Dysphagia Team Management: Continuous Quality Improvement in a Long-
Term Care Setting
By Nan D. Musson
The following article was originally published by ASHA in the Winter 1994 Quality
The emergence of feeding and swallowing Team implemented several interdisciplinary
intervention by speech-language programs to address the feeding/swallowing
pathologists in the 1970s has proved to be an needs of the patients residing in the Nursing
important aspect of total patient care and is Home Care Unit.
now routine in many medical facilities.
Increased numbers of individuals in our Quality Improvement Goals
rapidly aging population require institutional
care; as a result, maintaining nutrition and In 1987, quality improvement projects
hydration has become a critical concern for within the medical center focused on
health care professionals who work with structure monitors rather than outcome and
patients in long-term care settings. process monitors. Table 1 describes the
various types of quality assurance monitors.
In February 1987, the Dietary Service and
Speech Pathology Section at the Department Table 1. Types of Quality Improvement
of Veterans Affairs Medical Center in Monitors
Miami, Florida, documented that 57% of the
residents in the 240 bed Nursing Home Care Structure: Structure relates to
Unit presented with feeding and swallowing institutional and provider characteristics,
problems. A Dysphagia Team was such as budget, organizational mission,
established in July 1987 to address the needs policies, staff qualifications, specialty
of those residents. The present certification, the facility, and equipment.
interdisciplinary Team consists of a speech-
language pathologist, geriatrician, nurse Process: The sequence of activities,
practitioner, dietitian, psychologist, dental procedures, or functions used by
hygienist, and radiologist. practitioners and managers in the
delivery of care, such as nutrition
In addition to providing comprehensive screening and assessment; development
assessment and indirect dysphagia of care plans; treatment counseling and
intervention, the Team served as the primary education; production and distribution of
force in expanding an interdisciplinary food; and follow-up of monitoring of
continuous quality improvement program to care.
include a nutritionally supportive
environment within the long-term care Outcome: Observable end results or
setting. The focus of the overall program changes in the patient’s health nutrition
was to maximize physical and functional status.
abilities, consistently provide adequate
nutrition and hydration, provide attention to (American Dietetic Association, 1993)
the quality of feeding, and enhance the
quality of life for patients. The Dysphagia
After an initial 3- month review of clinical of life, as well as increased morbidity (i.e.,
care for individuals with dysphagia the skin, urinary tract, and pulmonary
Team concluded that each quality infections) and mortality (Siebens et al.,
improvement project should embrace these 1986; Silver, Morley, Strome, Jones, &
objectives: Vickers, 1988; Rudman & Feller, 1989).
(1) The major goal of intervention for One explanation for the high incidence of
individuals with dysphagia is to malnutrition and dehydration may be the
assure safe, adequate nutrition and large number of patients who require
hydration. feeding assistance and the lack of time for
staff to feed them. Because many of the
(2) The quality improvement process institutionalized elderly are unable to
would include meaningful data perform self-care activities, it is not
collection for quality patient care and surprising to find that most patients require
management, which in turn would some help in eating. Dysphagia is a sequela
facilitate professional and clinical to a variety of neurological and structural
development and provide objective disorders. Trupe, Siebens, and Siebens
data for administrators to support a (1984) found that 59% of the residents in a
dysphagia program. 240 bed nursing home exhibited clinical
signs of oral or pharyngeal stage dysphagia.
(3) Four major areas of clinical care
were targeted for quality Initiative #1 – Determine the prevalence
improvement and appropriate of dysphagia.
development of new procedures or The Fleming Index of Dysphagia (Veterans
programs. Administration, 1986) was used to assess the
Identification/screening entire population of the Miami VA Nursing
Education Home Care Unit. The Index showed
Assessment/diagnosis collection of demographic data and
Treatment/management identified specific swallowing problems that
suggested the need for a more detailed
Examples of the Dysphagia Team’s assessment and intervention.
continuous quality improvement process are
provided. Figure 1 provides a flowchart of Participants: Dietitian, speech-language
the four clinical areas and the year each pathologist, nurses.
program or outcome monitor was initiated.
The challenges, initiatives, Team Outcome: In February 1987, the Speech
participation, and outcome are described for Pathology Section and Dietary Service
each major area. documented that 43% of the residents in the
Nursing Home Care Unit presented with
Identification/Screening swallowing problems and were considered
at risk for aspiration. As a result, an
Challenge: The reported incidence of interdisciplinary Dysphagia Team was
malnutrition among geriatric established to address the needs of these
institutionalized patients ranges from 12% to residents.
70% (Cooper & Cobb, 1988).
