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					                            DYSPHAGIA POLICY




               POLICY NO.                     POL/001/031
               DATE RATIFIED                  28th October 2009
               DATE IMPLEMENTED               October 2009
               NEXT REVIEW DATE               October 2011




                   POLICY STATEMENT / KEY OBJECTIVE:
                    to provide a clear and structured awareness of
                                   dysphagia for staff



ACCOUNTABLE DIRECTOR:                    Director of Nursing

POLICY AUTHOR:                           Specialist Speech and Language Therapist




                                              KEY POLICY ISSUES

                                                 Causes and consequences of
                                                 Dysphagia
                                                 The management of Dysphagia




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                           POLICY DOCUMENT CONTROL SHEET
Title             Title:                Dysphagia Policy
                  Version:                 2
Supersedes        Supersedes:              1
                  Description of
                  amendments:
Accountable       Lead:                    Mr Phil Robertson
Director
                  Designation:             Director of Nursing
Policy Author     Lead:                    Lindsay King
                  Designation:             Specialist Speech and Language Therapist
Consultation      Circulation List:        Clinical Policy Sub Group
Circulation:
Approval by       Committees / Groups      Clinical Policy Sub Group
                  Consulted: Date
                  Executive Director:      N/A
                  Name / Date
                  Policy Monitoring        28th October 2009
                  Group: Date
                  Trust Board: Date (if    N/A
                  applicable)
Circulation:      Issue Date:              October 2009
                  Circulated by:           Head of Corporate Administration
                  Issued to:               As per policy distribution list
Review            Review date:             October 2011
                  Responsibility of:
Link              1)
Reference
Documents         2)

Training          See Appendix 5
Requirements      (Please state category
                  A, B or C)
Service User /    1)
Carer
Information       2)
e.g. leaflets
for service
users
Further           Contact No.
Advice

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Monitoring        Use standard template
Audit Tool        and attach to policy




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                                           TABLE OF CONTENTS

INTRODUCTION ........................................................................................................ 5
INTRODUCTION ........................................................................................................ 5
1.       DEFINITIONS. ................................................................................................. 5
2.       CAUSES OF DYSPHAGIA.............................................................................. 6
3.       CONSEQUENCES OF DYSPHAGIA .............................................................. 7
4.       SYMPTOMS OF DYSPHAGIA ........................................................................ 7
5.       MANAGEMENT OF DYSPHAGIA................................................................... 8
6.       REQUIRED PRACTICE................................................................................... 9
APPENDIX 1 - REFERRAL FORM .......................................................................... 10
APPENDIX 2 - GLOSSARY OF TERMS ................................................................. 11
APPENDIX 3 - COMMITTEE / BOARD / GROUP TERMS OF REFERENCE ......... 12
APPENDIX 4 - AUDIT TOOL GUIDANCE ............................................................... 14
APPENDIX 5 – EDUCATION AND TRAINING NEEDS ANALYSIS ........................ 15
AND ACTION PLAN ................................................................................................ 15
APPENDIX 6 - EQUALITY IMPACT ASSESSMENT FORM ................................... 18
APPENDIX 7 - Nutritional Support, Enteral Feeding and Dysphagia Protocol .. 21
ABI/NS/156-V1 ......................................................................................................... 21
Clinical Specialist in Neuro-Physiotherapy .......................................................... 26




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INTRODUCTION

 The Trust is committed to providing high quality of care to all service users, ensuring
equality and valuing diversity through offering correct dysphagia management
regardless of a person’s age, race, ability to speak/understand English, religion,
gender, disability, sexual orientation and culture.
 Language barriers and/or disabilities such as visual impairment, aphasia or learning
disability, may make it difficult for service users to understand the guidelines and
procedures necessary to prevent and reduce healthcare associated with dysphagia.
It may therefore be necessary for service users to access the relevant information in
a language other than spoken/written English and in a format they understand e.g.
pictures.

http://nww.staffweb.cumbria.nhs.uk/cumbriapartnership/communications/staff_inform
ation_leaflets/Access_to_interpreter.pdf - This link will provide detailed information
on how to gain access to interpreters within the trust. The main reception at
Carleton Clinic can provide access to face to face and over the phone interpreting.
Sign language interpreting assistance can be provided by Cumbria Deaf Association
and written translations via the Communications Department. All access to
interpreters must be logged through the Equality and Diversity Lead on 07747
562650 or by emailing equality@cumbria.nhs.uk

www.equip.nhs.uk - Links to information rich website with resources in all
languages, lists of support groups and services related to other languages or for
people from ethnic minorities.

www.mencap.org.uk - Valuing and supporting people with a learning disability and
their families/carers.

www.easyhealth.org.uk – Provides health leaflets and information for patients and
professionals that are easy to understand.

