Document Version Control

Document Type and Title:

Management of Dysphagia Guidance

Authorised Document Folder:

YELLOW - Clinical

New or Replacing: New

Document Reference:

C/YEL/cm/C

Version No. v1.0

Implementation Date:

January 2013

Author: Gerry Coulson Lead Specialist Speech and Language Therapist

Approving body: Quality Effectiveness and Risk Committee

Approval Date: 13th December 2012

Ratifying body: Board of Directors

Ratified Date: 31st January 2013

Committee, Group or Individual Monitoring the Document:

Quality Effectiveness and Risk Committee

Review Date: December 2016

South Staffordshire and Shropshire Healthcare NHS Foundation Trust

Contents 1. Introduction 3 2. Definition of Dysphagia 3 3. Emergency action if a patient is choking 4 4. How to detect Dysphagia 5 5. Management of Dysphagia 5 6. Indicators of Best Practice 6 7. References 8

Appendices

Appendix 1 Contact Details 9

Appendix 2 NICE and NPSA Guidance 10

Appendix 3 Easy Read version of Guidance 14

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1. Introduction 1.1 The South Staffordshire and Shropshire NHS Foundation Trust is committed

to providing a high standard of care to all patients. As part of that care, staff must be able to monitor and care for a patient who has difficulty swallowing, whether this is on an emergency basis or part of a long term management plan.

1.2 Disruption of swallowing can have serious effects, such as choking and aspiration (fluid or food going into the lungs instead of the stomach). Aspiration from Dysphagia can lead to pneumonia, malnutrition, urinary tract infections, food refusal, dehydration, constipation, chest infection and potentially death. (National Patient Safety Agency (NPSA), 2004)

1.3 An holistic approach to care, considering the patient’s physical needs as well as psychological and emotional needs, is essential. A key role for all staff within the Trust is to promote and enable wellbeing. The Physical Healthcare Pathway and the Nutrition Pathway should be used where cases of Dysphagia are suspected or present.

2. Definition of Dysphagia

2.1 Dysphagia is the medical term for any difficulty, discomfort or pain when swallowing. Dysphagia occurs when there is a problem with any part of the swallowing process in which food and liquid move from the mouth, through the throat, into the oesophagus, and finally, into the stomach. Swallowing is a complex process, with many muscles and nerves working together to move food from the mouth to the stomach. Some people with dysphagia may experience a slight discomfort or difficulty with movement while others experience a complete inability to swallow. Dysphagia has many causes. Any condition that affects the physical structure or movement patterns of the lower face and neck through damage to the muscles and nerves used in the movements associated with swallowing may cause dysphagia including the normal ageing process. (adapted from NHS Direct)

2.2 Dysphagia can cause a wide range and degree of difficulty the most severe being choking and aspiration. These are two different problems. Choking is when an object lodges in a person’s airway and impedes breathing. People who eat quickly and overload their mouth and/or do not chew are at an increased risk of choking. All people are at a mild risk of choking. Dysphagia can increase this risk. Aspiration is when items being swallowed pass into the airway through the larynx below the level of the vocal folds and sometimes into the lungs. Aspiration is a natural phenomenon but is usually only of a small amount of saliva or other secretions. Aspirated material may cause infection in the lung leading to aspiration pneumonia. Aspiration can occur without Dysphagia or in addition to it.

2.3 Dysphagia often causes weight loss, chronic low weight and malnourishment and dehydration

2.4 Some people may have additional problems that result in difficulty in swallowing. These may be caused by:

o Parkinson’s disease o Multiple Sclerosis

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o Stroke o Ageing o Cerebral palsy o Down’s Syndrome o Epilepsy o Developmental disorders o Autism o Alzheimer’s Disease o Rare syndromes and disorders without clear diagnosis

Dysphagia can also occur as a side effect of some medication, such as benzodiazepines, antiepileptics, that might alter neuromuscular function. Dysphagia may also affect a person’s ability to take oral medication.

