Dysphagia Management Policy

Transcription

1 Dysphagia Management Policy DOCUMENT CONTROL: Version: 7 Ratified by: Quality and Safety Sub Committee Date ratified: 1 August 2016 Name of originator/author: Nina Brookman Clinical Lead Speech and Language Therapist Name of responsible Clinical Quality Group committee/individual: Date issued: 1 September 2016 Review date: August 2019 Target Audience All staff in in-patient, residential or day service settings Page 1 of 37

2 SECTION CONTENTS PAGE NO. 1. INTRODUCTION 3 2. PURPOSE Definitions/Explanation of Terms Used 4 3. SCOPE 4 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 5 5. PROCEDURE/IMPLEMENTATION Identifying Dysphagia Referring to Speech and Language Therapy Managing Dysphagia Dysphagia Risk Assessment Choking Action 9 6. TRAINING IMPLICATIONS 9 7. MONITORING ARRANGEMENTS 9 8. EQUALITY IMPACT ASSESSMENT SCREENING Privacy, Dignity and Respect Mental Capacity Act LINKS TO ANY ASSOCIATED DOCUMENTS REFERENCES APPENDICES 10 Appendix 1 Guidance for Use and Storage of Thickening Agent 12 Appendix 2 High Risk Diet Items Advice Sheet 14 Appendix 3 RDaSH Modified Diet Advice Sheet 15 Appendix 4 RDaSH Modified Fluids Advice Sheet 18 Appendix 5 Referral Forms 19 Appendix 6 Procedure for Ensuring Communication with Regards Modified Diet and or Fluids Appendix 7 RDaSH Speech and Language Therapy Contact Details Appendix 8 Dysphagia and Choking Risk Assessment Page 2 of 37

3 1. 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 normally. 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, 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 texture modified diet/consistency to reduce the possible risk of aspiration (food/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. Swallowing problems in people with Learning Disabilities are also very common. 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/fluids, prolonged chewing and holding food/fluid in the mouth. Page 3 of 37

4 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. 2. 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 i.e. in patient wards, day hospital/services provision and RDASH Learning Disability care homes. This policy links to the Resuscitation Policy and the recommendations from the National Patient Safety Agency (NPSA). 2.1 DEFINITIONS/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. 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/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 normally 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. 3. SCOPE This policy applies to Trust staff who are involved in caring for all in-patients in residential areas and day services across Rotherham, Doncaster and North Lincolnshire. Page 4 of 37

5 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 Board of Directors The 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 Operational Services Director. 4.2 Inpatient/Residential Services Managers 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 using the Trust s Safeguard Incident Reporting System and investigating such incidents, involving the multidisciplinary team. 4.3 Inpatient/Residential Services Clinical Staff Clinical staff are responsible for the following: To be aware of patients who may be at risk of dysphagia by completing a risk assessment and following the recommended action 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 1); Reporting of choking incidents and contributing to the investigation of such incidents. 4.4 Speech and Language Therapists The Speech and Language Therapist 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. 4.5 Dietitian 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. Page 5 of 37

6 5. PROCEDURE/IMPLEMENTATION 5.1 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. Individuals with Dysphagia need to be risk assessed and carefully managed. A risk assessment must be completed by all Adult Learning Disabilities (ALD) and Older People s Mental Health (OPMH) inpatient areas on admission. For other inpatient areas the risk assessment is to be completed if there is a history of/reports of behaviours surrounding food and/or known difficulties swallowing. See Appendix 8. A Nutritional Screening Assessment e.g. MUST, can be completed as referred to in the Trust s Nutrition Policy and referral to a Dietitian where appropriate. It is well known that certain foods present a higher risk of choking than others (Appendix 2). Staff need to be aware of these and also ensure any food brought into the ward/care home or other situations by carers and relatives match the consistency that is deemed appropriate for the individual patient (see Appendix 3). The same applies for fluids (Appendix 4). 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. 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/taking a long time to finish meals Pooling of food, or food residue remaining in the patient s mouth Difficulties with chewing and manipulating food in the mouth Poor lip closure/difficulties in controlling fluid or saliva in the mouth Dribbling or drooling after eating 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 chest infections Regurgitation of food/nasal regurgitation Poor oral hygiene 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: Page 6 of 37