Undernutrition adversely affects the quality
Initiative #2 – Determine the prevalence meal times and provides documentation of
of feeding problems. the number of patients who require feeding
Residents were observed during meals and assistance. The computer-generated feeder
snacks. Their ability to eat was documented list has been used to tabulate the number of
and the need for partial, moderate, or total patients who require feeding assistance on
feeding assistance was determined. each unit. This information has helped in
setting staffing patterns for meals. The
Participants: Dietitian, diet technician, number of patients who require feeding
nurse, nurse assistant, speech-language assistance, multiplied by the number of
pathologist, psychologist, physician. meals and snacks per day and the amount of
time required to feed the patient, better
Outcome: In an initial survey in 1987, 57% defines the amount of staff needed to assist
of the residents required feeding assistance. in feeding the patients. A result was that the
Additional observations in 1988 and 1989 personnel service established an agreement
revealed that 60% of the residents required to recommend that all employees assigned to
partial, moderate, or total feeding assistance light duty assist in feeding patients.
during meals and snacks.
Initiative #3: Identification of patients
requiring feeding assistance. Challenge: A continuing education program
A computer-generated “feeder list” was was implemented for administrative,
initiated in 1992 to provide documentation professional, and nonprofessional staff and
of patients who required feeding assistance. volunteers to improve overall patient care in
The physician places orders for feeding the area of feeding and swallowing
assistance in the patient’s medical record disorders.
and the ward clerk enters the hospital
computer diet order. Nursing and dietary Initiative #1: Professional education and
staff can obtain an updated list daily. training for the Dysphagia Team staff.
Patients identified as requiring feeding Certification or licensure is necessary but
assistance have their meals delivered on a often not sufficient to support privileging of
different colored tray with the Silver Spoons many clinical procedures available for the
logo, rather than the traditional meal tray. diagnosis and treatment of dysphagia.
The special trays provide easy identification Therefore, practitioners have found it
of any patient who requires feeding necessary to pursue postgraduate education
assistance during meals. and training to meet the credentialing and
privileging requirements set by medical
Participants: Physician, nurse practitioner, centers. Dysphagia Team members
ward clerk, head nurse, nurse, nurse requested funding from the medical center to
assistant, dietitian, diet technician, food attend workshops. As the Team developed
service staff, speech-language pathologist, clinical expertise, proposals for educational
psychologist, personnel service staff, grants were submitted to bring experts to the
volunteers. medical center for workshops and on-site
demonstrations or to support travel funds for
Outcome: The interdisciplinary approach to mentorship training.
feeding assistance allows easy identification
of patients who require feeding assistance at
Participants: Dysphagia Team members,
supervisors or service chiefs, medical center Initiative #3: Nonprofessional education
education staff, research staff. and training.
In 1987 a training program was initiated to
Outcome: Initially three members of the train volunteers in appropriate feeding
Team were sent for a 3-day course. strategies to assist nursing staff with
Subsequently the members of the Team have supervised feeding. Volunteers attend a 2-
attended more tan 20 national and state hour training session. The training program
workshops/courses, two members of the was extended to spouse and family support
Team have been funded to observe with a groups, private duty sitters and aides, and
mentor, the team obtained education funding nonprofessional employee groups. The
to provide a national 3-day conference, and training is offered quarterly and all
five experts have served as on-site mentors volunteers are encouraged to attend initial
for the Team. and follow-up training. The Dysphagia
Team has also participated in health fairs,
Initiative #2: Professional education and assisted with the National Nutrition
training for house staff. Screening Initiative, and provided
The Dysphagia Team initiated an ongoing community support group training.
in-service program for house staff that
included basic lectures, as well as Participants: Dysphagia Team members,
workstation and role-playing activities. social work staff, voluntary service staff,
Nursing staff in-services are arranged with patients’ spouses and families, private duty
the head nurse and are offered at 7:30 a.m. staff, nonprofessional staff.
and 3:30 p.m. during shift changes.
Physician training was addressed during Outcome: To date more than 400 volunteers
Clinical Grand Rounds and by walking and family members have participated in the
rounds on high-risk units. The Team training, leading to increased awareness of
provides lectures for the weekly Geriatric individual patient needs for feeding
Seminars established for the Geriatric assistance, increased awareness of
Fellows and provides in-services for swallowing disorders and the need for
Medical Student Geriatric Rotation and appropriate diet modification, and increased
Medical Center Journal Club. participation of spouses and family members
in providing feeding assistance to maintain
Participants: Dysphagia Team members. nutrition and hydration.
Outcome: The number of consults to the Initiative #4: Administrative education.