The aim of this policy is to provide a clear and structured awareness of dysphagia for
staff who provide care to service users either directly or via the teams they manage.
The Department of Health has stressed the importance of assisting service users
with nutrition by setting this as a benchmark in The Essence of Care (DoH, 2001).

The Acquired Brain Injury Service provides community rehabilitation services to
those with brain injury living in Cumbria. A separate protocol is attached to this
policy for staff working within this specialist service.


 1.     DEFINITIONS

DYSPHAGIA

Dysphagia occurs when there is any disruption at the preparatory, oral and/or
pharyngeal stages of deglutition. Dysphagia is defined as difficulty, discomfort or
pain in swallowing. Swallowing is a very complex process involving many structures,
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muscles and nerves. The act of swallowing can be divided into three phases: oral,
pharyngeal and oesophageal.

DEGLUTITON

Deglutition is the process by which fluid or food is transported from the mouth to the
stomach for digestion. Successful deglutition is the result of a sequence of complex
events involving intricate anatomical oral and pharyngeal structures and multiple
neural pathways. Efficient deglutition is influenced by what is being swallowed and
factors specific to the individual (e.g. cognitive, physical, medical, psychological and
social).

ASPIRATION

Aspiration occurs when fluid, food, saliva, medication or refluxed materials enter the
airway. People with Dysphagia are at increased risk of aspirating. Aspiration can
occur without any obvious signs of difficulty (i.e. choking or coughing). Aspiration can
cause a partial blockage or infection in the bronchus which can lead to aspiration
pneumonia.

ASPIRATION PNEUMONIA

Aspiration pneumonia refers to lower respiratory tract infection caused by the
inhalation of oropharyngeal secretions colonised by pathogenic bacteria.

ASPHYXIATION

Asphyxiation occurs when the airway becomes occluded. People with dysphagia are
at increased risk of asphyxiation.


 2.     CAUSES OF DYSPHAGIA

Dysphagia may be present from an early age in childhood or have an onset in
adulthood. Its presentation may be acute but can also be chronic and symptoms may
progress over time.
Dysphagia may result from:

   •   Side effects of medication or drug abuse e.g. extra pyramidal symptoms,
       xerostomia (chronic, severe dry mouth), decreased levels of alertness or
       arousal, dyskinesia, etc.
   •   Acquired acute and/or progressive neurological conditions e.g. Epilepsy,
       Huntington’s disease, cerebral vascular accident, Parkinson’s disease, etc.
   •   Dementia e.g. Alzheimer’s disease, vascular dementia, Lewy Body or
       frontotemperol dementia.
   •   Psychiatric Illness e.g. ‘Fast- Eating Syndrome, psychogenic Dysphagia (or
       globus pharyngeus) any condition that alters level of alertness and orientation
       etc.

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   •   Congenital Syndromes e.g. Downs Syndrome, Retts etc.
   •   Disease which affects the anatomical structures of the oral cavity, pharynx or
       oesophagus.
   •   Normal Ageing.


 3.     CONSEQUENCES OF DYSPHAGIA

The primary function of deglutition is nutrition and hydration and this process will be
affected if dysphagic symptoms are present. Health and quality of life risks may
result as a consequence of Dysphagia if it is not recognised or goes untreated.
Some of the consequences being:
    • Poor appetite, weight loss and malnutrition
    • Dehydration
    • Increased risk of pressure sores and skin integrity
    • Constipation
    • Urinary tract infections
    • Choking and asphyxiation
    • Mental health issues e.g. depression, anxiety, altered body image
    • Reduced quality of life
    • Social isolation
    • Aspiration pneumonia
    • Increased risk of respiratory infections


 4.     SYMPTOMS OF DYSPHAGIA

Symptoms which may be reported by observers with service users at meal times or
when taking medication may include any or a combination of the following signs:
  • Difficulty or prolonged chewing
  • Coughing or choking during or after eating or drinking
  • Excessive drooling
  • Difficulty keeping food/fluid/medication in mouth
  • Food or medication becoming stuck in cheeks or roof of mouth
  • Gagging, retching, regurgitation or vomiting
  • Lack of interest, or avoidance or refusal to foods or drinks
  • Wet, weak or gurgly voice
  • Restricted diet
  • Increased time taken to eat and drink
  • Weight loss
  • Recurrent chest infections
  • Aspiration pneumonia




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 5.     MANAGEMENT OF DYSPHAGIA

The overall aim in the management of dysphagia is to ensure that individuals using
our services are identified and enabled to eat, drink and take medication in a safe
and comfortable manner. All communications by staff, with a service user, must be in
a format that they can understand and involve a family member as appropriate. (See
Introduction to this policy).

