DYSPHAGIA POLICY MAY This policy supersedes all previous policies for Dysphagia.

DYSPHAGIA POLICY MAY 2016 This policy supersedes all previous policies for Dysphagia.

Policy title Policy reference Policy category Relevant to Dysphagia Policy CL11 Clinical Date published May 2016 Implementation date Date last reviewed Next review date Policy lead Contact details All staff responsible for the care of dysphagia patients May 2016 April 2016 May 2019 Caroline Harris-Birtles, Deputy Director of Nursing Carmel Hayes, Speech and Language Therapist, Whittington Health, NHS Trust Simon.Rowe@candi.nhs.uk Accountable director Approved by (Group): Approved by (Committee): Document history Membership of the policy development/ review team Consultation Claire Johnston, Director of Nursing and People Physical Health and Nutrition Group 10 May 2016 Quality Committee 17 May 2016 Date Version Summary of amendments Jan 2006 1 New policy Apr 2016 2 Comprehensive review to meet Guidance requirements and the needs of Service Users Carmel Hayes, Speech and Language Therapist Mental Health, Whittington Health Fiona Nolan, Former Deputy Director of Nursing and Research Simon Rowe, Clinical and Corporate Policy Manager All members of the Physical Health and Nutrition Group and the Practice Development Nurses DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet. 2

Contents 1 Trust values 5 2 Policy and governance 5 3 Policy statement 6 4 Executive summary 7 5 Duties and responsibilities 7 6 Definitions 7 7 Causes of Dysphagia 8 8 Additional risk factors 8 9 Prevalence of Dysphagia 9 10 Consequences of Dysphagia 10 11 Signs and symptoms of Dysphagia 11 12 Management of Dysphagia 12 13 Choking 15 14 Good practice at meal times 16 14 Some important do s and don ts 18 15 Management of Dysphagia risks 17 16 Dissemination and implementation arrangements 18 17 Training requirements 18 18 Monitoring and audit arrangements 19 19 Review of the policy 20 20 References 20 21 Associated documents 21 22 Appendices 23 Appendix 1: Equality Impact Assessment Tool 23 Appendix 2: Referral Process to SLT 24 3

Appendix 3: Hospital Referral Form 25 Appendix 4: Community Referral Form 26 Appendix 5 : Safe storage of Thickening Powders 29 Appendix 6: Relevant Guidance 30 4

1. Trust values Camden and Islington NHS Foundation Trust developed its set of six values with more than 500 service users and members of staff. Our values are important to us. They are our promise to patients as well as to each other that we will behave in a certain way, no matter what our job title is or how under pressure we feel. Our commitment to our values makes us who we are. It gives our service users confidence that they will be treated in the most compassionate way possible as they go through their journey to recovery. It also gives us pride in the knowledge we are providing the best care. Our values show that we are welcoming, respectful and kind. Professional in our approach. Positive in our outlook. Working as a team, we are your partner in care and improvement. These values are part of a wider campaign, Changing Lives which is helping to drive up the standards of care across the Trust. In simple terms our values assure our service users that: They will receive a warm welcome throughout the journey to recovery; They, their dignity and their privacy will always be respected; Their care will be founded on compassion and kindness; They will receive high quality, safe care from a highly trained team of professionals; We work together as a team to ensure they feel involved and offer solutions and choices no decision about you, without you ; We are positive so they can feel hopeful and begin their journey of recovery knowing we will do our very best. 2. Policy and governance A policy is an organizational statement of rules and standards which govern performance and actions required to be followed by those in employment by the Trust. A policy provides a framework for the Trust to work within and should specify actions which are required. A policy may include detailed procedures which supply standardized methods of performing clinical or non-clinical tasks by providing a series of actions to be conducted in a certain order to achieve a safe and effective outcome in a consistent method by all concerned. Policies should take account of existing good quality evidence. The Whittington Health Library provides a library service to the Foundation Trust and can assist with literature searches and finding evidence to inform policy and practice. For more information please contact: 5

