Training and Competencies Framework Level C.

Nurses who have successfully completed the SLT led swallow screen training and competency framework may administer the nurse led swallow screen with people experiencing Acute Stroke only. All other registered and non-registered clinical staff should have undertaken awareness training of dysphagia.

SLT management crucially involves ensuring that all people with swallowing difficulties that are referred for assessment and management have dysphagia care plan that details recommendations for any modification food texture and drink thickness and any other day to day support or supervision needs.

The management of dysphagia should be based on MDT working and shared decision making.

This policy does not cover oesophageal dysphagia or paediatric dysphagia.

This policy will be disseminated to relevant staff members via the Area Nutrition Steering Group (ANSG) and will be accessible to all clinical staff involved in person care on AthenA.

Additional training may be required in order for staff to provide the care laid out in this policy. If any aspect of care is identified as falling short of these standards, this should be escalated to the Area Nutrition Steering Group (ANSG).

Swallowing is a highly complex skill organised by the cortex, brain stem and cranial nerves dependant on neuromuscular control, sensory feedback, and precise synchronisation with respiration and gastrointestinal function. The term dysphagia describes eating, drinking and swallowing difficulties which may occur in the oral, pharyngeal and oesophageal stages. Dysphagia includes difficulty swallowing safely and/or effectively.

Dysphagia is a common, and often unidentified, disorder. Dysphagia can be a transient, persistent or deteriorating state according to the underlying pathology. Prevalence is estimated to be 7-22% in the general population, with the incidence among elderly people requiring long term care rising to 40-50% and within the population of adults with a learning disability, the prevalence is given as 27%. Certainly, people requiring modified food textures and drink thickness are at high risk of poor nutrition (Pezzana et al., 2015) and sarcopenia (loss of muscle mass/strength) (Shimizu et al., 2018). Dysphagia can occur in response to a wide range of medical conditions, however the following populations are considered at higher risk of dysphagia:

• neurological conditions e.g. stroke, progressive neurological diseases, brain injury and dementia
• respiratory disease including COPD
• cardiac disease
• current or previous cancer e.g. head and neck cancer, lung cancer and the side effects of radiotherapy
• critical illness including when following an ICU admission (e.g. intubation, tracheostomy, ventilation, muscle atrophy)
• burns and inhalation injury
• surgery e.g. base of skull surgery, thyroid surgery
• adults with learning disabilities
• end stage disease processes
• frailty.

For people with swallowing difficulties there is an increased risk of pneumonia, dehydration, weight loss, malnutrition, increased length of hospital stay and an increased risk of morbidity and mortality. The psychological effects of dysphagia, including reduced quality of life, anxiety, and depression impact on physical recovery and should not be under-estimated.

However, with appropriate dysphagia management, these risks can largely be minimised or prevented. In order to achieve the best possible health and well-being outcomes for people with dysphagia, effective screening and management with multidisciplinary team (MDT) collaboration is essential.

There are significant cost implications associated with dysphagia. Length of stay in hospital is longer following stroke when people experience dysphagia compared with people without dysphagia, and people with dysphagia were twice as likely to be discharged to a care setting than those without (Odderson, Keaton and McKenna, 1995).

Purpose

The purpose of this policy is to ensure the identification and management of adults with dysphagia is safe and standardised across NHS Ayrshire and Arran. This policy is applicable to all staff and has been developed to:

• inform healthcare professionals of the role of the multi-disciplinary team in the management of dysphagia
• support healthcare professionals in the identification of people with dysphagia and the ongoing referral process
• provide clinicians and managers with explicit statements based on the current evidence, where available.

Definitions

Dysphagia - The term used to describe any difficulty a person may experience with eating, drinking or swallowing. Dysphagia is a difficultly in moving food from the mouth to the stomach, taking into account the cognitive, behavioural, sensory and motor components required in this process and how this impacts on emotional state.

Penetration - The entry of food, fluid, or other material into the laryngeal vestibule, but remaining above the vocal folds.

Aspiration - The passage of food, or fluid or other material past the vocal folds and into the airway.

NBM - Nil By Mouth; no oral intake. This includes food, fluids and medications.

VFS - Videofluoroscopic Study of Swallowing (VFS) is an assessment of the oropharyngeal stages of swallowing using a water soluble radio opaque contrast under radiological videofluoroscopic conditions. Also commonly referred to as a Videofluoroscopy, VFS, VFSS or Modified Barium Swallow (MBS).