If staff suspect the service user is showing any symptoms of dysphagia or there is a
swallowing difficulty present, the following steps should be followed:

   •   Any concerns identified with swallowing, to be recorded in the service users
       notes with any action taken;
   •   Contact shall be made with the service users consultant or RMO and visit
       requested to discuss current presentation and agree plan, the service user
       and their family/carer (where appropriate) must be fully involved in the
       assessment process;
   •   Risk assessment will be completed by staff if service user is deemed at risk of
       dysphagia.
   •   Referral routes will be identified and agreed by the Senior Clinician.
   •   If a professional, clinical assessment is required from the Speech and
       Language Therapist, referral will be made in writing by completing the
       appropriate referral form (see appendix 1).
   •   Service users will be seen for their initial Speech and Language Therapy
       assessment appointment, see protocol at back of the policy.
   •   Following professional clinical assessment and risk assessment, personal
       care planning will be agreed, written and implemented to meet the needs of
       the individual, reflecting the views and cultural needs of the service user and
       their family where possible and regularly reviewed;
   •   Links with other services to support identified needs should be made and
       recorded in the service users notes, i.e. Dietician, pharmacist, dental services,
       occupational therapist, psychologist, etc;

   The care plan should include as appropriate:

   •   Specialist equipment (i.e. utensils, crockery, cutlery, seating,)
   •   Environmental factors (i.e. noise, positioning of service user and nurse,
       location)
   •   Prescribed interventions (i.e. muscle exercises, physiotherapy, etc)
   •   Modification of food and drink as prescribed
   •   Summary of assessment and outcomes
   •   Nutritional and hydration requirements
   •   Other specialist services involved in care package (i.e. dietician, physio, OT,
       etc)
   •   Oral hygiene needs
   •   Support and assistance required with any specialist feeding techniques
   •   Administration of medication
   •   The patients preferred method of communication
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   •   Review dates
   •   Further assessments or specialist investigations (i.e. Videofluoroscopy,
       Gastroenterology Team) If oral feeding is assessed as posing a significant
       risk to the service user, and an alternative method of feeding is agreed, i.e.
       via a Nasogastric tube or Percutaneous Endoscopic Gastrostomy (PEG), it
       may not be appropriate for Cumbria Partnership NHS Foundation Trust to
       provide a specialist service within the setting if appropriate resources and
       skills not accessible and transfer to a more appropriate care setting may be
       arranged in conjunction with the multi disciplinary team, service user and
       carer/family. However it may be appropriate for specialist support services
       from other areas to work within our environment.


 6.     REQUIRED PRACTICE

Nutrition is a vitally important aspect of our lives, not only the physical aspect of
taking in food and nutrients, but also the psychological, social and spiritual factors.
Buttress (1995) states that “Maintenance of good nutrition contributes to health and
well being and recovery from trauma and illness”.
 In addition the Department of Health 2009 published a document entitled “Religion
or Belief. A practical Guide for the NHS” stressing that “nutrition is an essential
element in the recovery and treatment of patients” .
 Healthcare professionals have an important role to play to ensure food and fluids
provided are nutritious and well presented taking full consideration to the individual
service users need.

Cumbria Partnership NHS Foundation Trust have implemented a policy on Patients
Protected Mealtimes, (POL/002/034). The purpose of this policy is to protect
mealtimes from unnecessary and avoidable interruptions, providing an environment
conducive to eating, assisting staff to provide service users with support and
assistance with meals, placing food first and the client at the centre of the mealtime
experience.

Good nutrition plays an integral role in maintaining the good health of the individual.
Nutrition screening should be undertaken on a regular basis to assess and monitor
the situation. Refer to Nutrition Policy (POL/001/044).