7 Lack of interest or attention to food and drink and the feeding environment Cramming/overloading of food into mouth Will overload their mouth having taken food from others or from fruit bowls Holding food/drink in the mouth Will accept or put any item into the mouth Swallows 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 penetrates the patient s airway or enters the lungs this will manifest itself acutely as choking, coughing, wheezing and respiratory distress. 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, on-going problem, as opposed to an acute one, the patient may have chronic symptoms. Please refer to the Trust life support training for management of a choking episode. Signs of acute aspiration Pyrexia Coughing and choking Change of colour Sounds of respiratory distress Loss of voice or changes in voice quality Gasping Rapid heart rate Signs of chronic aspiration Loss of weight Repeated chest infections Hunger Excess/changes in oral secretions Respiratory problems Coughing and choking history Refusal to eat 5.2 Referring to Speech and Language Therapy Each Business Division within RDaSH has their own referral pathway (Appendix 5). 5.3 Managing Dysphagia 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 Page 7 of 37

8 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 consistency and this must be communicated to all staff involved in that patient s care on a daily basis (see Appendix 6). Patients on a recognised modified texture diet consistency must be given ONLY the correct diet consistency and this includes snacks/foods 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 Speech and Language Therapist and on a modified stage diet foods. The Dietician and Speech and Language Therapist can provide advice regarding individual s needs, and all requirements should be accurately documented in care plans. Contact details for Speech and Language Therapy are attached in the appendices (see Appendix 7). Dehydration and malnutrition can also result from dysphagia. Clinical staff must assess patients for possible signs of these and devise an appropriate care plan. When prescribing for patients with dysphagia, the following points should be considered: The patient's medication should be reviewed and unnecessary medicines stopped. It is important to consider whether continuation of all medicines is imperative. If the dysphagic state is likely to be temporary, then short-term discontinuation of some medicines may be more appropriate. For all medicines that need to be continued an alternative delivery route should be considered, such as patches or suppositories. Where an alternative route is not available, alternative dose forms may be available e.g. dispersible tablets or liquid preparation. In exceptional circumstances crushing a tablet or opening a capsule may be the appropriate option (ensure informed patient consent is obtained and that adequate documentation of this is made). Advice should be sought from the pharmacy department regarding suitable alternatives. 5.4 Dysphagia Risk Assessment Any choking incidents must be reported on the Trust s Safeguard Incident Reporting System. If the patient has a change in their level of need a reassessment must be undertaken in particular if their eating and drinking patterns have changed. As part of the measures to promote good practice and meet the patient s individual needs/requirements at mealtimes, the National Patient Safety Page 8 of 37

9 Agency has produced Dysphagia Mealtime Information Sheet. This can be obtained from Choking Action Please refer to the Trust life support training sessions and policy for recognition and emergency actions to take if a patient is choking. 6. TRAINING IMPLICATIONS No specific training requirements have been identified. However, staff should receive basic Dysphagia Awareness training where appropriate e.g. if required in relation to their working environment. Texture modified diet consistency sheets are available from the Speech and Language Therapy departments. Choking/risks hand outs are included in Life support training which is mandatory for all clinical staff. 7. MONITORING ARRANGEMENTS Area for monitoring Incidents of choking How Who by Reported to Frequency IR1 Reporting System Staff member involved in the incident Resuscitation Officer Matrons/Service Managers. As and when incidents occur. SALT area Leads IR1 reports Annual audit IR1 report reviews Resuscitation Officer Resuscitation Officer Matrons/Service Managers. SALT area Leads Resuscitation Committee Relevant Business Division forum Annually On exception basis 8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website. 8.1 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. Indicate How This Will Be Met Page 9 of 37

10 As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all patients 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). No issues have been identified in relation to this policy. 8.2 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 Individual s capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals 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. 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 interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. Indicate How This Will Be Achieved All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act (Section 1) 9. LINKS TO ANY ASSOCIATED DOCUMENTS Life Support Handout What may increase a person s choking risk May be read in conjunction with: Nutrition Policy Resuscitation Policy 10. REFERENCES The National Patient Safety Agency (NPSA) Guide to levels of negative health consequences from dysphagia The National Patient Safety Agency (2007) Royal College of Speech and Language Therapist Clinical Guidelines 2005 Problems Swallowing? Resources for healthcare staff. July Ensuring safer practice for adults with learning disabilities who have Dysphagia. RCSLT APPENDICES Appendix 1 Guidance for Use and Storage of Thickening Agent Appendix 2 Difficult Food Textures Guidance Sheet Appendix 3 RDaSH Modified Diet Guidance Sheets Appendix 4 RDaSH Modified Fluids Guidance Sheet Appendix 5 Referral Forms Page 10 of 37