3. Emergency action if a patient is choking 3.1 Choking has a variety of causes, but is usually the result of a foreign object,

such as food lodged in the trachea (windpipe), causing mild to severe airway obstruction. It is important to ask “Are you choking?”

3.2 If the victim answers or coughs, they have mild obstruction, encourage them to continue to cough but do nothing more.

3.3 If the victim is unable to speak or make vocal noise this is a severe airway obstruction; they may be unable to breathe, any attempts to cough are silent, they may have wheezy breath sounds and may even be unconscious. This requires URGENT emergency treatment

3.4 All of this will take place in a few seconds so a speedy response is needed.

Prior to any emergency, ensure familiarity with basic life support procedure. Annual Basic Life Support training is mandatory for ALL clinical staff. Specific risk assessments should be in place for any service users where the following practice is not possible e.g. physically compromised

1). Give up to 5 back blows.

Stand to the side and slightly behind the victim

Give up to 5 sharp blows between shoulder blades with the heel of your hand

2). If back blows fail to relieve obstruction, give up to 5 abdominal thrusts.

Standing behind the victim, clench your fist and place it above the navel but below the bottom end of the sternum

Cover the fist with your other hand and pull sharply inwards and upwards up to 5 times as required (If under 1 year old, chest thrust – 2 fingers over lower ½ of sternum)

3). Continue alternating between back blows and abdominal thrusts.

4). If at any point the victim becomes unconscious:

Gently lower them to the ground

Immediately call an ambulance

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Begin CPR as per guidance in Resuscitation Policy

4. How to detect dysphagia

4.1 Any staff who are with patients at meal times or when giving oral medication, may notice any or a combination of the following signs of dysphagia:

Prolonged meals Delayed swallowing reflex Lack of chewing Food residue in the patient’s mouth Drooling after eating or drinking Impaired ability to control food or drink in the mouth Excessive coughing or spluttering When eating or following eating an inability to cough, or a weak non-existent

cough although patient is trying to cough Eye watering Effortful swallow Wheezing after swallow Pain during and after swallow Gurgling sounds (wet voice) after liquids History of recurrent chest infections and productive cough Urinary Tract Infections Unintentional weight loss or chronic low weight Lack of interest or attention to food and drink or food refusal Dry mouth Poor dentition or oral hygiene Loss of food from the mouth Fatigue Reflux

5. Management of Dysphagia 5.1 If staff do suspect swallowing difficulty, a written referral should be made to a

Speech and Language Therapist for a swallowing assessment, indicating reasons for referral and brief medical history. Consent should be gained and recorded. Where this is not possible due to capacity a best interest decision should be made (Mental Capacity Act, 2005). Referrers and other staff will be required to inform the assessment and be fully aware of the recommendations made. They will need to understand them and transfer them into care plans. They will need to comply with the recommendations and inform of any changes. See ‘Resources for Healthcare Staff, National Patient Safety Agency (2007)’.

5.2 An entry should be made in Health Records on patient ‘Alerts’ to highlight Dysphagia once diagnosed.

5.3 In complex cases where there is a high level of risk those supporting an individual to eat, drink and take medication orally should have training from Speech and Language Therapy.

5.4 There will be different clinical pathways depending on the locality and underlying need of the patient or service user i.e. in South Staffordshire individuals should

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be referred to Speech and Language Therapists employed currently by South Staffordshire Primary Care Trust. In Shropshire, adults with an underlying Mental Health issue should be referred to the SLT employed by Shrewsbury and Telford Hospitals. Individuals in Shropshire who have a Learning Disability should be referred to the SLTs employed by South Staffordshire and Shropshire Foundation Trust based within the Shropshire Community Learning Disability Team at Mytton Oak or Tan Bank. (See Appendix 2 for contact details). The Speech and Language Therapist will carry out swallowing assessments as part of a multidisciplinary approach and liaison occurs with other professionals such as dietician, GP, physiotherapist, occupational therapist, consultant, nursing staff, support staff, carers and family, acute hospital staff, dental hygienist, psychologist.