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APPENDIX 1 - REFERRAL FORM

          SPEECH AND LANGUAGE THERAPY DEPARTMENT


NAME: _______________________________ MALE / FEMALE (DELETE)

DATE OF BIRTH: _____________________ PIMS NO: ______________

ADDRESS: ______________________________

             _______________________________

POSTCODE: ________________________

BASE / WARD: ______________________

HOSPITAL / ESTABLISHMENT _______________________

ADDRESS: _____________________________

             ______________________________

CONSULTANT: ___________________________ GP: ______________________

PRESENTING PROBLEM / NEED:
________________________________________

__________________________________________________________________


ANY ADDITIONAL INFORMATION:
________________________________________

__________________________________________________________________


REFERRING AGENCY / DISCIPLINE _____________________ BASE:
__________________

SIGNATURE: ___________________________ ADDRESS: __________________
PRINT:      ___________________________         __________________
                                                __________________
DATE: ___________________________




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APPENDIX 2 - GLOSSARY OF TERMS

Accountable Director

The Director accountable for the policies within a specific area of responsibility. Also
the person responsible for the process or production of specific policies.

Policy File Holder

Person in charge of the administration systems for policies and procedures in a
particular service location.

Policy Author

The person nominated by the Accountable Director to prepare the draft of a specific
policy.




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     APPENDIX 3 - COMMITTEE / BOARD / GROUP TERMS OF REFERENCE


1       Name of Committee         Clinical Policy Sub Group

2       Connectivity Reports to   Policy Monitoring Group

        Committees reporting to   Policy Development Clinical Groups such as
        this group                CPA Mental Health Policy, Vulnerable Adults
                                  Committee, Child Protection Committee, Illicit
                                  Drugs and Search Groups

3.      Chairman                  Vivienne Forster, Acting Head of Clinical
                                  Governance

        Vice Chairman             Jonathan Comber

        Management Lead           Vivienne Forster, Acting Assistant Director of
                                  Nursing

4.      Members of the            Vivienne Forster, Acting Assistant Director of
        Committee                 Nursing
                                  Representatives from Mental Health Directorate
                                  Inpatient and Community, Learning Disabilities,
                                  CAMHS, Addictive Behaviours, Psychological
                                  Therapies, OT, Medical Representative
                                  Training Manager
                                  Matt Jansen, Mentally Disordered Offenders
                                  Development Worker, Social Services
                                  Policy File Holders

5.      Reference No.             POL/007/003

6.      Function of Committee     To review, develop and audit all clinical policies
                                  To provide assurance to the Policy Monitoring
                                  Group that the feedback has been sought from
                                  relevant clinical areas regarding each submitted
                                  policy.

        Inputs                    Clinical policy sub groups

        Outputs                   Policy Monitoring Group

7       Quorum                    Chair plus 5 members
8       Review date for           Annually so next review March 2007
        committee terms of
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        reference / structure

9       Frequency               Monthly

10      Purpose                 To review, develop and audit all clinical policies

11      Terms of Reference      •   The priority of this sub group is to ensure that
                                    all clinical policies are reviewed to go through
                                    the new Policy Monitoring Group for
                                    ratification.
                                •   The structure of this sub group will be to look
                                    at policies from an organisational perspective
                                    and ensure appropriate representation from
                                    all relevant areas have been involved.

12      Principal Functions     To ensure the safe review of clinical policies
                                based on available evidence and ensure clinical
                                effectiveness

13      Basis of Authority      Reports to the Policy Monitoring Group




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                           APPENDIX 4 - AUDIT TOOL GUIDANCE

 STATEMENT

 The Trust will work towards effective clinical governance and governance systems.
 To demonstrate effective care delivery and compliance regular audits must be
 carried out. Policy authors are encouraged to attach audit tools to all policies.
 Audits will need to question the systems in place as outlined in the policy. It is
 suggested that each policy will list at least ten standard statements which can then
 be audited in practice and across the Trust.

                                     DYSPHAGIA POLICY
                                                                         Yes      No
STANDARD STATEMENT
Statement 1         Concerns relating to swallowing difficulty
                    are recorded in the patient care plan?
Statement 2
                    Does the care plan include reference to
                    special requirements?
Statement 3         Has a detailed risk assessment been
                    completed when Dysphagia is present?
Statement 4         If the patient required dietetic support
                    was this implemented?

Statement 5         Has the patien tand / or relatives been
                    involved in the care planning process?
Statement 6

Statement 7

Statement 8

Statement 9

Statement 10




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          APPENDIX 5 – EDUCATION AND TRAINING NEEDS ANALYSIS
                           AND ACTION PLAN

STATEMENT

All policies will provide clear analysis of the amount of education and training
required to ensure compliance. Policy authors will be asked to complete the
following table to support submission to the Policy Monitoring Group.