11 Appendix 6 Procedure for Ensuring Communication with Regards Modified Diet and or Fluids Appendix 7 Speech and Language Therapy Contact Details Appendix 8 Dysphagia and Choking Risk Assessment Page 11 of 37

12 Guidance for Use and Storage of Thickening Agent Appendix 1 Process: Use and Storage of Thickening Agent. Author: Adapted from DBHFT SOP (Stephanie Long/Simon Smith/ Sheila Maye) by Nina Brookman Version: 1 Date issued: 19/11/2015 Risks identified with performing Countermeasure this SOP 1 Daily establishments Follow this Guidance 2 Bank/agency/new starters to centre Follow this Guidance The purpose of this Guidance is to provide a structured guide for the individual who is responsible for the administration and safe storage of thickening agent. The Guidance is relevant to all RDaSH clinical areas where drinks are provided i.e. inpatient wards, Evergreen Day Services. List of people who may be involved in this Guidance: Nursing staff, therapy staff, service staff, visitors, patients Instruction Thickening agent should be stored in the ward kitchen, practice kitchen, on the drinks trolley or patient s bedside lockers. Whilst being stored it should be out of reach of patients unless they have been assessed as able to thicken their own drinks After thickening a patient s drink return the thickening agent to the ward kitchen, practice kitchen, drinks trolley or patient s bedside locker as per risk assessment After opening, thickening agent should be used within 2 months and should be labelled with the date opened and the date it should be used by. A Speech and Language Therapist (SLT) or dysphagia qualified practitioner should assess if a patient is competent to thicken their own drinks. This decision should be documented in the patient s care plan and on the sign above their bed All patients should be made aware of the risks of consuming thickening agent if not added to drinks. A patient must be assessed as competent to thicken their own drinks prior to self-management. This should be documented in their care plan. The patient should be made aware of the risk to other patients if thickening agent is left within reach of other patients. All staff need to be aware of the NHS England National Safety Alert Responsible All staff All staff All staff SLT or Dysphagia trained practitioner. SLT, Nurse, Dysphagia Trained Practitioner, Ward Manager. All staff Page 12 of 37

13 Instruction relating to ingestion of thickening powder and be aware of the risks of consuming thickening agent if not mixed with a drink Ensure the current SLT recommendations for fluid consistency are in place and up to date prior to use of thickening agent for any patient. Responsible Trained staff Refer to SLT entry in electric notes system for guidance regarding consistency and quantity of fluid. Refer to instructions on thickening agent tin regarding how to thicken drinks to recommended consistency. Patients admitted to the ward/day setting who are already using thickener, should continue to follow their current recommendations for thickening fluids unless new concerns arise, in which case follow SLT referral processes. Page 13 of 37

14 Page 14 of 37 Appendix 2

15 Page 15 of 37 Appendix 3

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18 Page 18 of 37 Appendix 4

19 Page 19 of 37 Appendix 5

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24 SINGLE ACCESS REFERRAL FORM: Adult Learning Disability Service Please complete all sections to ensure your referral is processed in a prompt and correct manner. SERVICE USER DETAILS NAME MAIN CARER DETAILS (e.g. FAMILY, KEY WORKER) NAME ADDRESS ADDRESS POSTCODE DATE OF BIRTH NHS NUMBER POSTCODE RELATIONSHIP TO SERVICE USER AGE: TELEPHONE NUMBER ETHNICITY TELEPHONE NUMBER MOBILE NUMBER REFERRER DE- TAILS ADDRESS NAME GP DETAILS NAME ADDRESS POSTCODE PROFESSION (if applicable) POSTCODE TELEPHONE NUMBER MOBILE NUMBER TELEPHONE NUMBER DATE OF REFERRAL DATE OF ALLOCATION MEET- ING: ALLOCATED TO: Return to: C.T.L.D. Ironstone, West Street, SCUNTHORPE DN15 6HX Page 24 of 37