In some cases, a person may need to be assessed for augmentative or alternative feeding such as a naso-gastric tube or Percutaneous Endoscopic Gastrostomy (PEG). In this case, liaison occurs with acute services and primary care, including the medics, dietician, gastroenterologist and PEG nurses.

5.5 It is usually possible to manage dysphagia using various therapeutic interventions. The Speech and Language Therapist will advise on these, such as modification to the texture of the food, environmental considerations and postural adjustments. The Speech and Language Therapist or Occupational Therapist can advise on specialist feeding equipment e.g. dysphagia cups. If postural adjustments are necessary, it may also be appropriate to involve a Physiotherapist. The dietician can advise on nutrition and necessary dietary changes.

6. Indicators of Best Practice 6.1 Suggested Standards for Best Practice in the Management of Dysphagia1 Outcome Individuals with dysphagia will be identified and assessed and the level of risk will be minimised as much as therapeutically possible Factor Standard 1. Choice and Consent Individuals are involved in the plan for the

safest management of their dysphagia or Best Interest has been applied (Mental Capacity Act, 2005). Where possible all patients will be given choice regarding intervention. Some who have capacity may not consent to intervention and this must be recorded in the patient’s notes.

2. Screening All individuals referred are screened for risk of dysphagia where insufficient evidence has been provided.

3. Assessment All individuals who fit the referral criteria are

1 (Adapted from Surrey Partnership Trust)

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offered a core observational dysphagia assessment in a familiar setting to the individual and within a multi-disciplinary framework (RCSLT – Communicating Quality 3, 2006)(Boaden and Davies, 2005)

4. Risk assessment A suitably qualified Speech and Language Therapist will identify the level of risk for all individuals identified as having dysphagia. This will be in writing in the patient’s notes.

5. Care Planning Recommendations will be given for the safest management of the dysphagia and these must be incorporated into the care plan by nursing staff. All nursing/care/support staff who assist with the individual should follow the recommendations and advice or contact the Speech and Language Therapist to explain why this may not be possible or when circumstances change which affect the recommendations e.g. improvement or deterioration.

6. Review, monitoring and discharge

A timescale should be given for review. Review of progress will be done by the Speech and Language Therapist contacting the individual, nursing staff or carers. A written update will be provided stating any further review times. Where no further intervention is required or suitable an individual is discharged from the service with written recommendations and advice including re-referral information.

7. Non-oral feeding Where oral feeding is compromised and severely affects overall health and wellbeing, augmentative or alternative methods are suggested. Any decisions are made within the multi-disciplinary framework and are led by the medics with full involvement of the patient and family/carers where possible.

8. Training and support for carers Nursing staff and other carers are offered advice, suggestions, recommendations and training in techniques to suit an individual’s needs.

9. Outcome measures All individuals or their supporters will be asked to agree outcomes and give feedback on the quality of the care received.

10. Quality All outcomes inform service development and delivery including compliments, complaints and incidents.

6.2 Best Practice related to Adults with Learning Disability who have Dysphagia - as recommended by NHS Evidence (2007)

There should be a local dysphagia policy

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The policy should ensure that all adults with dysphagia have an individual management plan that is regularly monitored and updated. It will also ensure that all adults with dysphagia are assessed so as to accurately determine the level of dysphagia they have and the associated risks. Ideally this assessment should be carried out by specialist practitioners, often Speech and Language Therapists and those trained to recognise the varying symptoms of dysphagia in adult clients with communication difficulties. The assessment is then shared with the clients and their carer’s and families

The safety of adults with learning disabilities who have dysphagia can be improved when accessible information on dysphagia management is made available for people with learning disabilities and their carer and families, including advice on the preparation of suitable food and fluids

To help continuously improve safety in the future, systems should be put in place for the accurate reporting of patient safety incidents involving all patients with dysphagia

Carers and staff working with clients with dysphagia need to be aware that a change in a person’s medication or general health could produce effects that may worsen their condition. Any such change should ideally be first checked with a GP, pharmacist or medication information centre. In addition, local liaison and care transfer protocols should be in place between the hospital and community services