Richard Peacock Librarian Whittington Health Library 020 7288 3607 richardpeacock@nhs.net Good governance lies at the heart of all successful organizations. Good governance helps protect the Trust, its staff and service users from poor decisions and exposure to risks. All Trust policies must be compliant with the relevant statutory legislation, e.g. the Mental Health Act 1983 (which was amended in 2007) and national expectations, e.g.: the NHS Litigation Authority Risk Management Standards 2012-13. A policy which has not been scrutinized and approved by the appropriate Trust committee but is being used by staff could lead to poor practice being delivered which could potentially harm service users and have consequences for staff. It is therefore essential that in either developing or revising a policy, managers ensure that the proper governance procedures have been followed. By following the correct governance procedures, we all help to reduce risk and assure safe and effective care is delivered to service users. 3. Policy statement Camden and Islington NHS Foundation Trust is committed to providing a high standard of care to all patients. This policy is relevant to all Trust staff that provides care to patients either directly or via the teams they manage. As part of that care, staff must be able to recognise the signs of dysphagia, know when, how and who to refer to for further specialist assessment and be able to care for a patient who has dysphagia whether this is on an emergency basis or as part of a long term problem. Staff must also be aware of the serious risks dysphagia can pose to patients and know the appropriate action to take. Dysphagia (difficulty swallowing) can have serious effects with complications such as malnutrition, pulmonary aspiration (fluid, food or medication going into the lungs instead of the stomach) or choking. In addition there are often emotional or psychological problems associated with difficulty eating and drinking. A holistic approach to care, considering the patient s physical health needs as well as mental health needs, is essential. Enabling patients, including those with dysphagia, to eat and drink as safely as possible whilst maintaining nutrition and hydration and quality of life which are vitally important aspects of care. Trust value They will receive a warm welcome throughout the journey to recovery They, their dignity and their privacy will always be respected; Their care will be founded on compassion and kindness 6 Yes/No

They will receive high quality, safe care from a highly trained team of professionals We work together as a team to ensure they feel involved and offer solutions and choices no decision about you, without you We are positive so they can feel hopeful and begin their journey of recovery knowing we will do our very best. Yes 4. Executive summary This policy aims to provide staff with an understanding of the issues related to dysphagia and guidance on best practice when caring for patients with dysphagia. 5. Duties and responsibilities The Chief Executive has ultimate responsibility for ensuring that mechanisms are in place for the overall implementation, monitoring and revision of policy. The Associate Director, Governance and Quality Assurance, via the Clinical and Corporate Policy Manager, is responsible for ensuring: Dissemination and implementation of the policy Identification of any resource implications to enable compliance Training and monitoring systems are in place Regular review of the policy takes place. Associate Divisional Directors are responsible for implementation of the policy within their own spheres of management and must ensure that: All new and existing staff have access to and are informed of the policy Ensure that local written procedures support and comply with the policy Ensure the policy is reviewed regularly Staff training needs are identified and met to enable implementation of the policy. All Trust staff are responsible for ensuring that they: Are familiar with the content of the relevant policy and follow its requirements Work within, and do not exceed, their own sphere of competence. 6. Definitions Swallowing is the process by which fluid or food is transported from the mouth to the stomach for digestion. Successful swallowing is the result of a 7

sequence of complex events involving anatomical oral and pharyngeal structures and multiple neural pathways. Swallowing is also influenced by features of what is being swallowed and factors specific to the individual (cognitive, physical, medical, psychological and social). Humans swallow on average once every minute and, when eating, this increases to between 6-8 times a minute. Dysphagia is defined as difficulty, discomfort or pain in swallowing. Dysphagia is usually caused by another health condition and may be mild to severe. Dysphagia can result from any disruption at the preparatory, oral, pharyngeal and/or oesophageal stages of swallowing. Aspiration occurs when fluid, food, saliva, medication or refluxed material enters the airway. People with dysphagia are at a significantly increased risk of aspirating. Aspiration may occur silently with the individual showing no outward signs of difficulty (such as coughing) although more subtle symptoms may be detectable to a trained observer. Aspiration pneumonia refers to lower respiratory tract infection caused by the inhalation of oropharyngeal secretions colonised by pathogenic bacteria. Aspiration pneumonitis (Mendelson s Syndrome) is a chemical injury caused by the inhalation of sterile gastric contents. People who have seizures or take sedating medication are most at risk. Choking / asphyxiation occurs when the airway becomes occluded. This may result in sudden death. People with dysphagia are at increased risk of choking. 7. Causes of Dysphagia Dysphagia may be present from childhood or have an onset in adulthood. As swallowing is a complex process, there are many reasons why dysphagia may develop including: progressive or acute neurological conditions; obstruction; muscular conditions and psychological or other cause s for example; chronic obstructive pulmonary disease, side-effects of medication. Patients with a diagnosis of Learning Disability are also at high risk of presenting with dysphagia. 8. Additional Risk Factors for people with Mental Health problems There are also additional factors that may increase the risk for and negative consequences of dysphagia, aspiration and choking in this client group: 8