Training Assessed at:         For which staff               Suggested cost
                                                            implications
Level A            yes        All Staff                     No cost      √
(Green)

Level B                       Clinical                      Minimal
(Amber)                       Staff                         cost

Level C                       Other: Please specify         Large
(Red)                                                       costs

Please refer to training                                    Comments
matrix below




TRAINING MATRIX

Level A (Green) - A policy will be designated for this required level of training if the
policy is felt to present minimal risk to the Trust. These policies designated green
would be disseminated to the local policy file holder. It is acknowledged that all staff
must be aware of all new and reviewed policies. A central record of acceptance from
local policy file holders will be recorded on the policy database. Local policy file
holders will need to place the new/reviewed in the correct policy file, change the
contents page which will be attached to the new/reviewed policy and inform all staff
in their area of the new/reviewed policies.

       EDUCATION AND TRAINING ISSUES ON POLICIES: ACTION PLAN

STATEMENT

All policies require an action plan to provide assurance to the Policy Monitoring
Group on education and training needs to ensure compliance with the policy. Policy
Authors will be asked to complete the following Action Plan to support submission to
the Policy Monitoring Group. Policy Authors are also requested to provide evidence
on education and training to the PA of the Director Responsible for the policy to
ensure that the SharePoint document management systems is kept updated.

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      TRAINING NEEDS ANALYSIS

Inpatient Unit     Community and/or                   Staff Group             Level of training required        How often
   (Please             Directorate
   specify)         (Please specify)
ALL               ALL                  Doctors                           Awareness of policy               Local induction and
                                                                                                           upon policy review
ALL               ALL                  Qualified Nurses                  Awareness of policy               Local induction and
                                                                                                           upon policy review
ALL               ALL                  HCA/Support Workers               Awareness of policy               Local induction and
                                                                                                           upon policy review
ALL               ALL                  Social Workers                    Awareness of policy               Local induction and
                                                                                                           upon policy review
ALL               ALL                  Occupational Therapists           Awareness of policy               Local induction and
                                                                                                           upon policy review
                                       Psychologists
                                       Psychotherapists
                                       Other Non Clinical Staff
                                       Admin and Clerical
ALL               ALL                  Managers                          Awareness of policy               Local induction and
                                                                                                           upon policy review
                                       or All Staff




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No.    Action Required         Criteria for Success     Lead Officer   Target   Completion Status
                               i.e.     evidence     of                Date     Date
                               education and training
1      Dissemination of policy Evidence of education re All managers   August
       via Trust news          policy recorded in
                               Minutes of Team
                               Meetings and on local
                               induction
2


3


4




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  APPENDIX 6 - EQUALITY IMPACT ASSESSMENT FORM

        (Please refer to the Equality Impact Assessment Guidance to complete the
       assessment contained with the Policy for the Development, Communication &
          Control, Ratification, Review & Destruction of Policies and Procedures)

Clinical Directorate / Area               Nursing

Name of person completing this            Vivienne Forster
assessment

Date                                      03.07.09

Name of proposed policy                   Dsyphagia Policy


                                    Stage 1: Initial Screening


1. What are the main aims of the policy?             To provide awareness of dysphagia and its
                                                     management for staff.

2. What evidence is available to suggest that the proposed policy could have an impact
   on people from the equality groups? Document reasons, e.g. research, results of
   consultation, monitoring data and assess relevance as:
   Not relevant / Low / Medium / High.

  Area                          Not     H/M/L        Evidence
                             relevant

a. Race                      X

b. Religion / Spirituality                L     Some religions prohibit certain types of
                                                food.*

c. Gender                    X
                                          H
d. Disability                                   There are many conditions involving neuro
                                                muscular damage resulting in dysphagia.

e. Sexual Orientation        X
                                          M
f. Age                                       Older people are more likely to suffer with
                                             dsyphagia and related difficulties.
If you assess the policy as not relevant, please proceed to Question 8.
If you assess the policy as relevant, continue to Stage 2, Full Equality Impact
Assessment.
   * The Essence of Care and Nutrition Policy highlights cultural and religious issues
   with regard to nutrition.
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                       Stage 2: Full Equality Impact Assessment


   3. Are there service user, public or staff concerns that the proposed policy may be
      discriminatory, or have an adverse impact on people from the equality groups?


   g. Public                           None

   h. Staff                            If staff adhere to this policy there will be no
                                       discriminatory issues

If there are no concerns, proceed to Question 5.
If there are concerns, amend policy to mitigate adverse impact (Question 5), consider
actions to eliminate adverse impact (Question 7), or justify adverse impact (Question 4).


