MANAGEMENT OF DYSPHAGIA POLICY Latest Revision September 2015 Next Revision September 2016 Reviewer: Head of Governance and Clinical Services; Clinical team Compliance Associated Policies Contents 1. Introduction 1 2. Purpose 1 3. Introduction to Dysphagia 1 4. Responsibilities, Accountabilities and Duties 2 5. Procedure 2 6. Choking Protocol 4 Process Flow Chart Dysphagia and/or Risk of Choking 5 Appendix 1 - Dysphagia Risk Assessment 6 Appendix 2 - Eating and Drinking Risk Assessment 8 Appendix 3 - Eating and Drinking Risk Management Plan and Review 9 1. Introduction Outcomes First Group provides high-quality care, education and clinical support every day. We create happy places that are safe, friendly and supportive, so that we can be trusted to be doing the best for each person in our care. 1.1 Purpose This policy applies to Outcomes First Group staff who are involved in caring for individuals in residential or educational services. 1.2 Implementation It is the responsibility of line managers to ensure that staff members are aware of and understand this policy and any subsequent revisions. 2. Purpose The purpose of this policy is to assist staff in identifying individuals with Dysphagia or those who may be at risk of choking, to minimise choking risk and provide guidance on actions to take to meet their nutritional needs. It also provides advice to staff on the action to take in the event of a choking incident. 3. Introduction to Dysphagia 3.1 Dysphagia is the medical term used to refer to difficulties with swallowing. It is a serious problem and can lead to malnutrition, dehydration, choking and aspiration pneumonia and a reduced quality of life. 3.2 Dysphagia is a problem found predominantly in older people but can be found in all other patient groups, especially those with learning disabilities or those who have conditions such as dementia or neurological conditions such as Huntington s Chorea or Motor Neurone disease. 3.3 Some adults may have behaviours which increase their risk from choking. These are detailed in 5.4. Some may also have an increased risk due to the long term side effects of some medications. Copyright Outcomes First Group, 2004. All rights reserved. 1 V1
3.4 Improving the safety of individuals with Dysphagia or those at risk of choking is essential. Introducing individualised care management guidelines may reduce the risks of choking caused by Dysphagia or behavioural difficulties. 4. Responsibilities, Accountabilities and Duties 4.1 Residential and Educational Services Managers Managers are responsible for staff, within their areas of responsibility, having an awareness of recognising and managing individuals who are at risk of choking. Managers are responsible to ensure choking incidents are reported to the Clinical Team/SLT wider service. 4.2 Clinical Staff It is the responsibility of clinical staff to be aware of individuals who may be at risk of choking and taking appropriate action to reduce the risks. Whilst meeting the nutritional and hydration needs of the individual. Clinical staff are to report choking incidents to their Clinical Team/SLT. 4.3 Speech and Language Therapists The Speech and Language Therapist, if appropriately qualified, will complete a comprehensive swallowing and Dysphagia assessment and advise staff on the individual s requirements and swallowing management. If the in house Speech and Language Therapist is not suitably qualified then they will make a referral to their local Dysphagia trained Speech and Language Therapist for advice and assessment. 4.4 Dietician If appropriate a dietician will be engaged to advise on the individual s diet, in order to meet nutritional needs and swallowing problems. 5. Procedure 5.1 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. 5.2 Individuals with dysphagia need to be risk assessed and carefully managed. This also includes a Nutritional Screening assessment and if needed a referral to a dietician. All staff need to be aware of an individual s requirements in order to maintain their nutritional needs and to minimise the risk of choking. 5.3 The following signs and symptoms of eating/swallowing difficulties may indicate dysphagia: The individuals inability to recognise food; Difficulty placing food in the mouth; Difficulties with chewing and manipulating food in the mouth; Difficulties in controlling fluid or saliva in the mouth; Excessive drooling; Coughing during or immediately after eating or drinking; Choking; Regurgitation of food; Food residue in the mouth; Foreign objects being placed in the mouth. 5.4 The following behaviours may increase the risk of choking: Will overload mouth; Copyright Outcomes First Group, 2004. All rights reserved. 2 V1
