The Board should recognise the seriousness and importance of dysphagia and its effect on person outcomes and is responsible for ensuring the compliance with local and national Standards.

The ANSG is responsible for agreeing and ensuring the provision of nutritional care across NHS Ayrshire and Arran in line with national standards and statutory requirements. It will co-ordinate and monitor appropriate education and training programmes for all staff involved in nutrition provision and develop and improve communication related to dysphagia food, fluid and nutrition.

Service Managers will promote awareness of this policy and ensuring adequate staff education on dysphagia, food, fluid and nutrition-related matters.

Across hospital and community settings Clinical Nurse Managers (CNM) and Senior Charge Nurses (SCN) have operational responsibility to ensure staff compliance with this policy and promote dysphagia awareness. Clinical Nurse Managers and/or the Senior Charge Nurse should review relevant DATIX or other incident reports related to dysphagia in collaboration with SLT when appropriate and escalated if required.

Medical staff will:

• Include information about swallow history during history taking or admission clerking.
• Identify people suspected of having dysphagia, and refer to the appropriate SLT team with up-to-date, detailed and relevant information ensuring a comprehensive dysphagia assessment is requested as soon as dysphagia is identified or suspected.
• Ensure the primary considerations in dysphagia management are safety and the provision of adequate nutrition and hydration, recognising the psychological impact on the individual’s everyday life. Decision making should take into account the individual’s preferences and beliefs to enable the individual to remain at the heart of all decision-making.
• Consider placing those people deemed to be at very high risk of aspiration on oral intake nil by mouth (NBM) until SLT assessment. Modified food texture or drink thickness should not be commenced prior to SLT assessment, because this can increase the risk of aspiration dependent upon the type of dysphagia.
• Clearly document a ‘NBM plan’ to include the plan, date and time and staff role responsible for review.
• Ensure people who are unable to take sufficient nutrition orally, but in whom the gastrointestinal tract is functioning, are referred to the Dietitian for individual assessment regarding enteral nutrition.
• Ensure a multidisciplinary discussion regarding long term alternative feeding has been considered if the prognosis for swallow recovery remains poor after approximately 4 weeks.
• Consider the complex ethical aspects of feeding decisions and to liaise closely with the individual, family, SLT, dietetic and nursing staff. This is particularly important in shared decision-making relating to eating and drinking with acknowledged risks (previously known as risk feeding) considering the best interests of the individual and their mental capacity.
• Support shared decision-making in dysphagia, where oral intake is consumed accepting a high aspiration risk and its potential consequences. This should always follow a SLT swallow assessment, and include a mental capacity assessment, discussion with the individual, their family and MDT. This decision must ultimately be approved by the treating Consultant/GP and be clearly documented.
• Monitor chest status and consider antibiotic treatment as appropriate.
• Prescribe medications for dry mouth or saliva management where appropriate.
• Review medications in collaboration with pharmacy colleagues for suitable alternatives if dysphagia impacts on the ability to swallow tablets safely or easily e.g. liquid solutions, via nasogastric tube (NGT)/percutaneous endoscopic gastrostomy (PEG)/radiologically inserted gastrostomy (RIG).
• Liaise with SLT to include relevant and up-to-date information regarding dysphagia diagnosis and swallowing recommendations in medical discharge summaries. This includes the addition of thickener as necessary to a list of prescribed medications.

Nursing staff have a vital role in identifying dysphagia and gathering information on admission regarding the person’s pre morbid eating and drinking habits, preferences, and dietary intake. Nursing staff will:

• Understand the risks and health consequences associated with dysphagia and complete relevant dysphagia training throughout their employment.
• Include information about swallow history during history taking or admission clerking.
• Identify people suspected of having dysphagia, and to refer to the appropriate SLT team with up-to-date, detailed and relevant information to request a comprehensive swallowing assessment be undertaken as soon as possible once dysphagia is identified or suspected.
• Ensure that in hospital, people who have been placed NBM awaiting SLT review remain so until this occurs.
• Ensure all people admitted with a suspected stroke or with trans-ischaemic attack being cared for out with wards dedicated to stroke care are placed NBM on admission and follow the Acute Stroke Protocol. Nurses should request a Water Swallow Test and general advice about safe swallowing.
• Ensure oral hygiene is managed in hospital settings following the G106 Guideline for the Basic Oral Care of Inpatients.
• Ensure that, in all nursing/ward settings, people with longstanding dysphagia and existing recommendations of food textures and drink thickness have their usual food textures and drink thickness provided. This information must be recorded using the IDDSI descriptors on admission and displayed in all relevant locations to ensure safe patient care.
• Ensure any change to a prescription of food textures and/or drink thickness is included in handovers and the pantry whiteboard is up-to-date and accurate.
• Ensure when a person moves bed, transfers between wards or hospitals, or has to spend some time in an environment where their usual team are not present, the appropriate texture prescription is transferred with them. Complete menu cards correctly including the prescription of food textures and drink thickness where this impacts on the provision of meals e.g. cereals with milk, soups and sauces as well as other requests and recommendations from SLT and Dietetics e.g. portion sizes
• Explain the use of dietary codes and ensure that only foods with the appropriate IDDSI levels 3-6 are chosen and ensure the use of an accessible communication (pictorial) menu where required.
• Refer all individuals who require IDDSI level 3 or level 4 diet to the Dietetic Department for assessment. Referral of people on other levels of food texture or fluid thickness should be based on the results of nutritional screening.
• Complete Malnutrition Universal Screening (MUST) within 24 hours of admission and repeat weekly in acute setting.
• Ensure that SLT dysphagia care plans are implemented in full, including prescription of food textures and drink thickness, safety and accessibility strategies, and supervision and assistance recommendations made by SLT including when MDT discussion and shared decision-making relating to eating and drinking with acknowledged risks (previously known as ‘risk feeding’) are implemented.
• Observe and assess for changes in a person’s swallowing ability and discuss any change in a person’s swallow promptly with SLT.
• Document all oral intake accurately on Nutritional Intake Record Chart (NIRC), highlighting inadequate oral intake, discuss with the multidisciplinary team and alert the dietitian.
• Liaise with medical, pharmacy and SLT colleagues about the management of oropharyngeal secretions.
• Consult with the pharmacist if there is concern over the suitability of medication if dysphagia impacts on the ability to swallow tablets safely or easily e.g. liquid solutions.
• Liaise with medical, pharmacy and SLT colleagues to ensure the appropriate administration of medication for people with dysphagia.
• Liaise with medical and pharmacy colleagues to ensure anyone requiring thickener has an appropriate prescription and supply of a thickening agent, particularly after initial SLT intervention and at the point of discharge.
• Ensure appropriate storage of thickener following ward protocol.
• Check MDT discharge plan and ensure all actions relating to dysphagia management are complete.
• Ensure that a copy of the current SLT dysphagia care plan is included in transfer documentation on discharge to another care setting.

Only nurses who have successfully completed the SLT led swallow screen training and competency framework may administer the nurse led swallow screen (see appendix 3). Nurses trained in swallow screening will:

• Administer the nurse led swallow screen when stroke is suspected or confirmed, within four hours of admission. The nurse led swallow screen should not be administered on other (non-stroke) person groups.
• Discontinue the nurse led swallow screen when a person lacks the ability to sustain alertness or upright seating for at least ten minutes. The nurse led swallow screen may be repeated by trained nursing staff if and when these abilities return.
• Refer individuals who have failed the screening immediately to Speech and Language Therapy for a full swallow assessment. The person should be placed NBM awaiting SLT review.
  N.B. at weekends and public holidays when there is no SLT service available the screening can be repeated 12 hourly or when there is an improvement in neurological presentation.
• Never re-screen any person whose swallowing difficulty is already being managed by SLT. Any deterioration in a person’s swallow should be reported immediately to SLT allow for prompt re-assessment.
• Complete SLT led refresher training on the nurse led swallow screen every 12 months.

Community based nursing staff e.g. Learning Disabilities nurses or District nurses have a key role in both raising awareness of dysphagia as a possible diagnosis and monitoring adherence to any dysphagia care plan assigned by speech and language therapy.