25 SECTION A: This section should ONLY be completed if the person is already known to Adult Learning Disability Services and has an allocated Community LD Team worker. (Now complete SECTION C) Please outline the nature and reason for your referral & tick the additional services you wish to access. Community Nurse LD / HAP Clinical Psychology / Counselling Psychiatry Speech and Language Physiotherapist Social Worker/Community Care assessment Acute Liaison Nurse Behavioural Support Practitioners MCI/DUTY Please go to Section B & complete questions 4 15 SECTION B: This section must be completed if the person is NOT known to the Community LD team or if they are not accessing adult Learning Disability services. REASON FOR REFERRAL Please outline the nature and reason and expected outcome for your referral. SECTION C: 1 LEARNING DISABILITY SCREEN The following questions provide further information relevant to learning disability. a Does the person already have a diagnosis of learning disability? YES NO b Is the person known to Looked After Children Services? YES NO c Does the person have communication difficulties? YES NO d Does the person struggle to cope with tasks of daily living (e.g., self-care, budgeting, and travel)? YES NO e Does the person have difficulties in forming relationships? YES NO Does the person have difficulties in gaining employment? YES NO f Has the person experienced a significant head injury, accident or illness resulting in damage to the brain, post 18 years of age? YES NO g Does the person have a diagnosed mental health problem? YES NO h i Are they accessing mental health services? Does the person have a physical disability? YES YES NO NO j Does the person have a sensory disability? YES NO Page 25 of 37

26 2 LEARNING DISABILITY SCREEN Does the person display any other difficulties that lead you to believe they have a learning disability? YES: The person has a specific condition associated with learning disability Please give details: YES: The person s educational history/statement of need highlights learning disability Please give details: YES: The person has received services from Learning Disability services in the past Please give details: 3 REFERRAL ONSET & CONTEXT In relation to the reason for this referral, when were the person s difficulties first observed? What life circumstances were they experiencing at this point in time? 4 FAMILY BACKGROUND Please provide information regarding the person s family background. 5 MEDICAL FACTORS & MEDICATION Please provide a list of other medical problems and medications the person is taking. Include information on all physical and mental health diagnoses & current medications. 6 PSYCHOLOGICAL IS- SUES Please describe any psychological, emotional and trauma related issues relevant to the person. Include information on difficult life events here. Page 26 of 37

27 7 COMMUNICATION IS- SUES Does the person have any difficulties communicating? 8 SENSORY & MOBILITY ISSUES Does the person have a physical disability or sensory/mobility issues? Do they have difficulties with swallowing? 9 RISK Please provide information on the following areas of known risk. YES: Is the person vulnerable to risk? (e.g., self-neglect, physical health, physical, sexual or financial abuse)? Please give details: YES: Does the person pose a known risk to themselves (e.g., suicidal ideation, substance misuse, self-harm)? Please give details: YES: Does the person pose a known risk to other people (e.g., property damage, physical harm, sexual harm)? Please give details: YES: Does the person pose a known risk to staff and professionals? Is a joint visit necessary? Please give details: YES: Does the person live in a household with children under the age of 18 years or have substantial access to their own or others children under the age of 18 years? Please give details: YES: Are there any known Safeguarding Children issues that you are aware of? Please give details 10 FORENSIC ISSUES Does the person have a history of offending? Please provide details. Page 27 of 37

28 11 DIVERSITY Does the person require an interpreter or access to any other communication supports in order to access this service? 12 CAPACITY, CONSENT & BEST INTEREST If the person has capacity, has consent for this referral been obtained? Has a best interest decision been documented? Capacity & consent: YES NO Best interest decision: YES NO 13 OTHER AGENCIES/ PROFESSIONALS Which other agencies or professionals are involved in supporting the person? 14 SIGNATURE Please sign and date this referral ( ) if DUTY CALL Name: Date: ACTION/FOLLOW UP: Date of Allocation Meeting. Signed.. For Office Use Only N.L.Authority Health Authority Page 28 of 37

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31 Appendix 6 Procedure for Ensuring Communication with Regards Modified Diet and or Fluids DONCASTER COMMUNITY INTEGRATED SERVICES: Details of the swallow assessment and recommendations are recorded on the patient s electronic notes. The recommendations are also noted on the patient status at a glance board in nurse stations and are also noted on patient s bedside whiteboards. Older Peoples Mental Health Services: Patient specific diets and texture modifications are recorded in the patient s electronic notes. Information is added to a patient status at a glance board and is updated as required. ALD: Following assessment, appropriate diet/fluid information sheets and written guidelines (known as Interim Guidance Sheet) is given to the Named Nurse/Nurse in Charge. The guidance is then formalised and forwarded to care settings accessed by the client as deemed appropriate. The assessment and recommendations are recorded on the patient s electronic record. Page 31 of 37