Cognitive / behavioural factors - poor organisation, reduced attention and poor self-monitoring at mealtimes leading to eating very quickly / in a disinhibited / impulsive way and cramming or bolting food (particularly in schizophrenia and bipolar disorder); swallowing without chewing (Bazemore et al 1991) Mood pacing and agitation when eating and drinking Poor oral care including missing and decayed teeth. Higher levels of poor oral acre are recorded in people with mental health problems (Malmstrom et al 2002). Respiratory pathogens may be aspirated and predispose to lung infections Reflux; Use of alcohol, antipsychotics and other medication and polypharmacy may affect levels of alertness, muscle tone and coordination, increase / decrease salivation, delayed swallow, tardive dyskinesia (Wyllie et al 1986, Hughes et l 1994, Sokoloff et. al 1997, Carl & Johnson 2005) Co-morbid medical diseases / other neurological or other causes of dysphagia. Heavy smoking; Reduced insight into level of own difficulties 9. DYSPHAGIA PREVALENCE: General population: The prevalence of dysphagia is thought to vary according aetiology and age of the individual (RCSLT 2009). Dysphagia is reported to occur in 6% of the general population (Groher and Bukatman 1986). People with Mental Health problems: Evidence from the literature suggests that dysphagia is a common problem in adults with mental health problems. Prevalence rates vary from 19% - 32% (Aldridge and Taylor 2012, Regan et al 2006). People with Dementia: Prevalence studies of dysphagia in people with dementia show that 68% of patients with dementia / in care home present with dysphagia (Steele et al 1997). This is associated with an increased risk of choking incidents and aspiration due to problems with chewing, difficulty swallowing, effects of 9

medication, eating too fast etc. The majority of people with advanced dementia have significant dysphagia (Feinberg et al 1992). Oropharyngeal dysphagia is an important factor leading to pneumonia in the elderly, with pneumonia being the leading cause of death among residents in nursing homes (Marik & Kaplan 2003). It is also known that those most at risk of aspiration pneumonia are those who are reliant on others for both oral care and assistance with eating & drinking (Langmore et al 1998). Learning disability Research suggests that between 30%-50% of pole with a learning disability in the UK have Mental Health problems (Smiley 2005). It is well established that people with a learning disability rate at higher risk of choking as a result of dysphagia, behavior presented (e.g. bolting food) and the effects of medication Hampshire Safeguarding Adults Board 2012). Choking & Mental Health Problems: Craig (1980) found that 0.7 % deaths could be attributed to asphyxiation consequent on choking after a meal in a psychiatric hospital. Corcoran et al (2003) reported that 6% of psychiatric in-patient deaths in a 10 year period were due to asphyxiation consequent on choking. Fioritti et al (1997) reported that 19% patients experienced choking incidents in an 18 month period. Ruschena et al (2003) report that the risk of death by choking was 30 times greater in people with schizophrenia than in the general population and people with an organic disorder had 43 times increased risk of death by choking than the general population. The death rate from choking in the mental health population was found to be 100 times more than the general population by Mittleman & Welti (1982). A review of choking incidents at Broadmoor & St Bernard s Hospitals (Bryan et al 2002) found that 3 patients died as a result of choking on food and there were a further 14 incidents of patients choking where nursing and medical interventions were successful in preventing possible death. 10. Consequences of dysphagia Serious health and quality of life risks may result as a consequence of dysphagia if it is undiagnosed and untreated/unmanaged: 10 Poor appetite, weight loss and malnutrition Dehydration;

Choking Aspiration, respiratory infections and aspiration pneumonia; Inaccurate drug levels; Increased risk of pressure sores and slower wound healing; Anxiety, distress and depression; Reduced quality of life. 11. Signs and symptoms of dysphagia Dysphagia can present in many ways and the patient may demonstrate one or several symptoms. Staff must be aware of the following warning signs of swallowing difficulty and be vigilant for these signs especially in high risk patients (those with for example mental health problems, Cerebrovascular Accident i.e. Stroke, Parkinson s Disease, Huntington s Disease, dementia, Learning Disability and patients starting or changing medication regimes) Staff may notice any or a combination of the following signs of dysphagia: 11 Avoidance or refusal of certain foods or drink Patient complains of difficulty swallowing or a sensation of something sticking in their throat when eating and drinking Difficulty chewing or prolonged chewing with a delayed or absent swallow (the patient holds food in their mouth without swallowing for a short or longer period of time) Retention of food residue or medication in the patient s mouth (food, remains in the cheeks or on the roof of the mouth) Difficulty keeping food, drink, medication or saliva in the mouth (dribbling or drooling of food, drink, medication or saliva during or after eating or drinking). Drooling of saliva or excessive salivation Food, fluid or medication coming down the nose Gagging, retching or vomiting at mealtimes Choking episode with food or medication Coughing or spluttering during or after eating or drinking Throat clearing during eating / drinking Difficulty breathing or changes in breathing pattern (shortness of breath, stridor) when eating, drinking or taking medication Eyes watering or face reddening when eating, drinking or taking medication