• Understand the risks and health consequences associated with dysphagia and complete relevant dysphagia training throughout their employment.
• Include information about swallow history whilst populating the individuals care plan/health needs assessment.
• Identify individuals suspected of having dysphagia, and to refer to the appropriate Speech and Language Therapy (SLT) team with up-to-date, detailed and relevant information to request a comprehensive swallowing assessment be undertaken as soon as possible once dysphagia is identified or suspected.
• Promote that all current dysphagia care plan recommendations are being adhered to by the individual or their care provider and refer back to speech and language therapy for review/re-assessment when appropriate and necessary.
• Participate in multi-disciplinary discussions regarding the implementation of any dysphagia care planning that may include but not exclusively: anticipatory care planning, discussions regarding capacity, consent and dysphagia care planning and discussions regarding alternative means of feeding.

Speech and Language Therapists have a key role in the identification and management of dysphagia and work closely with other members of the team. The SLT takes a lead role in the development of a management plan and will discuss the nature of the intervention with the individual (where possible), the multidisciplinary team, carers and the family. Therapeutic intervention will be decided with reference to the NHS Ayrshire and Arran SLT Department Levels of Intervention Tool (see appendix 4).

SLT team leads

Speech and Language Therapy Team Leads will:

• Hold operational responsibility for ensuring compliance with and implementation of this policy by the SLT Department.
• Ensure all SLTs undertaking clinical work with dysphagia have the appropriate level of knowledge and relevant competencies, and attend relevant training as required. To work autonomously, clinicians should have attained RCSLT Dysphagia Training and Competencies Framework Level C.
• Ensure all SLTs, working with individuals with dysphagia comply with the Health and Care Professional Council (HCPC) standards and operate only within their scope of practice.
• Ensure all SLT Assistant Practitioners work within their scope of practice as delegated by a qualified clinician.
• Review DATIX or other incident reports relevant to dysphagia and action as appropriate.
• Collect and audit outcome measures regarding dysphagia where appropriate.
• Be accountable for ensuring that SLTs audit dysphagia practice.
• Highlight issues relating to management of people with dysphagia within the Board via SLT Governance and the ANSG.

Speech and language therapists

Speech and Language Therapists will:

• Triage all referrals using a clinical risk vs SLT impact tool. It is good practice that SLTs inform referrers of the outcome of triage and provide an expected response time when clinically appropriate. Timeframes vary according to procedures, guidelines and staffing of local teams.
• Liaise closely with the individual, all relevant professionals and carers regarding medical and social history, and swallowing history including previous and current dysphagia.
• Carry out a full clinical bedside swallowing assessment, as appropriate (multiple assessments may be required over time) to allow accurate diagnosis of dysphagia and safe management. Assessment and recommendations should take into account the individual’s cognitive abilities, their individual requirements, as well as any guardianship arrangements, circumstances, culture, wishes and preferences.
• Recommend a video-fluoroscopic evaluation of swallowing if further information on the anatomy or physiology of the swallow is required to supplement clinical decision-making.
• Refer or request referral to other members of the MDT where clinically indicated, e.g. Dietitian, Ear Nose and Throat (ENT), Gastroenterology.
• Document in electronic patient records or SLT paper notes, the results of assessment and the management plan.
• Liaise with other members of the multidisciplinary team as required to ensure that individual postural, nutritional, and behavioural and equipment needs are met.
• Discuss the proposed dysphagia care plan with the individual and where appropriate, relevant others including members of the MDT, other health and social care professionals, and family or carers. In all inpatient settings, this must include the named nurse on duty at the time of the assessment. SLTs should refer to individual site SOPs for further guidance.
• Provide a dysphagia care plan in all settings for any individual identified as having dysphagia that clearly communicates recommendations about modification of food textures and drink thickness, levels of supervision and assistance, safety and accessibility strategies that may include posture, bolus size, pacing and presentation of food and/or drinks, rehabilitation of the swallow, and recommendations related to shared decision-making in relation to eating and drinking with acknowledged risks (previously known as ‘risk feeding’) as required.
• Ensure dysphagia care plans must be shared with all relevant parties. In an acute setting, this can be found on the information board at the head of the bed (inpatient) with food textures, drink thickness and supervision and safe swallowing strategy requirements. In community settings this may be with the individual, their family, carers and appropriate professionals.
• Provide swallowing rehabilitation where appropriate, review, and reassess as required to ensure intervention continues to be appropriate.
• Contribute to ward rounds, MDT, social work reviews and family/paid carer meetings regarding dysphagia management (including tracheostomy) where appropriate.
• Contribute to the education and training of those responsible for providing food and drinks, or supporting people with dysphagia.
• Provide support, education and information (verbal and/or written) for the individual, their family and carers regarding dysphagia diagnosis, enabling informed decisions concerning eating and drinking.
• Liaise with medical colleagues to ensure up-to-date information on dysphagia diagnosis and swallowing recommendations in inpatient medical discharge summaries. This may include the addition of thickener to a person’s list of prescribed medications.
• Ensure the provision of appropriate information when the care of people with dysphagia is transferred between teams and settings.
• Send a discharge report to the person, their GP and any other relevant professionals on the completion of an SLT intervention. This should include how to contact the SLT if concerns or questions arise including when re-referral may be required.
• Highlight issues relating to management of people with dysphagia within the appropriate hospital and community sub group of the Area Nutritional Steering Group.