   4. Can the adverse impact be justified?



   5. What changes were made to the policy as result of information gathering?

An increased level of communication is required on the part of staff to ascertain a service
user’s comprehension and compliance with the specified management of dysphagia.



   6. What arrangements will you put in place to monitor impact of the proposed policy
      on individuals from the six equality groups?

The audit tool guidance will determine if the policy is being adhered to.

   7. List below actions you will take to address any unjustified impact and promote
      equality of outcome for individuals from equality groups. Consider actions for any
      procedures, services, training and projects related to the policy which have the
      potential to promote equality.
                Action                          Lead                     Timescales
No unjustified impact identified.




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   8. Review date                             October 2011

I am satisfied that this policy has been successfully equality impact assessed.

Date: 07/10/09
Name of policy author: Lindsay King Specialist Speech and Language Therapist


Please send the completed assessment for scrutiny to: Liba Stones, Equality and
Diversity Project Lead, Cumbria Partnership NHS Foundation Trust, Carleton Clinic,
Cumwhinton Drive, Carlisle, CA1 35X, or liba.stones@cumbria.nhs.uk.


I am satisfied that this policy has been successfully equality impact assessed.

Date: 13th October 2009
Equality and Diversity Project Lead: Sue Mason




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APPENDIX 7 - Nutritional Support, Enteral Feeding and Dysphagia Protocol
ABI/NS/156-V1

1.0     Introduction

This document describes the considerations and actions for team members involved
with ABI clients that require Nutritional Support, are enterally fed and/or have
Dysphagia.

Specialist ABI dietetic support should be should be sought when a need has been
identified. If this is not available community dietitian should be contacted as a
secondary option.

2.0     Originating Service: Acquired Brain Injury Service

Increasingly, brain rehabilitation services in the UK are based on patient’s needs,
rather than on underlying pathology, and so do not distinguish between conditions.
The guidelines therefore address the broader spectrum of ABI which actually
presents to rehabilitation services.1

3.0     Objective

3.1     Clients are usually referred to the ABI Service by acute or rehabilitation
        unit services. Although it is likely that prior to their head injury this client
        group would be at a low risk of malnutrition, evidence suggests that up to 70%
        of hospital in-patients are likely to become malnourished due to the effects of
        injury, investigations and treatment.

3.2     The physical, cognitive and social consequences of Acquired Brain
        Injury (ABI) may affect the client’s ability to maintain adequate nutritional
        intake when discharged into the community. All new referrals to the ABI
        service should be screened to identify those that are at risk of malnutrition and
        may require nutritional support.

3.3     ABI Service clients that are enterally fed require expert
        Dietetic assessment and regular monitoring and review to ensure that their
        changing nutritional needs are met.

3.4     ABI Service clients that have dysphagia require specialist Speech and
        Language Therapy and Dietetic advice to ensure that they achieve safe oral
        dietary and fluid intake whilst maintaining their nutritional requirements.

4.0     Scope

This policy applies to all staff working within the acquired brain injury service working
within Cumbria Partnership Trust.




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5.0     NUTRITIONAL SUPPORT

5.1     All clients referred to the ABI Service to be screened for risk of malnutrition by
        an ABI team member at their initial assessment.

5.2     The consequences of the client’s head injury on personal, social and care
        arrangements, and on the client’s ability to maintain adequate nutritional
        intake in the community setting, to be identified at initial assessment.

5.3     Clients to be referred to the Dietitian for urgent assessment if they have:
        - BMI of <18 and/or unintentional weight loss of >10% in 3-6 months
        - Are unlikely to eat/drink for >5 days.

        Clients will be referred to the Dietitian for routine assessment if they have:
        - BMI of <20 and/or unintentional weight loss of 5-10% in 3 months.

5.4     Urgent referrals to be seen by the Dietitian within 5 working days.

5.5     Routine referrals to be seen by the Dietitian within 20 working days.

5.6     For clients that cannot be weighed, initial assessment will include subjective
        criteria to assess any risk of malnutrition and requirement for referral to the
        Dietitian.

5.7     Clients with other dietary conditions (e.g. diabetes, coeliac disease, raised
        lipids) should also be referred to the Dietitian for advice on implementing
        dietary requirements within the context of the effects of their head injury and
        their altered lifestyle.