Dysphagia Team more than tripled during a In addition to traditional quarterly and
1-year period. The Nursing Service annual reports, the Dysphagia Team hosts an
recognized the value of a training program annual Dysphagia Team Birthday Party.
and a member of the Dysphagia Team has During this party the Dysphagia Team
been invited to provide a 1-hour in-service presents an historical review of the
on feeding and swallowing disorders during Dysphagia Team development, the results of
the monthly nursing orientation. Appendix the quality improvement projects over the
A provides an example of a pre-/ past year, the current research projects and a
posttraining observation tool for nursing list of publications and presentations, and
staff. also reviews goals for the next year.
Participants: Dysphagia Team members, families have become active participants in
supervisors and service chiefs, assistant preventing malnutrition and dehydration.
director, director, chief of staff, personnel
service staff. The new term for such educational programs
may be interpreted as “marketing.” The
Outcome: An annual Dysphagia Team Dysphagia Team learned to develop a
Birthday Party with a formal presentation of marketing or promotional plan that
objective data and accomplishments has identified the audience, estimated the cost
been successful in heightening awareness of (staff time required to plan and present,
the dysphagia programs at the Miami VA. audiovisuals, and literature), and determined
the time (time of day and length of activity),
Initiative #5: Educational literature. frequency (how often to provide the activity)
The Dysphagia Team identified a need for and duration (how long to continue the
educational literature to address the needs of activity within the professional setting) for
specific patient populations and to reinforce each activity or in-service. The Team also
professional and nonprofessional training learned how important it is to evaluate the
programs. A booklet was designed to train outcome of the activity and to determine if it
volunteers to assist in supervised feeding. was productive to continue the educational
Three brochures were developed for program initiative.
patient/caregiver training: “Oral
Management for the Dysphagic Individual,” Assessment/Diagnosis
which introduces strategies for the oral and
dental care of patients with dysphagia; Challenge: The clinical examination is the
“Swallowing Problems and Liquid most widely used diagnostic technique in the
Modification,” which provides strategies for evaluation of dysphagia and, if warranted,
patients who require modification of liquid an instrumental technique may be
consistencies to prevent aspiration; and recommended to complete the assessment.
“Tube Feeding Instructions,” a guide for Instrumental techniques help evaluate oral,
individuals who require enteral tube feeding. pharyngeal, laryngeal, upper esophageal,
Finally, a brochure for house staff was and respiratory function as it applies to
developed to provide information regarding normal and abnormal swallowing. Reports
early identification of feeding and in the literature have indicated that there
swallowing disorders, appropriate referral may be intra and interobserver variability.
sources, and lists of diet and feeding Ekberg, Nylander, Fork, et al., (1988)
modifications for persons with dysphagia. studied the interobserver variability of six
The literature is distributed during training radiologists during retrospective reviews of
sessions or appropriate counseling sessions. 72 cineradiographic examinations. There
was high concordance for the assessment of
Participants: Dysphagia Team members, contrast medium reaching into the trachea,
support staff. absent pharyngeal constriction, and the
presence of Zenker diverticula; concordance
Outcome: Increased referrals to the was less for normal pharyngeal function.
Dysphagia Team have promoted early The authors concluded that the number of
identification of high-risk patients. disagreements varied according to the
Nondietary staff, volunteers, patients, and observer’s experience. No data were
available regarding the intra- or
interobserver variability of two instrumental Table 2. Videofluoroscopic Examination of
tests used by Miami VA speech-language Swallow Function Examples of Inter-/
pathologists, and a quality improvement Intraobserver Reliability
activity was initiated to enhance proficiency
in review of videotaped studies and to Aspiration observed yes/no
provide a structured opportunity to assist in
credentialing and privileging requirements Number of times
within the service. aspiration observed
Initiative #1: Videofluoroscopic exam of
Time of aspiration observed
swallow function observer reliability.
Before the swallow yes/no
Videofluoroscopic study of oral and During the swallow yes/no
pharyngeal swallowing is a procedure often After the swallow yes/no
referred to as the “modified barium
swallow” (Logemann, 1986). To enhance Consistency aspirated
proficiency and knowledge in evaluating the Thin liquid yes/no/na
structures and function of the oral, Thick liquid yes/no/na
pharyngeal, laryngeal, and upper esophageal Ultrathick liquid yes/no/na
areas during oral preparation and Formable solid yes/no/na
swallowing, the speech-language Particulate solid yes/no/na
pathologists reviewed videotapes of Multitexture yes/no/na
videofluoroscopic studies and completed an Crunchy solid yes/no/na
observation check sheet. Interobserver Aspirated during
reliability data were collected and reviewed Single bolus yes/no/na
for agreement. Table 2 provides examples of Consecutive swallow yes/no/na
high-risk observations monitored for inter-
and intraobserver reliability. Aspirated when using
Participants: Speech-language pathologists, Cup yes/no/na
radiologists. Straw yes/no/na
Outcome: As reported by Eckbert et al., Residue in
(1988), clinicians obtained 100% agreement
Pyriform sinus yes/no
for observation of tracheal aspiration of the Laryngeal vestibule yes/no
contrast medium. Initially there was 80%
agreement for other parameters listed on the Residue cleared with
observation check sheet; within a 3-month automatic second swallow yes/no
period there was 100% agreement. verbal cue to swallow yes/no
Patient successfully cleared yes/no/na
Transit time will allow for
Adequate nutrition yes/no
Adequate hydration yes/no
Initiative #2: Fiberoptic endoscopic average of only 14 minutes of staff feeding
evaluation of swallowing (FEES); assistance per day.