Patient needs to swallow more than once per mouthful to clear food or fluids When eating or following eating, inability to cough or a weak non-existent cough although the patient is trying to cough Gurgling sound (wet voice) after eating or drinking History of repeated chest infections Increased shortness of breath or respiratory rate when eating and drinking Lack of interest or attention to food and drink Increased time taken to eat and drink/take medication very long mealtimes Panic or anxiety when eating or drinking History of aspiration pneumonia. Inability or reluctance to talk during mealtimes Dry mouth Weight loss 12. Management of dysphagia The overall aim is to ensure that patients at risk of, or presenting with, dysphagia are identified and are enabled to eat, drink and take medication as safely and comfortably as possible. The following standards of good practice should be in place in services providing care for those at risk of dysphagia: Nursing / Care Staff: 11.1 As part of each patient s assessment staff must consider the following: a) Has the patient experienced or is the patient experiencing swallowing difficulty is the patient coughing on oral intake etc.? b) If the patient has a known history of dysphagia has he/she been assessed by SLT and are there recommendations or a care plan for eating & drinking in place? c) Has the patient ever had a previous choking episode? d) What is the status of the patient s teeth/dentures and level of oral care? e) Are there are any risk factors for dysphagia, including other medical conditions? f) Does the patient s medication need to be considered (is it easier / safer to swallow liquids / capsules /or not at all and administer via another route i.e. IM injection 12

This information may be sought from the patient, their carers or from observation at mealtimes. Community staff may need to assess during review meetings with clients / carers Dysphagia symptoms and any known / suspected risks of aspiration or choking should be recorded in the appropriate section of the patient Electronic Patient Record (EPR) system Staff must also alert the shift coordinator, team leader or ward manager if a patient in their care is showing signs of dysphagia If staff suspect swallowing difficulty, a referral should be made to speech and language therapy (SLT) services for a professional clinical assessment using the appropriate referral form at Appendices 3 & 4 and document that a referral has been made in the patient s EPR Responsibility for referral to the SLT service lies with the patient s primary nurse on inpatient wards and in residential services, and their allocated key worker in day care centres and community settings. 13 All staff members must be aware of the care plans for each patient and be familiar with these in advance of participating in any mealtimes and must comply with the care plan at all times. Risk assessments must also be completed and documented as required. The manager of each ward, residential or day care service will be responsible for ensuring that hard copies of care plans are printed out and accessible for reference during all mealtimes. These will not be left in public areas and must be stored securely when not in use. Staff must ensure that relatives / visitors of patients with dysphagia are aware of any risks of aspiration / choking, are aware of the SLT recommendations for eating / drinking and ensure that they do not provide unsuitable or unsafe food / drinks Dysphagia assessments and decisions must be reviewed following any change or deterioration in the patient s health or presentation, and a referral for re-assessment or SLT review should be made in these instances. This must be documented on the patient s EPR For patients with dysphagia the primary nurse or key worker will retain responsibility for making further recommended referrals: a) If postural adjustments are necessary referral should be made to physiotherapy b) If adaptations to cutlery are required referral to occupational therapy should be made c) If advice on dietary changes / nutritional requirements is required referral should be made to a dietician d) If a dental assessment / treatment are required referral should be made to dental services

e) Where there is a choking / aspiration risk associated with taking tablets staff will need to seek advice on alternative forms of medication soluble /liquid - from pharmacy or the patient s GP. Staff must ensure patients receive the correct modified diet, including snacks, and thickened fluids as recommended by SLT at all times Staff must ensure that any safe feeding strategies are carried out as recommended by SLT and that the level of supervision recommended at mealtimes by SLT is provided at all times Staff must inform SLT and MDT / GP of any concerns regarding a patient s swallow and document this on the patient s EPR When a patient is discharged or transferred from one service to another staff must ensure that the care plan including any SLT report and recommendations for eating and drinking and all risk information (including choking / aspiration) is forwarded to the team / location the patient is being discharged to. This includes transfer of patients to other mental health settings in C&I, local acute hospital services / out of area mental health or acute settings / care homes / patients own home etc. As dehydration and malnutrition can result from dysphagia. Staff must assess patients for signs of these, such as weight loss, fatigue, and dry skin, concentrated urine with a low specific gravity and reduced output, and muscle cramps. A care plan should be devised, with the involvement of a speech and language therapist and dietician, and progress carefully monitored. Staff must include dental checks as part of regular health checks In some cases, as a result of best interest s decisions, patients safety may need to be maintained through limiting patient access to certain environments. Sometimes this will result in Deprivation of Liberty Safeguards (DoLs) and staff must refer to the relevant policy / procedures. Where a patient at risk of choking or aspiration has the mental capacity to make choices around their nutrition and diet they may choose to have food or fluids which they enjoy even though they know it may put them at risk of choking / aspiration. The patient's choice must be respected although it may pose challenges for staff. This must be documented in the patient s EPR Near misses from non implementation of care plans / recommendations for eating and drinking must be reported on the Trust incident recording system, which is currently the Datix system. Safeguarding procedures may also need to be considered if a vulnerable client is placed at risk. Speech and Language Therapy (SLT): 14