IDDSI - International Dysphagia Diet Standardisation Initiative.

Thickener - Commercial thickening agent, added to drinks following comprehensive swallowing assessment to increase the viscosity with the aim of reducing risk of aspiration.

NGT - nasogastric tube.

ONS - oral nutritional supplements.

PEG - percutaneous endoscopic gastrostomy.

RD - registered dietitian.

RIG - radiologically inserted gastrostomy.

SLT - speech and language therapist.

OT - occupational therapist.

PT - physiotherapist.

ANSG - Area Nutritional Steering Group.

Scope

This policy applies to all staff (temporary and permanent) working in any of the locations registered by NHS Ayrshire and Arran to provide regulated activities. Locations are not necessarily geographically based or determined. Therefore, the term location(s) does not just refer to Board buildings; it is the term used to describe the hub of operations for a service or range of services and includes all activities and duties performed in the course of employment.

Multidisciplinary working is the key aspect of effective care for people with dysphagia. The composition of the multi-disciplinary team will vary depending upon the clinical setting.

The following professionals will be involved in differing roles within the team:

• Speech and Language Therapist (SLT)
• Dietitian (RD)
• Nurse
• Occupational Therapist (OT)
• Physiotherapist (PT)
• Social Work
• Care providers
• Catering
• Medical staff
• Pharmacist
• Pharmacist Technician.

The primary considerations in dysphagia management are safety and adequate provision of food and drinks to maintain good nutrition and hydration. It is also recognised that even a mild swallowing difficulty can have a significant social and psychological impact on the individual’s everyday life, therefore management should always aim to reduce this impact taking into account the individual’s preferences and beliefs. All decisions should be made in the individual’s best interest and their wishes should be at the heart of decision-making.

All decision-making discussions and outcomes that relate to a person’s dysphagia care plan must be carefully documented. If a situation should arise where a person with dysphagia does not wish to follow the recommendations of the SLT, this should be seen as an opportunity to review shared decision making and may include consideration of the person’s capacity in line with the Adults with Incapacity (Scotland) Act.

If oral intake is not possible or a person is unable to meet their nutritional requirements the Dietitian will assess each patient individually. The decision to embark on artificial feeding must be made by the multidisciplinary team following nutritional screening and assessment in consultation with the person (where possible), their family/carer, or legal representative in line with the G080 Enteral Feeding Guideline.

Education and support for the person with dysphagia along with their family/carers, is essential to ensure the best possible outcomes of a management plan. The treating SLT will provide information for individuals, carers and staff who are responsible for supporting eating and drinking using a standard template dysphagia care plan (see an example in appendix 1).

The International Dysphagia Diet Standardisation Initiative (IDDSI) framework is a global initiative that provides a common terminology to describe food textures and drink thickness (Cichero et al., 2017). The IDDSI framework consists of a continuum of 8 levels (see appendix 2):

Fluids: level 0 normal thin fluids, level 1 slightly thickened fluids, level 2 mildly thickened fluids, level 3 moderately thick fluids and level 4 extremely thick fluids.

Foods: level 3 liquidised, level 4 pureed, level 5 minced and moist, level 6 soft and bite sized, level 7 is split into two categories; level 7a easy to chew and level 7 regular foods.

NHS Ayrshire and Arran uses Levels 0-6 for modification to food texture and drink thickness, and level 7 regular diet. Level 7a (easy to chew) is not used in NHS Ayrshire and Arran as it is not currently possible to provide a level 7a in the hospital settings.

Supervision

People with swallowing difficulties often require assistance, support, or supervision to manage their swallowing difficulties safely. SLT recommendations should include a clear indication of the level of support and supervision required. It is the combination of modification to food texture and drink thickness alongside the adoption of strategies and supervision that promotes swallow rehabilitation progress and helps to reduce the risk of harm associated with dysphagia.

Decisions regarding the assignment of staff to deliver supervision or strategy completion support is based on the skills and experience of staff available to meet each person’s needs. Wherever possible, staff who know the person best should provide higher levels of supervision. The nurse in charge must ensure that staff are provided with relevant information and that each staff member has the skills to appropriately support the person with dysphagia.