Dietitians have a vital role to play in the nutritional assessment and management of people with eating, drinking and swallowing difficulties, and work in close conjunction with Speech and Language Therapists to support people with dysphagia. On referral, the dietitian will:

• Complete a full nutritional assessment and implement a person specific treatment plan which will be monitored and adjusted accordingly depending on need.
• Take into account modification to food textures and drink thickness recommendations when determining appropriate interventions for diet including a food first approach and nutritional supplementation.
• Discuss the proposed treatment plan with the person, their nurse, relative, or carer including the provision of appropriate information when the care of people with dysphagia is transferred between teams and settings.
• Work closely with other healthcare professionals including Catering Department.
• Evaluate the need for alternative routes of feeding depending on the SLT recommendations and liaising with the MDT.
• Advise on the most appropriate artificial feeding regime, liaising with pharmacy in relation to drug and enteral feeding interactions.
• Monitor and review, adapting dietetic goals accordingly.
• Arrange appropriate training education and support on home enteral nutrition for patient, family or health/care agencies.
• Liaise with medical team for individuals considered at high risk of refeeding syndrome.

Pharmacists provide pharmaceutical care to people with eating, drinking and swallowing difficulties both in the ward setting and in Medicines Information. They prescribe new medicines, alternative formulations or routes of medicines or stop medicines (if the pharmacist is an independent prescriber) and advise on administration of medicines and interactions with drugs and dietary products. On identification, or notification by appropriate members of the multi-disciplinary team, of people with eating, drinking and swallowing difficulties the pharmacist will:

• Review if all prescribed medicines are required and which may be safely withheld during acute treatment.
• Review all prescribed medication ensuring suitability for safe and effective administration using references such as NEWT guidelines (North East Wales NHS Trust, 2006), or Handbook of Drug Administration via Enteral Feeding Tubes (The Royal Pharmaceutical Society, 2021).
• Prescribe, or advise clinicians on, alternative medicines, alternative formulations or routes of medicines if the person is unable to swallow prescribed medications safely.
• Advise nursing staff of any additional instructions on suitable and safe administration of medicines.
• Review prescribed medications regularly to ensure medication is prescribed appropriately if ability to swallow improves or deteriorates.
• Advise on the suitability and safety of medicines for those people requiring modification to food textures or drink thickness.
• Advise on medicines used for dry mouth or to reduce, or loosen secretions and to aid secretion management.
• Liaise with medical, nursing and SLT colleagues when reviewing the need for inclusion of thickener in medications.
• Inform staff of any specific information regarding the administration of medicines via nasogastric or gastrostomy tube (refer to NHS Ayrshire and Arran Enteral Feeding Guideline)
• Review and validate Immediate Discharge Letters and ensure additional instructions for the preparation of off-label medicines (such as crushing tablets and opening capsules) are added.
• Provide information to the person, their family, or carers regarding medication if necessary.
• Be aware of the implications of using unlicensed and “off-label” medicines (see appendix 6)

Pharmacy technicians are involved in the pharmaceutical care of patients. The pharmacy technician can:

• Provide information from relevant sources on alternative medicines, formulations or routes of medicines if the person is unable to swallow prescribed medications safely. In this case the clinical decision on the appropriateness or choice of medicine and how to administer the medicine will be made by a pharmacist or relevant prescriber.
• Advise nursing and medical staff, as well as the person, their family or carers of any additional instructions to ensure suitable and safe administration of medicines.