The SLT service will acknowledge referrals by telephone/email and patients will be seen for their initial SLT assessment as promptly as possible and following local professional guidelines; 2-5 working days for in-patients and 5-10 working days for community clients The SLT will provide written recommendations for eating and drinking to be included in the patient s care plan following the initial assessment (these will be either in the electronic patient progress notes, clinical documentation or in both). SLT Eating & Drinking Guidelines / Mealtime Information will address the risk areas identified in the assessment, and aim to reduce the risks and promote safer, comfortable eating and drinking and taking medication. The SLT recommendations will include information on any dietary modification necessary, postural or environmental strategies, level of assistance or supervision required and any other strategies required to facilitate / support safer eating and drinking. SLT reports and recommendations will be made available on the patient s electronic record. The allocated primary nurse/key worker for each patient will be responsible for adding the SLT reports and recommendations to the care plan. If clinically indicated the SLT will refer the patient for further investigation of swallow function - i.e. Videofluoroscopy (VFSS) or Fiberoptic Endoscopic Evaluation of Swallowing (FEES) - following discussion with the multi-disciplinary team, the patient and any available carers. Consent and capacity issues will be need to be taken into account and Best Interests decisions considered as required. If oral feeding is a significant risk then referral for alternative means of nutrition/hydration i.e. PEG may need to be considered. In some cases risk managed feeding / eating and drinking may be considered a more appropriate management option. These options will be considered with the MDT and patient / carers. Consent and capacity issues would need to be taken into account and best Interests decisions considered as required. MDT assessment may be required in complex cases. A best interests meeting will be required for patients unable to make informed decisions about their care in line with the Mental Capacity Act (2005). 13. Choking Choking can happen to anyone and although it is not possible to prevent all episodes of choking, reducing the risk of choking and improving the safety of patients who have swallowing difficulties is an essential part of care. Choking can have fatal consequences. 15 A person who is choking will usually present with changes in facial colour, have difficulty breathing, will be unable to speak, they may be trying to cough,

and they may be clutching their throat. They may feel panicky, frightened and may become aggressive. If no action is taken to remove the object the person s face will turn blue, and they will become unconscious. If left untreated they will eventually die. Difficulties associated with dysphagia increase the risk of choking. Assessment of the risk of choking must investigate all possible causes and result in recommendations which aim to manage and reduce this risk whenever possible. All staff need to be aware of, trained in and adhere to Basic Life Support procedures for managing choking in line with the Cardiopulmonary Resuscitation (CPR) policy. Basic Life Support / First Aid care must consider any wheelchair users or those cared for in a bed. The need for first aid and the intervention must be documented in the patient s care plan. Following any choking incident, whether or not any harm occurs, the incident should be recorded in the patient s records and the patient s GP / ward doctor informed so that an appropriate health assessment can be carried out. Appropriate referrals should then be made to relevant professionals e.g. SLT. A Datix form must also be completed. Any patient who has or is known to have had a choking episode should be referred to SLT services for assessment. SLT will consider if an assessment is required and if so organise this in line with local guidelines. Incidents of sudden death, including death by choking, must be reported to the police and Local Authority as a safeguarding alert. If neglect is suspected i.e. the patient is known to be at risk and either did not have a care plan, or had a care plan that was not followed which caused the patient to choke - the appropriate local procedures must be followed. The Care Quality Commission should be informed of the incident. 14. Good practice at mealtimes For Patients with Dysphagia 16 a) Staff should adhere to guidance in the Food and Nutrition policy and ensure that food and any fluids are well presented, served at the correct temperature and at the right consistency/texture for each patient, in line with their eating and drinking recommendations and care plan. b) Any adapted crockery / utensils must be available for patients. c) Similarly specialist seating for patients who require it must be available and used appropriately. d) Storage of thickening products for fluids staff must be aware of local procedures to ensure safe storage of such products due to the potential risks such products may pose for some patients. See Appendix 5.

