Speech and Language Therapy Service Inpatient services Management of Dysphagia in individuals on inpatient wards (excluding adults with acquired brain injury) Author(s) Joanna Brackley Amy Foster V03 Issue 1 May 2015
1 DEFINITION OF CLIENT GROUP 1.1 The speech and language therapy team manage dysphagia in adults on in-patient wards including service users with dementia in collaboration with all team members. Dysphagia in inpatient populations can arise from disordered swallowing mechanisms, medication effects, compromised cognitive-communicative skills, psychiatric and behavioural disturbance thus explaining its complex and multi-faceted nature. 1.2 The inpatient populations can be divided into two broad groups 1) service users with organic illnesses 2) service users with functional conditions. The age range of this population spans from 18 to end of life. Significantly the older age service user population will typically have co-morbid conditions such as; COPD Parkinson s Parkinsonism Stroke UTI and possible associated delirium Poor nutrition and hydration Diabetes Heart disease Depression Psychosis Paranoia Delusions 1.2.1 These additional factors impact significantly on the diagnosis, and subsequent management of dysphagia. 1.3 The service delivers care into all adult inpatient wards within Northumberland, Tyne and Wear NHS Foundation Trust (the Trsut/NTW). 2 TEAM MEMBERS 2.1 The speech and language therapist is a central component of dysphagia management team and as such, work in close collaboration with: the service user the service user s family primary nurse nursing staff the Consultant and other medical staff Occupational Therapist 1
Physiotherapist Social Therapy and Recreational Rehabilitation Team (STARRT) Dietician Social Worker Rehabilitation Assistant And others as specifically indicated by the particular patient s circumstances 3 AIMS OF SERVICE 3.1 The speech and language therapy service aim to facilitate the service users with dysphagia to ensure optimal safety when eating and drinking, optimal nutrition and enjoyment from oral intake. Clinicians aim to evaluate and manage the risks caused by impairments in oral and pharyngeal dysphagia whilst balancing this with quality of life particularly in progressive conditions. 3.2 They also seek to collaboratively devise management plans reflecting the risks that need to be managed, the environment the service user is in and the service user s wishes. 3.3. Speech and language therapy accept responsibility for training and education about dysphagia in service users with dementia, as part of the mandatory training for staff working in inpatient dementia wards and specific to clinical management of specific service users. 4 REFERRAL PROCEDURE 4.1 Patients can be referred to inpatient speech and language therapy services by e-mailing DysphagiaSALT@ntw.nhs.uk. There are specific wards, such as the organic wards, which have a dedicated speech and language therapy service and referrals on these wards may be made through Multi-Disciplinary Team (MDT) meetings on the ward or direct requests from the ward team. 4.2 On some occasions service users are referred for swallowing assessment/ review following transfer from acute hospital settings onto the dementia wards. Referrals in these cases will be telephoned through to speech and language therapy from the acute therapists. 4.3 Referrals made via the e-mail address will be followed up with a telephone screening questionnaire (see adult LD). This enables clarification of information and prioritisation of the referral. 4.4 Urgent referrals will typically be seen within 2 days of referral as per RCLST guidance. Less urgent referrals will be seen within 10 working days. 5 ASSESSMENT PROCEDURE 2
5.1 The speech and language therapist reviews the referral information from the ward staff or referring speech and language therapists, checks for relevant information in the core document and any scanned documents in RiO. From this point they initiate their own assessment and clinical management, which may take a variety of forms. Assessment is typically repeated over multiple mealtimes/eating/drinking situations to encompass a variety of foods and fluctuations in the individuals presentation. 5.2 Assessment of dysphagia in patients with dementia:- Oral motor examination: to look for signs of oral dysphagia; weakness, sensory impairment, reduced oral movement within the oral cavity, presence of gag, evidence of spontaneous swallowing, voluntary cough Clinical examination for signs of pharyngeal dysphagia: reduced saliva management, reduced or absent laryngeal elevation, suggestion of pharyngeal pooling, present voice quality, and altered respiratory presentation Evaluation of awareness levels, communication abilities, cognitive awareness and behaviour, for its impact on ability to self-report, ability to use compensatory strategies, compliance, and sufficient alertness to manage oral feeding Evaluation of mealtime environment; factors affecting the preparatory stage of swallow including noise, distractions, communication of mealtime event, table setting, communication, support given by staff Evaluation of physical status: positioning safety for eating and drinking, ability to feed selves Information from nursing staff and other team members in relation to psychiatric history and presentation including medication 5.3 Information from the assessment is recorded in the service user s clinical notes with risks updated in the face risk assessment form. Care plans are written in the inpatient care plan section under the heading feeding/eating difficulties by the speech and language therapist assessing. Care plans are written and reviewed by speech and language therapy only. 5.4 Additional information about the service user s swallowing ability may be obtained by referring for Videofluoroscopy this may incur a cost. Due to the nature of the difficulties of this client group VF is not a routine assessment. 6 MANAGEMENT 3
6.1 Service users will remain under the care of a named speech and language therapist for the duration of their admission. Management of their dysphagia may include any or several of the following approaches. Environmental manipulation e.g. being supported to eat in a different room to minimise distractions and enhance attention and safety Modified diet Thickened fluids Oral trials of alternative consistencies Compensatory strategies, such as modified positioning Education of the individual (where possible) and staff Treatment to improve awareness and minimise fatigue Changes to medication (in liaison with the medical team) 6.2 Some interventions will be carried out by other team members, such as rehabilitation assistants, but remain under the supervision and responsibility of the treating speech and language therapist. Interventions will be recorded in the clinical notes of the patient. 6.3 Dysphagia risks will be managed within the context of the progressive condition of the patient. Care decisions will be taken within this context and will involve multi disciplinary decision making and involvement of the family and the service user (if capacitated). Nonoral feeding decisions are not typically made in relation to this population but where this is considered- speech and language therapist will liaise with decision maker medical team. 7 DISCHARGE 7.1 As discussed, a service user with a swallowing difficulty will remain under a named speech and language therapist for the duration of their admission whilst their swallowing difficulties are present. Should a swallowing difficulty resolve, the care plan will be closed on RiO. 7.2 On discharge or leave, the care plan will be shared with receiving location (care home/ family home). 7.3 Should a service user be discharged whilst being assessed, need a review or have unstable dysphagia (frequent changes in presentation or additional complicating physical health), the patient will be transferred to the community SALT team via a telephone handover. 7.4 On discharge from hospital, the service user with dysphagia is transferred to local speech and language therapy services for ongoing management of their dysphagia. 4