5.8     Initial ABI team assessment and referral to the Dietitian to be
        recorded in the client’s notes.

5.9     The Dietitian will assess, treat and monitor clients that require
        nutritional support, providing advice on dietary manipulation and fortification,
        the use of prescribed nutritional supplements and lifestyle/social/carer
        requirements.

5.10    Client’s nutritional and dietary targets will be included in ABI
        interdisciplinary goal planning and review.
5.11    The Dietitian will determine the frequency of client monitoring and
        review (i.e.: weekly, two weekly or monthly).

5.12    The Dietitian will record dietetic interventions in the client notes.

5.13    Parameters the Dietitian may monitor for nutritional support will include:

        dietary and fluid intake records            anthropometric measurements
        biochemistry                                GI function


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                                                                             28th October 2009
        clinical status                        medical history and diagnosis
        additional nutritional requirements    prescribed medications
        requirements for and compliance with prescribed dietary supplements

5.14    The Dietitian will inform the client’s GP of nutritional advice provided
        and advise on requirements for prescribed supplements.

5.15    The Dietitian will provide advice and training on the client’s nutritional
        requirements for the ABI team, supporting agencies and care providers.

5.16    The Dietitian will provide nutritional support training for ABI team
        members at their induction and at least bi-annually thereafter, to raise
        awareness of indicators for nutritional support, so that all team members can
        identify any nutritional concerns for clients in their care.


6       ENTERAL FEEDING

1       Clients that are enterally fed to be assessed at home by the Dietitian within 5
        working days of discharge to the ABI service.

2       Clients will be registered with the appropriate Home Care Service for feed and
        equipment delivery, training, advice and access to out of hours support ie:
        UHMBT patients (Currently South Cumbria supplied by Nutricia Homeward).
        Cumbria PCT patients (Currently Carlise/N Cumbria supplied by Abbott
        Nutrition).

3       The Dietitian will calculate the client’s nutritional and fluid requirements and
        daily feeding regimen, assess feed tolerance and advise on the most suitable
        method of feed delivery.

4       Depending on individual feed tolerance clients will initially be reviewed by the
        Dietitian weekly or monthly.

5       Once enteral feeding is established the Dietitian will monitor and review the
        client’s feed prescription and feed tolerance at least 3 monthly, with a
        minimum face to face contact time of 6 months.

6       The Dietitian will provide written advice and training on the recommended
        feeding regimen for clients and carers.

7       The Dietitian will provide advice and training for clients and carers on other
        aspects of enteral feeding in line with the registered Homecare company’s
        policies and patient information leaflets.

8       The Dietitian will inform the client’s GP of the recommended feed prescription
        and notify the appropriate Homecare service of feed and equipment
        requirements or amendments.


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                                                                            28th October 2009
9       The Dietitian will liaise with the GP or specialist Homecare Nurse, District
        Nurses or Nursing Home on any issues that may arise at the client’s feed
        reviews,
        e.g.: delivery of medications, feed hygiene, oral and stoma care, bowel
        management, nausea, risk of aspiration, care of feeding tubes and the
        provision of equipment and replacement feeding tubes.

10      The Dietitian will monitor nutritional status and feed tolerance using the
        following parameters:
        - prescribed feed, volume and method of feed delivery
        - additional nutritional requirements
        - medical history and diagnosis
        - food and fluid intake charts, bowel and fluid output charts
        - anthropometric measurements
        - biochemistry e.g.: urea and electrolytes, liver function, blood glucose
        - GI function
        - clinical status e.g.: chest or urinary tract infections, pressure areas
        - prescribed medications

11      The Dietitian will provide training for ABI team members on basic aspects of
        enteral feeding (at induction and bi-annually) to raise awareness of the
        management, hygiene and reduction of possible complications of enterally fed
        clients

7       DYSPHAGIA

1       Clients with Dysphagia will be assessed by the Speech and Language
        Therapist (S&LT) and the Dietitian within 5 days of referral to the ABI service.

2       S&LT assessment will include formal and informal assessment of
        oro-motor function, oral and pharyngeal swallow ability, the client’s cognitive
        ability and their physical ability to prepare food and feed themselves.

3       The S&LT will provide written guidelines on dietary texture and fluid
        consistency requirements, swallowing maneuvers and compensatory
        strategies.