e) Assisting people to eat and drink. The shift coordinator is responsible for ensuring that only suitably trained staff are allocated to assist patients with dysphagia with eating and drinking. Staff must be able to provide assistance appropriate for each individual. This may range from prompting, to hand over support, to full assistance with eating and drinking. Some patients require supervision at mealtimes. Patients with cognitive impairments may need reminding to eat and drink. Patients may also need assisting and prompting to select appropriate food options according to their care plan and/or reminding of any risk of choking or aspiration by staff. Staff must assist one patient at a time, focus their attention on that patient (not talking with other staff) and sit down to assist patients, staff must be aware of when to terminate eating / drinking if an adverse situation arises and follow local procedures for dealing with such an event. 15. Management of dysphagia risks DO Do take any patient reports of dry mouth or difficulty swallowing food, drink or medication seriously. Do ensure that patients oral hygiene is addressed in their care plan. Do ensure patients dentures are available at mealtimes and make appropriate referrals to dental services. Do remember that lack of dentition may pose a serious choking risk Do ensure that patients are alert when eating, drinking or taking medication (some patients may need to eat little and often in order to ensure they do not become too fatigued). Do ensure that when eating, drinking or taking medication patients are seated in an upright, midline position with their head in the midline and slightly forward. DO NOT Do not assume that the patient s perception is inaccurate or just part of their mental health condition. Do not assume that if someone has not got teeth or if they are fed by a non-oral route that oral hygiene is not important. Do not assist a patient to eat or drink if they are drowsy or have just had a seizure. Do not ever assist a patient to eat, drink or take medication if their head is tipped back, if they are reclined in the chair or lying down. 17

Refer to physiotherapy or occupational therapy for advice around seating, posture and positioning as appropriate Do be vigilant for any symptoms of dysphagia as listed in section 5 - remember not all patients will be able to report difficulties. Do remember that some patients can aspirate silently (i.e. without coughing). This will require you to be especially vigilant in observing for other possible signs of aspiration such as recurrent chest infections and weight loss. Do not assume that because a patient has always had difficulty at mealtimes that it is normal for them and so acceptable. Do not assume that because the patient is not reporting difficulties with swallowing that they are not experiencing difficulties Do not assume that because a patient is not coughing that they are not aspirating 16. Dissemination and implementation arrangements This policy will be published on the Intranet and disseminated to all clinical staff via the Staff Bulletin. 17. Training requirements All staff must be able to identify those patients at risk of dysphagia and refer these patients to relevant professionals with the skills and training in the diagnosis, assessment and management of dysphagia (NICE 2006) Additionally all staff caring for patient with dysphagia must have the skills to be able to prepare modified food/fluids according to the recommendations in the patient s care plan; be able to provide support or assistance with eating and drinking in accordance with the recommendations in the patient s care plan and must understand the implications or consequences of not following an agreed eating and drinking care plan. The Trust Speech and Language Therapy Service will deliver relevant training to staff, supported by the Practice Development Nurses as required. The training delivery will take place in ward environments / team bases where possible, to minimise release time for staff. 18

All staff working in older people s services (in-patient, residential and day care / community settings), should receive training in the recognition and management of dysphagia. A minimum of two members of staff in all other wards, residential services and day / community services should receive training in the recognition and management of dysphagia. Staff will require refresher training every 3 years Records of trained staff will be kept by the Trust s Learning and Development department Staff will also need to have completed Basic Life Support training which includes responding to choking and Mental Capacity Act Training and be aware of any other relevant Trust policies, e.g. Food and Nutrition Policy 18. Monitoring and audit arrangements Elements to be monitored Lead How Trust will monitor compliance Frequency Reporting Acting on recommendations and Lead(s) Change in practice and lessons to be shared Assessment and Referral process Training a) Initial Training b) Refresher c) 2 Trained staff per clinical area SLT Audit 6 Monthly PHNG Required actions will be identified SLT Audit Annually PHNG / L&D and completed in a specified timeframe Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 19

19. Review of the policy This policy will be reviewed in 3 years or earlier should new national guidance be published. 20. References Aldridge KJ and Taylor NF (2012) Dysphagia is a common and serious problem for adults with Mental illness: a systemic review. Dysphagia (2012) 27:124-137 Avidan B, Sonnenberg A, Giblovich H, Sontag SJ.(2001) Reflux symptoms are associated with Psychiatric disease. Ailment Pharmacol Ther: 15(12):1907-12 Bryan, K, Nicholas R, Webb. H and Gatawa T (2002) Dying to Eat: a thematic review of choking incidents at WLMHT over a ten year period. Unpublished Applebaum KL, Bazemore P, Tonkology J Anath R and Shull S (1992) Privilege and Discharge Decisions for psychiatric Patients with Dysphagia, Hospital 7 Community Psychiatry 4: 1023-1025 Bazemore PH, Tonkology J and Anath R (1991) Dysphagia in Psychiatric Patients: clinical an videoflouroscopic study Dysphagia 6 2-5 Carl, L and Johnson, P 2005 Drugs and Dysphagia: how medications can affect eating and swallowing, Austin, TX: Pro:Ed Craig TJ. (1980) Medication use and deaths attributed to asphyxia among psychiatric patients. Am J Psychiatry 1980; 37(11); 1366-73 Corcoran E and Walsh D (2003) Obstructive asphyxia: a cause of excess mortality in psychiatric patients. Ir J Psych Med 20(3): 88-90 Feinberg MJ, Ekberg O, Gegall L and Tully J (1992) Deglutition in Elderly Patients with Dementia findings of videoflouroscopic evaluation and impact staging and management Radiography 183 (3) 811 814 Fioritti A, Giacotto L and Meleag V (1997) Choking Incidents among Psychiatric Patients ; retrospective analysis of thirty one cases from West Bologna psychiatric wards Canadian Journal of Psychiatry 42:515-519 Groher ME, Bukatman R The prevalence of swallowing disorders in two teaching hospitals Dysphagia 1986; 1:3-6 Hamdy, S. (2004) The diagnosis and management of adult neurogenic dysphagia. Nursing Times. Vol 100, No 18 Hampshire Safeguarding Adults Board, Multiagency Partnership (2012) Reducing the Risks of choking for people with a learning disability- a multiagency review in Hampshire 20