32 RDaSH Speech and Language Therapy Contact Details Appendix 7 LEARNING DISABILITY SERVICES Doncaster: Rotherham: Scunthorpe: OLDER PEOPLES MENTAL HEALTH SERVICES Doncaster: Rotherham: DONCASTER COMMUNITY INTEGRATED SERVICES SALTS based in Doncaster Community Stroke Rehabilitation Team: and Neurological Outreach Team: Page 32 of 37

33 Appendix 8 DYSPHAGIA AND CHOKING RISK ASSESSMENT NAME DATE OF BIRTH NHS NUMBER ADDRESS PATIENT LOCATION DATE RISK ASESSMENT CARRIED OUT CONSULTANT/MANAGER DIAGNOSIS Page 33 of 37

34 PHYSICAL SIGNS YES NO MANAGEMENT IF YES ACTION Coughing during/after meals/drinks Choking during/after meals/drinks Weak cough/inability to clear throat History of frequent chest infections and or pneumonia History of choking requiring intervention Known to aspirate Difficulties chewing/prolonged chewing time. Wet gargly voice quality/changes in voice quality. Frothy secretions in mouth DANGER SIGN DANGER SIGN DANGER SIGN DANGER SIGN DANGER SIGN DANGER SIGN DANGER SIGN DANGER SIGN DANGER SIGN Immediate referral to SALT Immediate referral to SALT Immediate referral to SALT Immediate referral to SALT Discuss with SALT Immediate referral to SALT if no recommendations already in place. Immediate referral to SALT if observations identify warning signs. Immediate referral to SALT Immediate referral to SALT PHYSICAL SIGNS YES NO MANAGEMENT IF YES ACTION Slurred speech and/or facial weakness Monitor Check if specifically coughing on food or drinks Page 34 of 37 Refer to SALT if concerns If YES refer to SALT

35 PHYSICAL SIGNS YES NO MANAGEMENT IF YES ACTION Breathing difficulties/copd Poor sitting balance Poor head control Dehydration Rapid weight loss Support an upright position/and consider referring to Physiotherapy Support a flexed position/refer to physiotherapy Monitor fluid intake and refer to medics if moderate to severe. Refer to medics/dietetics Check any spillage/refusal Refer to SALT if still concerns Refer to SALT if still concerns If ruled out refer to SALT. Refer to SALT if still concerns Known trauma to throat/neck Monitor Mealtimes Refer to SALT if concerns On known medication that affects Monitor at mealtimes and review Refer to SALT if difficulties continue. swallowing medication NON PHYSICAL SIGNS YES NO MANAGEMENT IF YES ACTION Poor dentition/loose or no dentures Improve dentition and refer to dentist if appropriate. Monitor and consider referring if any risks also evident. Holds food/drinks in the mouth Consider verbal prompts If still problems refer to SALT Eats/drinks too fast Consider physical and verbal prompts Refer to SALT if still concerns Reduce food quantities Cramming food in the mouth Trial use of smaller cutlery e.g. teaspoon. Check bite size is suitable (no more than 1.5cm). Use of physical and verbal prompts. Refer to SALT if still concerns Page 35 of 37

36 Regularly leaving food/drink or refusing. Is on a modified diet Is taking thickened drinks Fatigue at mealtimes Difficulties managing to feed/drink independently Difficulties cutting up food. Presents with behaviour of taking and hiding food or non food items which could occlude the airway. History of self harm by occluding the airway Reduce food quantities Trial smaller cutlery e.g. teaspoon Monitor during mealtimes Ensure they are receiving the correct diet consistency Ensure they are receiving the correct fluid consistency Use alerting strategies, consider offering foods little and often. Time meals around fatigue. Consider referring to OT Cut up pieces into bite size (1.5cm) pieces. Consider referral to OT. Ensure ALL staff are aware of such behaviours. Ensure ALL staff are aware of such behaviours. If still concerns discuss with SALT. Refer to SALT if no existing recommendations in place or if not tolerating current recommendations. Refer to SALT if no existing recommendations in place or if not tolerating current recommendations If still concerns discuss with SALT If still concerns discuss with SALT If still concerns discuss with SALT Page 36 of 37

37 Outcome of Risk Assessment: Immediate referral to SALT? Yes No Managed as per actions identified following completion of the risk assessment Yes Details of actions to be taken This form must be placed within the patient s clinical notes and scanned onto the patient s electronic notes. Referrals to SALT should made to the appropriate team using the appropriate referral system. Name of Completing Professional Job title and Band Signature Date/time Review Date (after relevant incident or after any changes to patient s condition) Page 37 of 37