SLT will use the following terminology when making recommendations regarding supervision:

Constant 1:1 supervision:

Is required for people who have been clinically assessed as requiring uninterrupted 1:1 supervision by a designated, appropriately skilled staff member who ensures the dysphagia care plan is adhered to in full. This type of supervision is only requested for people at the highest risk of aspiration or choke, who may have low insight into their swallowing difficulties or who require careful support to carry out strategies that help reduce risk.

Cohort supervision:

Is required for people who have been identified as having some managed risk of choke. This should be provided by a designated and appropriately skilled member of staff who can see the person at all times and be close enough to respond to any incident immediately. This type of supervision is often used for people who have a history of intermittent choke or who are progressing in dysphagia rehabilitation.

Intermittent supervision:

Is required for people who have been clinically assessed as requiring intermittent prompts to follow strategies. This level of supervision should be provided by a designated and appropriately skilled member of staff. This type of supervision is often used when independence is being encouraged or where recommendations have recently changed.

Encouragement, support and assistance (+/- mealtime set-up):

Is required for people who have mild swallowing difficulties or people who require support with encouragement, prompting, or assistance with dexterity and coordination tasks. This level of supervision can be provided by any designated member of staff. This type of support can include ensuring all necessary items are in reach and assisting with opening, cutting or spreading.

Independent:

No supervision or support is required.

Roles and responsibilities of teams and staff in adult dysphagia

All dysphagia related incidents should be reported via the DATIX system. This includes near misses, incidents where no appropriate meal or snacks were available and harm events. All relevant professionals should be included in the review process and contribute to any shared learning.

The provision of modified food texture and drink thickness to people in hospital, care, and home settings will involve various people and staff groups working in collaboration.

1. All NHS Ayrshire and Arran staff

All staff must be made aware of the importance of the correct provision of food and drinks to individuals with dysphagia through appropriate education and training.

2. Other health and social care staff

Staff working in community settings that are not employed by NHS Ayrshire and Arran are regulated by policies specific to their employer.

Related NHS Ayrshire & Arran documents/guidelines

There are a number of additional supporting policies and documents available to support the delivery of people’ nutritional needs. Local NHS Ayrshire and Arran documents relating to food fluid and nutrition can be found here on Athena

Other related NHS Ayrshire and Arran documents include:

G080 Enteral feeding guideline (2021)
G081 Insertion and care of fine bore NG tubes for enteral feeding and medication in adults (2019)
G094 Food, fluid and nutritional care policy (2020)
G095 Guideline for the provision of oral nutritional supplements (2017)
G098 Provision and management of patient meals (2021)
G106 Guideline for the basic oral care of inpatients (2021)

National documents

National documents used to inform this policy include guidance from:

• National Patient Safety Agency
• Scottish Intercollegiate Guidelines Network (SIGN)
• National Institute of Clinical Excellence (NICE)
• Royal College of Speech and Language Therapists (RCSLT)
• International Dysphagia Diet Standardisation Initiative (IDDSI)
• British Dietetic Association (BDA)
• BAPEN: Malnutrition and Nutritional Care in the UK

Bibliography

Brennan, K. (2015) Choosing formulations of medicines for adults with swallowing difficulties: Specialist Pharmacy Service. Available at: https://www.sps.nhs.uk/articles/choosing-formulations-of-medicines-for-adults-with-swallowing-difficulties/?UID=58799995320211024131547.

Cichero, J. A. Y., Lam, P., Steele, C. M., Hanson, B., Chen, J., Dantas, R. O., Duivestein, J., Kayashita, J., Lecko, C., Murray, J., Pillay, M., Riquelme, L. and Stanschus, S. (2017) 'Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework', Dysphagia, 32(2), pp. 293-314.

Marsh, K., Bertranou, E., Suominen, H., Venkatachalam, M. (2010) An economic evaluation of speech and language therapy, London: Royal College of Speech and Language Therapists. Available at: http://www.rcslt.org/giving_voice/matrix_report.

North East Wales NHS Trust (2006) NEWT Guidelines for administration of medication to people with enteral feeding tubes or swallowing difficulties Available at: http://www.newtguidelines.com.

Odderson, I. R., Keaton, J. C. and McKenna, B. S. (1995) 'Swallow management in patients on an acute stroke pathway: quality is cost effective', Archives of Physical Medicine and Rehabilitation, 76(12), pp. 1130-3.