Hughes, J.C., Enderby, P.M., and Langton Hewer, R 1994 Dysphagia and multiple sclerosis: a study and discussion of its nature and impact. Clin Rehab. 8: 18-26 Langmore SE, Terpenning MS, Schork A Chen Y, Murray JT, Lopatin and Loesche WJ (1998) Predictors of Aspiration Pneumonia: how important is dysphagia? Dysphagia 13: 69-81 Logeman JA (1998) Evaluation and Treatment of Swallowing Disorders, 2 nd Ed Pro-ed publishing Malmstrom, K., Lu, S. et al 2002 Concomitant mon AGA technical review on Management of oropharyngeal dysphagia. Chest 2002: 121: 361-9 Marks L, Rainbow D, 2001. Working with Dysphagia. Speechmark, Oxfordshire Matik PE and Kaplin D (2003) Aspiration Pneumonia and Dysphagia in the Elderly Chest (1): 328-336 Mittleman RE and Welti VC (1982) the fatal café Coronary: foreign body airway obstruction, Journal of American Medical association 247, 128501288 NHS Modernisation Agency (2003) Essence of Care: Benchmarks for Food and Nutrition. Department of Health. NICE 2006 Nutrition support in adults NICE 2013 Patient experience in adult NHS services NPSA 2004 Understanding the patient safety issues for people with learning disabilities Regan J, Sowman R and Walsh I (2006) Prevalence of Dysphagia in Acute & Community Mental health settings. Dysphagia 2006; 2192):95-101 21 Royal college of speech and language therapists (1996) Communicating quality 3 2 nd Ed Royal college of physicians 2010 Oral feeding difficulties and dilemmas; a guide to practical care, particularly towards the end of life Jan 2010 Smiley, E (2005) Epidemiology of mental health problems in adults with learning disability: an update. Advances in Psychiatric Treatment, 11, 214-222 Sokoloff, L.G., Pavvlakovi, R. 1997 Neuroleptic induced dysphagia. Dysphagia 1997, 12: 177-9 Steele, C., Greenwood, C, Ens, I., Robertson. C and Seidman-Carlson, C. 1997 Mealtime Difficulties in home for the Aged: Not just dysphagia. Dysphagia, 12:43-50 Stewart J (2003) Dysphagia associated with Risperidone Therapy. Dysphagia 18(4):274-275 Surrey Safeguarding Adults Board (2014) Choking prevention Policy

Sullivan, S. Tucker, R. (1999) Meeting the nutritional needs of people with mental health problems. Nursing Times. Vol 13, No. RCSLT, Dysphagia, in RCSLT Resource Manual for commissioning and planning Services for SCLN, RCSLT 2009 Ruschena D Mullen P, palmer S, Burgess P, Cordner SM, Drummer O, Wallace C & Barry-Walsh J (2003) Choking Deaths: the role of antipsychotic medication British Journal of Psychiatry 183 446-450 Wyllie, R., Cruse, R.P., et al 1986 The mechanism of nitrazepam-induced drooling and aspiration. N Eng. J Med. 1986 314: 353-358 21. Associated documents Food and Nutrition Policy 22

Appendix 1 Equality Impact Assessment Tool Yes/No Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? No No No No No No No No No No N/A No N/A N/A N/A 23

Appendix 2 Referral Process REFFERALS TO SPEECH AND LANGUAGE THERAPY Mental Health Complete SLT referral form Email referral form to slt.mentalhealth@nhs.net You must email the referral form from your nhs.net email account only Make sure the referral has been received telephone 020 3316 8520 Carmel Hayes, Speech and Language Therapist Mental Health Jan 2016 24