To improve safety for people with learning disabilities who have dysphagia, NHS organisations and carers who provide a service for such clients should consider the benefits of having a lead clinician with overall responsibility for dysphagia services. This lead could be part of the role of a Speech and Language Therapist

Where possible, care from trained carers/practitioners should be available for adults with learning disabilities who have dysphagia and all staff and carers in direct contact with clients with dysphagia should have knowledge of dealing with choking incidents

These recommendations are also appropriate for adults with Mental Health needs

7. References Boaden, E. and Davies, S. (2005) Inter Professional Dysphagia Framework on behalf of National Dysphagia Competence Steering Group www.uclan.ac.uk

Mental Capacity Act, 2005

National Patient Safety Agency (NPSA) report, 2004 Understanding the patient safety issues for people with learning disabilities NHS Evidence: National Patient Safety Agency 2007 Ensuring safer practice for adults with learning disabilities who have dysphagia National Institute for Clinical Excellence (NICE) www.nice.org.uk

Royal College of Speech and Language Therapists – Communicating Quality 3, 2006 - Clinical Guidelines by Consensus, 2005

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Appendix 1 Contact Details for Speech and Language Therapy Shropshire Adult Learning Disability Gerry Coulson Mytton Oak Royal Shrewsbury Hospital (North) Shrewsbury SY3 8XQ 01743 261181 Shropshire Adult Mental Health Karen Jackman Royal Shrewsbury Hospital (South) Shrewsbury SY3 8XQ 01743 261417 South Staffordshire Adult Mental Health via Sandra Morton Modern Matron /Senior Nurse Quality and Standards Consulting Room 2 George Bryan Centre Plantation Lane Tamworth B78 3NG South Staffordshire Adult Learning Disability Alison Wyatt New Burton House Stafford ST17 9JW 01785 258178

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Appendix 2 NICE Dysphagia Guidance There is no single guidance for Dysphagia. There is reference to it within guidance specific to certain neurological conditions as shown below. NICE Dementia and Dysphagia Guidelines

1.10.1.4 Health and social care staff should encourage people with dementia to eat and drink by mouth for as long as possible. Specialist assessment and advice concerning swallowing and feeding in dementia should be available. Dietary advice may also be beneficial. Nutritional support, including artificial (tube) feeding, should be considered if dysphagia is thought to be a transient phenomenon, but artificial feeding should not generally be used in people with severe dementia for whom dysphagia or disinclination to eat is a manifestation of disease severity. Ethical23 and legal24 principles should be applied when making decisions about withholding or withdrawing nutritional support.

Reference: Issue date: November 2006 Dementia Supporting people with dementia and their carers in health and social care NICE Clinical Guideline 42

Developed by the National Collaborating Centre for Mental Health

http://www.nice.org.uk/nicemedia/live/10998/30318/30318.pdf

NICE Stroke and Dysphagia Guidelines: 1.6 Nutrition and hydration Many people with acute stroke are unable to swallow safely, and may require supplemental hydration and nutrition. This section provides recommendations on assessment of swallowing, hydration and nutrition. 1.6.1 Assessment of swallowing function 1.6.1.1 On admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication. 1.6.1.2 If the admission screen indicates problems with swallowing, the person should have a specialist assessment of swallowing, preferably within 24 hours of admission and not more than 72 hours afterwards. 1.6.1.3 People with suspected aspiration on specialist assessment, or who require tube feeding or dietary modification for 3 days, should be: re-assessed and considered for instrumental examination referred for dietary advice. 1.6.1.4 People with acute stroke who are unable to take adequate nutrition and fluids orally should: receive tube feeding with a nasogastric tube within 24 hours of admission

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be considered for a nasal bridle tube or gastrostomy if they are unable to tolerate a nasogastric tube

be referred to an appropriately trained healthcare professional for detailed nutritional assessment, individualised advice and monitoring.