Pezzana, A., Cereda, E., Avagnina, P., Malfi, G., Paiola, E., Frighi, Z., Capizzi, I., Sgnaolin, E. and Amerio, M. L. (2015) 'Nutritional care needs in elderly residents of long-term care institutions: Potential implications for policies', The Journal of Nutrition, Health & Aging, 19(9), pp. 947-954.

Shimizu, A., Maeda, K., Tanaka, K., Ogawa, M. and Kayashita, J. (2018) 'Texture-modified diets are associated with decreased muscle mass in older adults admitted to a rehabilitation ward', Geriatrics & Gerontology International, 18(5), pp. 698-704.

The Royal Pharmaceutical Society (2021) MedicinesComplete: The Royal Pharmaceutical Society. Available at: https://about.medicinescomplete.com/#/.

Employees are reminded that they may have people/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some people/carers may have difficulties with written material. At all times, communication and material should be in the person’s/carer’s preferred format. This may also apply to people with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining people.

Some people may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure requiring adaptations to be made.

People’ sexual orientation may or may not be relevant to the implementation of this guideline, however, non-sexuality specific language should be used when asking people about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality Impact Assessment Tool Kit. No additional equality & diversity issues were identified.

SLT dysphagia care plan example

IDDSI framework

Nurse led swallow screen protocol (water swallow test)

Speech and Language Therapy levels of intervention

Thickened Fluids Level 1 – 4 supplements should be served at room temperature only.

No other supplements should be offered.

The following supplements are not recommended for people requiring thickened fluids:

1. Clinical and legal aspects of administration of medicines by altering solid-dose formulations

Referral to the ward clinical pharmacist should always be made if advice is required or there is concern over the suitability of medicines in people with swallowing difficulties.

The pharmacist should follow this stepwise approach when reviewing formulations of medicines in people with swallowing difficulties: Specialist Pharmacy Service Choosing Formulations of Medicines for Adults With Swallowing Difficulties (Brennan, 2015).

This stepwise approach includes reviewing which medicines are needed, considering how the patient eat and drinks, considering who will prepare and administer the medicines, choose a licensed products where possible, check if a tablet can be crushed or a capsule opened and decide if a medicine can be given with soft food or thickened fluid.

When tablets are crushed or capsules opened to facilitate safe administration of medicines to people with eating, drinking or swallowing difficulties, they are being used out with the terms of their Marketing Authorisation and are referred to as “off-label” medicines. “Off-label” use is an unlicensed use of a medicine.

Responsibility for the clinical use of that medicine rests with the prescriber, and by implication NHS Ayrshire and Arran. Prescribers must ensure that they are aware of the implications of using medicines “off-label” and ensure that “off-label” use is restricted to situations where there is no suitable licensed alternative to meet the clinical need of the individual patient.

For further information please refer to NHS Ayrshire and Arran Code of Practice For Medicines Governance Section 9b - "Off Label Use of Medicines

Some liquid formulations of medicines do not possess a Marketing Authorisation and are classified as unlicensed medicines. These liquid medicines are manufactured according to a defined specification from the holder of a Manufacturer’s “Specials” Licence.

The clinical responsibility for the use of an unlicensed medicine lies with the prescriber. If a patient is harmed by an unlicensed medicine, and not because of any defect in the product itself, then the prescriber is directly liable for that harm. Prescribers must ensure that they are aware of the implications of using unlicensed medicines and undertake an assessment to ensure that there are no licensed alternatives available to meet the clinical need of the individual patient.

For further information please refer to NHS Ayrshire and Arran Code of Practice For Medicines Governance Section 9(a)-Unlicensed Medicines

The prescriber should prescribe medicines for people with eating, drinking or swallowing difficulties in accordance with a hierarchy of risk based on product origin. Refer to UKMI North West Choosing medicines for patients unable to take solid oral dosage forms.

A procedure for administrating medication in people with swallowing difficulties is included below. This should only be used after the appropriateness of the medication via that route has been determined.

2. Preparation and administration of medication in people with swallowing difficulties

This procedure should only be used after the appropriateness of the medication route has been determined.

Each medicine should be administered separately and immediately after preparation. Do not mix two or more drugs. Do not leave prepared drugs unattended.