Occupational Therapists provide a key role in improving function and promoting independence. For people with eating, drinking and swallowing difficulties, the occupational therapist will:

• Assess for the use of eating and drinking utensils and equipment where appropriate.
• Provide information about how to purchase equipment suggested if not available through statutory provision.
• Review sitting position, including position of feet, pelvis trunk and head in chair.
• Provide environmental advice and identify sensory processing needs if appropriate.

The physiotherapist can provide specialist advice regarding the therapeutic positioning and make recommendations regarding position and/or requirements to reduce risk of aspiration.

Physiotherapy can also have a role in the management of respiratory sequelae or complications of the aspiration of food or fluids. In the process of respiratory management e.g. during suctioning, the physiotherapist may identify the presence or suspicion of food or fluid in the airway. As such they can play a key role in the early identification of patients where aspiration is a risk.

For people with eating drinking and swallowing difficulties, the physiotherapist will:

• Review postural stability, alignment and symmetry.
• Suggest alternative positioning techniques.
• Liaise with Speech and Language Therapists regarding potential impact of respiratory issues on dysphagia management.

The catering department and staff have a key role in the provision of nutritious and suitably fortified foods. For people requiring modification to food textures or drink thickness, a competency assessed cook will prepare all food and adhere to the NHS Ayrshire and Arran Diet Bay Manual for preparation of these diets. Catering staff are not responsible for thickening drinks. Staff will:

• Understand the risks and health consequences associated with dysphagia and complete relevant dysphagia awareness training throughout their employment.
• Ensure there is sufficient provision of appropriate food for all people with eating and swallowing difficulties on, and throughout admission.
• Ensure the provision of appropriate food for the purposes of dysphagia assessment, liaising with SLT as required.
• Refer to information communicated by the nursing staff, SLT, or Dietetics regarding an individual’s eating and drinking prescription and recommendations.
• Ensure that all food textures that include IDDSI Levels 3-6 follow SLT recommendations, with particular attention to food with mixed consistencies e.g., cereal and milk, soup.
• Ensure the provide food and drinks is compliant with eating and drinking guidelines, including when a person is NBM and should not receive food or fluid. Catering staff are not to provide food or drinks outside of these guidelines, even if the person requests them.
• Ensure the provision of appropriate food and drink for all people with dysphagia, including the provision of cultural food or drink preferences and/or allergy requirements.
• Assist with preparation, plating and service of diets with modification to food textures.
• Ensure food is prepared to the correct texture in line with IDDSI guidelines and is attractively presented when leaving the kitchen.
• Issue commercial thickening agent to wards on request, checking ‘Best Before’ dates prior to issue.
• Place meal on a red tray, when a red dot on menu card for assisted service.

Paid carers in the community can work with individuals with dysphagia in a variety of settings e.g. the persons home, a residential home care or day services. In line with the requirement to meet assessed need, employers must ensure that all relevant staff have been provided with appropriate training were a dysphagia care plan is in place. All paid carers would be expected to:

• Understand the risks and health consequences associated with dysphagia and complete relevant dysphagia training in accordance with their employer’s protocols.
• Ensure that all food, fluid and support recommendations as outlined in the dysphagia care plan by the speech and language therapist, are followed.
• Be aware of the signs of both acute and chronic dysphagia and request a review or initial assessment by the speech and language therapist as appropriate.
• Ensure that the individual has access to their prescribed thickening agent in all settings, if this is part of the individual’s dysphagia care plan.
• Provide people with eating, drinking and swallowing difficulties with access to a copy of an accessible communication (pictorial) menu where required.
• Refrain for making adaptations to an individual’s dysphagia care plan unless under the guidance of an appropriately qualified speech and language therapist.
• Ensure that the dysphagia care plan is filed appropriately so that all carers working with the individual know where to access the appropriate information, in accordance with their employer’s protocols.
• Follow any other specific requirements as detailed in the dysphagia care plan.

For a variety of reasons, some people require assistance with eating and drinking. To support the MDT, volunteers may be recruited as ward mealtime volunteers. Duties may include opening packages, cutting up food or helping people during mealtimes. These volunteers should receive training through an induction and a mealtime volunteer training day that is delivered by appropriately identified healthcare staff. Once allocated to a ward, the volunteers will receive on-going support and supervision from the MDT and their NHS named contact.

Mealtime volunteers must not support people that have been identified by Speech and Language Therapy as having eating, drinking and swallowing difficulties.

All members of staff with direct person care have a duty to be aware of dysphagia and its consequences.