4       The Dietitian will assess the client’s nutritional status and nutritional intake.

5       If the Dietitian or S&LT consider the client is unable to achieve safe or
        adequate dietary and fluid intake by the oral route they will inform the client’s
        GP and recommend referral for assessment for the provision of enteral
        feeding.

6       Advice to modify dietary texture and fluid consistency may affect the
        nutritional adequacy of dietary and fluid intake. The Dietitian will provide
        advice for the client to adjust nutritional intake to compensate for any foods
        that the client may be unable to eat.


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                                                                             28th October 2009
7       The Dietitian will recommend and request prescribed supplements for the
        client, if these are deemed necessary to support adequate nutritional intake.

8       The Dietitian will monitor the client’s nutritional status and intake weekly
        (initially), monthly or three monthly (once stable).

9       The S&LT will re-assess weekly or fortnightly initially, modifying dietary
        texture and fluid consistency requirements if the client’s dysphagia alters.

10      Clients that are re-acquiring the ability to chew or swallow (transitional feeding)
        will be reviewed by the S&LT and Dietitian monthly and provided with written
        advice for their transitional feeding plan.

11      The S&LT and Dietitian will provide training and advice for clients and carers
        on dietary texture and fluid consistency modification, the use of thickeners,
        nutritional support, safe feeding and positioning to reduce the risk of
        aspiration and choking.

12      The ABI physiotherapist or OT will assess and advise on client positioning
        and seating to reduce the risk of aspiration and choking.

13      Clients that are considered unsafe for any oral diet or fluids will be re-
        assessed by the SLT every 6 months for 2 years and 12 monthly thereafter
        (whilst they remain on the ABI caseload).

14      The Dietitian and S&LT will provide dysphagia training for members of the ABI
        team at their induction and bi-annually to raise awareness of the risks,
        treatment and management of clients with Dysphagia.


8.      Responsibilities

        It is the responsibility of the authors of the protocol and the line manager(s) to
        ensure that all staff are aware of, and understand, the contents of this
        document and where and how to access it. It is the responsibility of individual
        staff members and the line manager(s) to ensure they adhere to the contents
        of this document, and that they undertake their roles in a safe and correct
        manner, identifying training and resource requirements where relevant.


9.      Definitions

9.1     Nutritional Support- Fortification of diet and/or use of food supplements to
        adjust daily energy or nutrient content

9.2     Enteral Feeding – naso-gastric, naso-jejunal, gastrostomy or jejunostomy tube
        feeding

9.3     Dysphagia – difficulty chewing and/or swallowing

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                                                                            28th October 2009
           ABI Acquired Brain Injury-is an inclusive category that embraces acute (rapid onset) brain
           injury of any cause, including:
           Trauma- due to head injury or post surgical damage (e.g. following tumour removal)
           Vascular Accident –(stroke or sub-aracnoid haemorrhage.
           Cerebral anoxia
           Other toxic or metabolic insult (e.g. hypoglycaemia)
           Infection (e.g. meningitis, encephalitis) or other inflammation (e.g. vasculitis).

10.        Document Implementation

           1. A copy of this document to go in relevant client’s notes (Named Dietitian/SLT to action
              this).
           2. A copy of this document to be in the ABI induction file.
           3. A copy of this document to go in the “Three File” system.
           4. A copy of this document is available on the Trust internet.


11.        Audit

           Procedural; Initial audit of this policy to happen 1 year after implementation.


12.        Training

           To be part of the induction of new team members.



13. Details of Consultation:

      1.   Consultant in Rehabilitation
      2.   PPI
      3.   Morecambe Bay Nutrition Dept UHMBT
      4.   Physiotherapy Lead

Clinical Specialist in Neuro-Physiotherapy




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References

Current Perspectives on Enteral Nutrition ion Adults – A report by a working party of
the British Association for Parenteral and Enteral Nutrition 1999.
Homeward Policies and Patient Advice Sheets Sept 2006 Nutricia Clinical Care
Report Royal College of Speech and Language Therapists and British Dietetic
Association Joint Working Party May 2002. National Descriptors for Texture
Modification in Adults
National Institute for Clinical Excellence 2006
Nutrition Support in Adults: Oral Nutritional Support, Enteral Tube Feeding and
Parenteral Nutrition. London N.I.C.E.
Logemann, Jeri. A. 1998. Evaluation and Treatment of Swallowing Disorders, 2nd
edition. Pro-ed publishing, USA.




Dysphagia Policy                          27                        Our Ref: POL/001/031
                                                                        28th October 2009

				
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