Appendix 3 Referral Form INPATIENT Speech & Language Therapy in Mental Health Hospital Referral Form *** To ensure patient confidentiality please telephone the department to ensure someone can receive this fax *** Name: Address: DOB: M / F Consultant: GP: Community team: Telephone no: Has the person given consent for this referral? YES / NO If NO, why? Has the person given consent for information sharing? YES / NO If NO, why? Reason for referral: Diagnosis & current mental state: How urgent is this referral? The client should be seen within: 1-2 days 5 days 2 weeks Please complete this section in order for the referral to be processed Summary of key risk information: Suicide/self-harm Harm to others Self-neglect No apparent risk *** Please enclose a copy of a relevant reports e.g. medical, psychiatric, OT etc or provide title of report from Carenotes*** Referred by: Date: Job title: Address: Contact no: Dr s signature: 25 Please return to: SLT in MH, Goodinge Health Centre, 20 North Rd Islington N7 9EW Direct line: 020 3316 8520 email: slt.mentalhealth@nhs.net SLT team: Wendy Tuson & Carmel Hayes

Appendix 4 Referral Form COMMUNITY Speech & Language Therapy in Mental Health Community Referral Form Name: Sex: M / F DOB: Address: Telephone no: Is it appropriate to contact the person? YES / NO Interpreter required? YES / NO If NO, Name & Telephone no. of key contact: Person given consent to referral? YES / NO If NO, why? Person given consent to information sharing? YES / NO If NO, why? Consultant: Community team: GP details: Reason for referral: Psychiatric & medical history: Social history: i.e. significant other(s), current living arrangements etc 26

Please complete in full to ensure the referral is processed Risk Assessment Information: 1. Please detail all known risks: Suicide/ self-harm Not considered risk Harm to others Self-neglect Harm from others Other (including forensic history) 2. What safety factors need to be considered for the therapist working alone? (e.g. safety of access etc.) 3. Please give details of any warning signs indicating deterioration in mental state: 4. Please indicate who would be most appropriate person to participate in ongoing liaison regarding Speech & Language Therapy input (if different from the referrer): Name: Position: Contact details: Other agencies involved: YES NO Contact details Recovery Centre / Day Centre: Social Worker/ Care manager: Psychologist: Occupational Therapist: Physiotherapist: Dietician: Other e.g. voluntary services etc.: Other Information: Does the client have regular CPA reviews? YES / NO Next review due: Does the client have any visual or hearing difficulties? YES / NO 27

*** Please enclose a copy of a relevant reports e.g. medical, psychiatric, OT etc or provide title of report from Carenotes*** Referrer details: Name: Job title: Address: Date: Tel number: GP/Doctor s signature for swallowing: Signature: Please return to: SLT in MH, Goodinge Health Centre, 20 North Rd, Islington N7 9EW Direct line: 020 3316 8520 email: slt.mentalhealth@nhs.net SLT team: Carmel Hayes & Wendy Tuson 28

Appendix 5 Safe Storage of Fluid and Food Thickening Powders 1. Fluid / Food thickening powders must be stored in a safe place as appropriate within easy access to staff. 2. Fluid / Food thickener must not be stored on drinks trolleys or within reach of patients 3. All staff need to be aware that there is a risk of asphyxiation and choking if the dry powder (for thickening fluids / food) is accidentally ingested. 29

Appendix 6 Relevant Guidance: Source Recommendations NICE 2006 Nutritional support in adults NICE 2013 Patient experience in adult NHS services CQC Essential Standards of quality and safety Persons who present with signs of dysphagia should be referred to healthcare professionals with the relevant skills and training in the diagnosis, assessment and management of swallowing disorders Requirement for appropriate support for the patient s eating and drinking requirements, e.g. staff trained in the provision of thickened fluids Ensure personalised care by providing adequate nutrition, hydration and support. Where the service provides food and drink people who use the services have their care treatment and support needs met because : - Staff identify when people have swallowing difficulties - Action is taken when swallowing difficulty is noted and a referral made to appropriate services - A care plan includes how any identified risks will be managed - All assistance necessary to eat and drink is provided - Service users have supportive equipment available - Service users are helped into an appropriate position that allows them to eat and drink safely - service uses have any specialist or dietary supplements that their needs require arranged on the advice of an 30

appropriately qualified or experienced person - Service users have access to specialist advice and techniques for receiving nutrition where their needs require it Essence of care Benchmarking :Food & drink NPSA Guidance Royal College of Speech and language therapist (2006) Royal College of Physicians guidance A system must be in place to ensure those people requiring assistance to eat & drink receive it The level of assistance required is assessed on every occasion food and drink is served Assistance to eat & drink is provided according to individual need Relevant staff are involved on providing advice and or assistance e.g. SLT Food and fluid intake is monitored and documented Individuals should receive specialist assessment by SLT, a regularly updated individual dysphagia management plan and accessible information for the patient and significant others Patients should be seen within 2 working days for inpatient. Acute dysphagia referrals and 10 days for community referrals. chronic patients Early diagnosis and treatment of dysphagia has been found to reduce the incidence of pneumonia s improve quality of care and outcomes 31