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Residential Care Speech Pathology Service

Successful Swallowing

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Residential Care Speech Pathology Service

Successful Swallowing:Provision and Preparation of

Thickened Fluids in Residential Care Facilities: Greater Newcastle Region

Presented by Project Supervisor Selena McCaig, Speech Pathologist

Project Coordinators, Speech Pathologists

- Jessica Passmore, Kellie Meredith

Acknowledgement for contributions:

- Paula Machin, Maree Herzog,

Larissa Mason, Amanda Bailey,

Renae Mannix, Elisha Cooper

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Overview of presentation Scope of Project

Methodology

Results

Conclusions

Recommendations for future management

and development

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Who we are and what we do Residential Care Speech Pathology Service

Compensable - utilising Federal funding for Allied Health services for high care residents in RCFs

Provide assessment/treatment for communication and swallowing (Dysphagia) in RCFs

Our mission: to prevent hospital readmission due to aspiration

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Problems for solving Initial Findings:

• limited knowledge: preparation and provision of thickened fluids

• only one consistency provided

• no consistency in viscosity of fluids

• used as ‘quick fix’ for dysphagia

• no SP consult

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Scope of project

Initial Goals: 2008

– Encourage trial of pre-packaged thickened fluids - ideal consistency

– Limited shelf life / costly

Most RCFs were not willing to trial

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1. Review current knowledge and practices

2. Provide free educational inservice

3. Increase use of three consistent levels of thickened fluids

4. Impact referrals

Scope of project – revised March 2011

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Methodology Approached 50 RCFs : telephone

interviews

18 facilities participated: – 62 individuals interviewed:

• 44 nursing staff, 18 kitchen staff

Subjective rating:– allocated colour for perceived level

of knowledge/current practice • ‘Green’, ‘Yellow’, ‘Red’

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Methodology

Educational inservices (over 9 weeks)

Questionnaires assessedknowledge pre and post inservice

Interview data analysed qualitatively

Quantitative data analysis undertaken

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Colour Codes for Perceived Knowledge and Current Practices

Green Managing current system well.

Good knowledge of purpose / function of thickened fluids

Consistent & monitored approach to preparing thickened fluids

Three levels of thickened fluids available (if required)

Thickened water available

Staff have good knowledge of warning signs for swallowing issues

Facility consistently uses speech pathologist to provide swallowing assessments

Yellow Knowledge around current system is inconsistent

Reasonable knowledge of purpose / function of thickened fluids

Inconsistent approach to preparing thickened fluids

Three levels of thickened fluids available (if required)

Thickened fluids may not be consistent on a day-to-day basis

Thickened water available

Staff have some knowledge of warning signs for swallowing issues

Facility consistently uses speech pathologist to provide swallowing assessments

Red Knowledge around current system is inconsistent and/or poor

Poor knowledge of purpose / function of thickened fluids

Inconsistent approach to preparing thickened fluids with no monitoring system in place

Less than three levels available of thickened fluids

Limited knowledge of warning signs for swallowing issues

Facility may or may not use a speech pathologist to provide ‘swallowing assessments’ and prescribe thickened fluids

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Results– 4 green, 8 yellow and 6 red

– Most using thickening powder only

– RCFs not monitoring hydration levels

– RNs assessing and modifying

– variation with terminology used

– feel they have adequate knowledge of dysphagia/modified diet fluids

– Not all facilities offering 3 levels! Some did not offer thickened water at all!

– Consistently inconsistent

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Results1. The current level of knowledge of

preparation and provision is not sufficient

2. Resident safety breeched due to inability to provide modified diets/fluids to National Standards

3. SP input redundant if RCFs unable to follow our recommendations

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Results: pre/post educationComparison of nursing staff pre-test/ post-test scores

Comparison of kitchen staff pre-test post-test scores

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20

40

60

80

100

Pe

rce

nta

ge

(%

)

Pre Post

0

20

40

60

80

100

RCF1

RCF2

RCF3

RCF4

RCF5

RCF6

RCF7

RCF8

RCF9

RCF10

RCF11

RCF12

RCF13

RCF14

RCF15

RCF16

RCF17

Pe

rce

nta

ge

(%

)

Pre Post

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Results% change

% change by colour classification

-10

0

10

20

30

40

50

Pe

rce

nta

ge

(%

)

Nursing Kitchen

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5

10

15

20

25

30

RCF Colour Severity Classification

Perc

en

tag

e (

%)

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Results% change in key areas of education

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20

40

60

80

100

Pre Post

Percentage (%)

Awareness of Standard Terminology Recognition of Clinical Signs of Aspiration

Rationale for Implementing Thickened Fluids Consequences of Dysphagia

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Results - 1: RCF education significantly improved:

– Awareness of dysphagia and aspiration– Awareness of consequences of inadequate

management. i.e. infection, dehydration, malnutrition

– Awareness of standard terminology and definitions for texture modified diets/fluids

– Understanding of the rationale for prescription of thickened fluid regimes

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Results - 2: Greatest change in knowledge

for ‘Red’ category facilities

Knowledge remains relatively low despite improvement being measured

Need for ongoing education!!!

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Results - 3: Kitchen/catering staff attendance –

approx. 20%.

- Kitchen staff complete most of the preparation of thickened fluids (up to 86%).

Need to target kitchen staff responsible for preparation of thickened fluids

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Conclusions Findings largely reflect available literature:

thickened fluids consistently inconsistent

Overall increased awareness - identified current weaknesses in provision of thickened fluids in Newcastle region

Ongoing consultation and education within RCFs is required! Specifically, education of kitchen staff

Greater input from speech pathologists to ensure that each facility is able to implement changes

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Were goals achieved? …1

Thorough review of current knowledge/practices re thickened fluids and dysphagia management within the Newcastle Region

Provide free education to those RCF who participated

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Were goals achieved? …2Knowledge and rationales for need

for three consistent levels of thickened fluids however….

– Unable to determine if this

education has led to %RCFs offering three consistent levels of thickened fluids

– Timeframe has not allowed for review of appropriateness of RCSPS referrals as a result of education provided

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Successful outcomes Open and ongoing dialogue

between RCSPS and RCFs

Increased awareness within RCFs of need for three levels of fluid thickness

Increased awareness of importance of referral to SP for dysphagia management

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Feedback RCF feedback

–SP need to provide clear guidance re: how to mix fluids. Suggested that “recipe” would be helpful

–RCFs identified need to change: ‘where to start?!?’

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Now what?Measuring long-term outcomes:

– ?Measure impact of training on patient outcomes

– Further questionnaire 3-6 months post education - are RCFs using 3 consistencies?

– ?Obtain feedback from nursing and kitchen staff re: impact of education on daily performance at mealtimes and confidence with feeding

– Measure any change in nature and quantity of referrals to the RCSPS

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Where to next….? The thick fluid ready

reckoner!?!

Stay tuned for project 2012

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Questions or Comments?

Residential Care Speech Pathology Service - 2011