Will overload mouth having taken food from others or for example fruit bowls; Will swallow without chewing; Will accept or put any item into mouth; Has issues around eating with others; Will bolt food to move onto next activity; Will eat walking/running around. 5.5 Difficulties with swallowing may mean that there is a chance that small particles of food or fluids can enter into the lungs and could cause a serious and possible fatal lung infection (Aspiration Pneumonia). 5.6.1 A full eating and drinking screen must be made on admission or at first point of contact with the service, using the Checklist for identifying possible eating and drinking and/or swallowing difficulties (see Appendix 1, also available in Downloadable Resources). Once completed this screen should be handed back to the clinical team. Any screen that has ticks in the shaded categories will need further observation and assessment by the Speech and Language Therapist. A copy of the screen should be kept in the clinical files and in the individual s care file. An intervention plan and a risk management plan must then be implemented and brought to the attention of the Registered Manager. All staff and carers involved in an individual s care should be offered training to ensure they are aware of the care plan. 5.7 Good quality assessment may require the involvement of other MDT members such as the Occupational Therapist, Dietician and Nurse. The team should work in close partnership with the individual, care team and family. 5.8 Upon review, any changes made to the intervention plan should be discussed with the individual we support, carers and MDT as appropriate. 5.9 Every intervention (direct or indirect) and recommendation should be documented in the relevant clinical and care records. 5.10 Any choking incidents must be reported through the Incident Reporting System. And the Clinical Team informed within 24 hours. 5.10 If the individual has a change in their level of need a re-assessment must be undertaken. 5.11 As part of the measures to promote good practice and to support staff to meet the needs of the individual s needs/requirements at mealtimes then please see Appendix 2 and 3 (Also available in Downloadable Resources). These are examples of the National Patient Safety Agencies Individual s Mealtime Information Guidance which can be obtained from their website www.npsa.nhs.uk. 5.12 Actions to take if an individual is choking. RECOGNITION OF CHOKING Foreign bodies (choking) may cause either a mild or severe airway obstruction. The signs and symptoms of each are summarised in the table below. It is important to ask the question are you choking? if you know that the person is able to comprehend or acknowledge. GENERAL SIGNS OF CHOKING Attack occurs whilst eating Victim may clutch their neck Witnessed episode Sudden onset Recent history of eating or touching small objects Copyright Outcomes First Group, 2004. All rights reserved. 3 V1
Signs of mild obstruction (effective cough) Victim is able to say yes to the question are you breathing? They are able to speak, cough or breathe Crying or verbal response to questions Loud cough Able to take a breath before coughing Fully responsive Signs of severe obstruction (ineffective cough) Victim cannot speak (if they could normally) Victim unable to breathe Breathing sounds wheezy Attempts at coughing are silent Decreasing levels of consciousness Quite or silent cough Cyanosis (the appearance of blue or purple colouration of the skin or mucous membranes) 6. Choking Protocol Assess Severity If you feel it is necessary, because the person is unable, check the mouth Severe airway obstruction ineffective cough Mild airway obstruction effective cough Unconscious Start basic Life Support (BLS) DO NOT attempt more than 2 breaths each time, if the breath does not go in the, blockage remains and the chest thrust will remove. Conscious 5 back blows 5 abdominal thrusts (In an infant or those who it is physically impossible to use abdominal thrust a chest thrust should be used) Encourage to cough Continue to check for deterioration to ineffective cough, or relief of obstruction. CONTINUE TO REPEAT BACK SLAPS AND ABDOMINAL THRUSTS UNTIL BLOCKAGE CLEARS, OR INDIVIDUAL BECOMES UNCONSCIOUS, IF THIS HAPPENS START BASIC LIFE SUPPORT (BLS) ATTEMPTING NO MORE THAN 2 BREATHS EACH TIME. ONCE YOU HAVE USED THE CONSCIOUS PROTOCOL TWICE - PHONE FOR AN AMBULANCE. ONCE THE FOREIGN BODY IS REMOVED, MONITOR INDIVIDUAL TO ENSURE THEY CONTINUE TO BREATH AND THEY HAVE NO DETRIMENTAL EFFECTS. IF AN ABDOMINAL THRUST IS USED THE PERSON SHOULD BE SEEN BY A DOCTOR. Copyright Outcomes First Group, 2004. All rights reserved. 4 V1