1.8 Avoidance of aspiration pneumonia Aspiration pneumonia is a complication of stroke that is associated with increased mortality and poor outcomes. 1.8.1.1 In people with dysphagia, food and fluids should be given in a form that can be swallowed without aspiration, following specialist assessment of swallowing. Reference: Issue date: July 2008 Stroke Diagnosis and Initial Management of acute stroke and transient ischaemic attack (TIA) NICE Clinical Guideline 68 Developed by the National Collaborating Centre for Chronic Conditions http://www.nice.org.uk/nicemedia/live/12018/41331/41331.pdf NICE Parkinson’s Disease and Dysphagia Guidelines 1.9.4 Speech and language therapy 1.9.4.1 Speech and language therapy should be available for people with PD. Particular consideration should be given to: • improvement of vocal loudness and pitch range, including speech therapy programmes such as Lee Silverman Voice Treatment (LSVT) B • teaching strategies to optimise speech intelligibility D(GPP) • ensuring an effective means of communication is maintained throughout the course of the disease, including use of assistive technologies D(GPP) • review and management to support safety and efficiency of swallowing and to minimise the risk of aspiration. D(GPP) Reference: Issue date: June 2006 NICE clinical guideline 35 Parkinson’s disease Diagnosis and management in primary and secondary care Developed by the National Collaborating Centre for Chronic Conditions http://www.nice.org.uk/nicemedia/live/10984/30088/30088.pdf Multiple Sclerosis Guidelines 1.7.16 Swallowing difficulties Dysphagia (disturbance of swallowing) may lead to choking and aspiration of food or liquid into the lungs. It is more common in those with severe impairment. Facilities for the insertion of percutaneous endoscopic gastrostomy (PEG) tubes are widely available.

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1.7.16.1 Any person with MS who is unable to transfer from bed to chair independently or who has any symptoms or signs of bulbar dysfunction such as any abnormality of eye movements, slurring of speech or ataxia, should be asked whether they have difficulties with chewing, or swallowing food or fluids (for example, coughing), also whether they have altered their diet because of previous problems. 1.7.16.2 Any person with MS with any bulbar symptoms or signs, and any person with MS who has a chest infection, should have their swallowing assessed by a competent person (using a standardised swallowing test). 1.7.16.3 People with MS who, on formal assessment, have an abnormality of swallowing should be further assessed by a specialist speech and language therapist. Advice should be given on specific swallowing techniques, and on adapting food consistencies and dietary intake. Further diagnostic assessment (for example, by videofluoroscopy) should be undertaken if: • first-line therapy and advice are ineffective • a specific objective of the investigation can be identified. 1.7.16.4 Any person with MS who has difficulty swallowing for more than a few days should be assessed by a neurological rehabilitation team, to review the need for: • adjustments to or provision of seating that will increase ease and safety of swallowing and feeding • chest physiotherapy • short-term use of nasogastric tube, especially if recovery is anticipated. 1.7.16.5 Any person with MS who has swallowing difficulties for more than 1 month should have his or her weight or nutritional status checked on a monthly basis (using a validated nutritional measure if needed). Dietary intake should be reviewed if there is continuing weight loss or evidence of malnutrition. 1.7.16.6 If PEG feeding is anticipated as being a likely future option, discussions with the person with MS should be commenced at an early stage and their wishes documented. 1.7.16.7 If swallowing difficulties persist, a PEG tube should be considered if any of the following occur: • recurrent chest infections • inadequate food and/or fluid intake • prolonged or distressing feeding • nasogastric tube in situ for over 1 month. 1.7.16.8 If PEG placement is indicated and agreed, the PEG tube should be inserted by a suitable specialist. Before the person with MS is discharged from hospital, full training should be given to any family members and carers who are going to be involved in feeding. Reference: Multiple sclerosis Management of multiple sclerosis in primary and secondary care Clinical Guideline 8 November 2003

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Developed by the National Collaborating Centre for Chronic Conditions http://www.nice.org.uk/nicemedia/live/10930/29199/29199.pdf For NPSA guidance related to Learning Disability see Problems Swallowing? using the following link: www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60130...

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Clear Words and Pictures

Dysphagia or Swallowing Problems

Written by Gerry Coulson, Lead Specialist Speech and Language

Therapist

February 2012

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What is Dysphagia?

Dysphagia is the medical word for a problem with swallowing. Swallowing is where food and drink goes from the mouth to the stomach. Swallowing problems can make people ill People can sometimes die from not being able to swallow properly. Swallowing problems happen because the nerves and muscles are not working properly.

Swallowing problems can cause these things:

Low weight Not being able to drink enough

water Chest infections Not being able to take tablets Choking and not being able to

breathe because something is stuck in the throat

Ring 999 if a person chokes and cannot breathe

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Meals take a long time or the person eats too fast

They do not swallow They do not chew Food is left in the mouth or falls out

of the mouth Dribbling Coughing Watery eyes Loud breathing noises like wheezing Pain Gurgling voice Chest infections Other Infections Low weight Not wanting to eat Dry mouth Smelly breath or bad teeth Tiredness

How do you know if someone can’t swallow?

The person tells you or you notice some of these things:

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What to do: Tell a doctor or a nurse or a Speech and Language Therapist who can do an assessment

The Speech and Language Therapist will also write a report to tell people what to do to swallow more safely.

It is important that people who are working with someone who cannot swallow know what to do to help.

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They must do what it says and write it down in a person’s records.

They might need some training from the Speech and Language Therapist to help them know what to do.

Usually people can be helped by making changes to food or drink. A person might be given soft food so it is easy to eat.

What is the best way to work with people who cannot swallow?

Speech and Language Therapists work with lots of other people like family members, Nurses, Doctors and Physiotherapists to help a person who cannot swallow.

When a swallowing problem is very bad some-times people need to get food and drink through a tube. This is an operation done at a hospital. The tube can make sure people get enough food or drink to keep them as well as possible.

Choice and Consent People with swallowing problems are asked how they would like to be helped

Screening This can be done by those given special training by Speech and Language Therapists to make sure that there is a physical problem with eating drinking and swallowing

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Care Planning There will be a written plan of what to do to make sure the person is able to eat and drink safely. This will be copied from the Speech and Language Therapy report by nurses or paid carers.

Assessment All people who have a physical problem with swallowing should be offered an assessment. This should be done in a place they know. Other people who know the person should be included. Other people who could help should also be asked. Risk assessment A Speech and Language Therapist will say how safe a person’s swallow is. They will write this in the notes.

Review, monitoring and discharge The Speech and Language Therapist will check how well the person is doing after an agreed time. They will ask everyone who knows about the person’s swallowing. They will write down any new things which should be done to help. If a person does not need to be seen anymore by the Speech and Language Therapist there will be a report saying how to carry on helping with eating drinking and swallowing. There will also be a telephone number and an address to write to if there are any more problems.

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Not being able to eat and drink:

If a person’s eating or drinking is very bad and they have to have a tube everyone will talk with the person about if this is the best

Training and help for carers Nurses and other staff and other carers are offered help and may be shown how to help a

person

Outcomes Everyone who needs help will be asked to say what help they want. They will also be asked to say how good the help was

Quality All the things people say about the help Speech and Language Therapists give to people with swallowing problems will be collected to try to make things even better

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The National Health Service says we should:

Give clear information in the right way to people who have swallowing problems and to others who are looking after them. This should show how to make food and drinks right for the person.

Carers and staff working with people with dysphagia need to know that changes in a person’s medication or general health could make things worse. Changes should be checked with a doctor

There should be a clear way to get information between different services who look after a person with a swallowing problem so everyone who should know about what to do is told.

There should be one person who works for the Trust who is in charge of making sure that swallowing problems are cared for properly

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Produced by

Development Neurosciences and Learning Disabilities Directorate

Mytton Oak Royal Shrewsbury Hospital

Shrewsbury SY3 8XQ

Telephone 01743 261181

DNLDD

With acknowledgment to Photosymbols