PROCESS FLOW CHART DYSPHAGIA AND/OR RISK OF CHOKING All Options staff to develop awareness of dysphagia /risk of choking (Via induction training) Dysphagia/risk of choking to be considered as part of multi-professional holistic risk assessment. All new admissions into Options services will be screened for dysphagia using a checklist. The in house SLT will decide if the individual is at risk from dysphagia or is at risk of choking and decide on the action required. Specialist Dysphagia assessment requested. The multi professional team will carry out further observation and assessment. Referral made to local NHS Dysphagia team via GP in first instance. Referral in specialist independent practitioner, following agreement from X if NHS assessment is not available. A risk assessment will be carried out by the multi professional team with the management team, based on information gained through further assessment. Assessment completed by Specialist Dysphagia SLT and findings discussed with in house SLT. Risk assessment completed by Multi professional team together with the management team, based on the external dysphagia report. Specialist multi professional intervention and personalised eating and drinking guidelines written with the support of the external specialist. Specialist multi professional intervention and personalised eating and drinking guidelines will be written and communicated to the management team. The management team to communicate guidelines to staff with the support of the multi professional team. Regular reviews to be carried out during review meetings or sooner if other concerns come to light. Staff training to be delivered on personalised eating and drinking guidelines. Copyright Outcomes First Group, 2004. All rights reserved. 5 V1
Appendix 1 Dysphagia Risk Assessment DYSPHAGIA RISK ASSESSMENT NAME : DOB: Date of Assessment: Risk assessments carefully examine systems to identify factors that could cause or contribute to harm to an individual. They investigate whether adequate precautions are in place to prevent injury, or if further measures are required. The NPSA dysphagia risk assessment seeks to answer the following questions: 1. What is the current situation? 2. What could go wrong? 3. How serious is the harm to the person? 4. How likely is the harm to occur? 5. What actions are needed to prevent harm? 6. How and when will the situation be reviewed? Assessment Group Members (Group should include health practitioners, family members, the individual supported if appropriate, social worker, home manager and carers from day and residential provision. (Tick box for those involved)) Individual supported Date of birth: Address: Family member/caregiver Residential staff Day centre staff Speech and language therapist Dietician Physiotherapist Occupational therapist GP Other (give details) Notes (including any additional members of the group): Copyright Outcomes First Group, 2004. All rights reserved. 6 V1
Nature of problem (for example, risk of choking, risk of chest infection, risk of nutritional comprise and risk of dehydration Is this a new problem or an existing problem that has worsened? (Please tick) Other existing needs (include details of current medication) Current eating and drinking situation (include where meals are taken and level of support needed) Previous health and risk issues (include any previous factors which have the potential to affect the swallow) Copyright Outcomes First Group, 2004. All rights reserved. 7 V1
Appendix 2 Eating and Drinking Risk Assessment Eating and Drinking Risk Assessment Name of individual supported: Date of Birth: Date: Impact of problem Likelihood of harm occurring What needs to be done Agreed actions Named person responsible for actions Timescale (date by which action is to be completed) low med high low med high Clinician s Signature: Copyright Outcomes First Group, 2004. All rights reserved. 8 V1
Appendix 3 Eating and Drinking Risk Management Plan and Review Eating and Drinking Risk Management Plan and Review Name of individual supported: Date of Birth: Date: What could go wrong (risk area) Impact of problem Likelihood of harm Agreed actions Named person Agreed timescale Progress to date Revised problem impact Revised harm likelihood Revised agreed actions High med low high med low high med low high med low If ***** begins to choke staff to call 999 immediately Other staff to start emergency first aid procedures Date of next review: Signed: Clinician Signature Date Signed: RM Signature Date Signed: H&S Mgr Signature Date Signed: HoS Signature Date Signed: CEO Signature Date Residual Risk Likelihood of Harm Low Registered Manager to approve Medium Registered Manager to approve High Head of Service / Health and Safety Mgr to approve and CEO must be informed of risk Copyright Outcomes First Group, 2004. All rights reserved. 9 V1