Langmore, Schatz, and Olsen (1988) Elderly individuals often have a deficit in
introduced the use of the fiberoptic thirst perception (Phillips, Rolls, Ledinghan,
nasopharyngolaryngoscope to evaluate et al., 1984) and regulation of fluid intake,
pharyngeal swallow to assist in the diagnosis which may lead to a decline in renal
of aspiration among adult patients unsuited function, electrolyte imbalance, or
for videofluoroscopic studies. Observations dehydration. Individuals with special diet
obtained by FEES are made by directly modifications, dysphagia, memory or
viewing events that occur before and after cognitive impairments, and physical
the swallow. Endoscopy provides a view of limitations are at greater risk for
the hypopharynx and larynx; aspiration or dehydration.
evidence of aspiration can be observed.
Inter- and intraobserver reliability of Initiative #1: Silver Spoons.
physical signs of glottic closure, pharyngeal The Dysphagia Team and Nursing Service
residue, laryngeal penetration, and tracheal developed the Silver Spoons Program in
aspiration are obtained by viewing 1988. Volunteers aid nursing staff by
videotaped FEES procedures of all of the providing eating assistance to patients with
patients evaluated each month. feeding/swallowing problems. All
volunteers interested in participating in the
Participants: Speech-language pathologists, feeding program attend an orientation and
otolaryngologists. are given practical training in important
aspects of feeding.
Outcome: Interobserver reliability of FEES
has improved from 80% to 100% on the Participants: Voluntary service staff, nurses,
variables of glottic closure, pharyngeal dietitians, speech-language pathologists,
residue, laryngeal penetration, and tracheal volunteers.
aspiration during a retrospective review of
videotapes. Initiative #2: Happy Hour.
Happy Hour is a daily afternoon gathering
Treatment/Direct Feeding Assistance when fluids and snacks are offered to
patients in a social milieu. This hydration
Challenge: Many institutionalized elderly hour was specifically designed to ensure the
are unable to perform self-care activities, so provision of fluids at least once per day (in
it is not surprising to find that most patients addition to meal times) to decrease the
require some help in eating. The incidence of dehydration. Consistencies of
responsibility for nutrition and hydration of foods and liquids are varied as necessary for
the patients was left to the nursing staff. individuals with dysphagia.
Feeding an eating-dependent patient requires
a minimum of 30-45 minutes of personnel Participants: Nurses, dietitians, diet
time; patients with moderate to severe technicians, speech-language pathologists,
dementia may take up to 90 minutes per volunteers, recreation therapists.
meal to feed. It has been reported (Hu,
Huang, & Cartwright, 1986) that patients
who live in a nursing home are provided an
Initiative #3: Dining environment. a change in environment for patients, and an
Prior to the interdisciplinary dysphagia opportunity for increased pleasure in eating.
management programs, patients with
feeding or swallowing problems were fed in Initiative #4: Dietary modifications and
their rooms. Patients left in their rooms were cost justification.
often poorly positioned during feeding, were Overall cost-benefit analysis of a dysphagia
left in bed for many hours of each day, and treatment program may include food costs,
were rushed in the eating process. Dietary patient length of stay, and staff utilization.
and nursing staff coordinated efforts to The Dysphagia Team initially addressed
provide a second seating in the dining room. food costs savings.
Patients with feeding and swallowing
problems, identified by the Dysphagia Team Daily Meal Costs: The cost of the daily
and nursing staff, were taken to the dining meals for each patient was tabulated before
room at a time when the most staff/volunteer the Dysphagia Team’s evaluation and after
assistance is available. recommendations for modification of the
diet and feeding were implemented.
Participants: Dietary staff, nurses, building
management staff. Participants: Dietitian, nurses, food service
Outcome: Initiatives #1, #2, and #3:
Seventy-two percent (72%) of the patients Outcome: Analysis of the data collected
fed in dining rooms gained weight; 28% lost showed an average food cost savings of 85
weight. There was an average weight gain of cents per patient per day or an average
2.06 lbs. for individuals fed in the dining savings of $71.40 per patient per quarter.
rooms. Staff ability to provide feeding Standard diets for patients with dysphagia
assistance improved in the dining room, were established with improved patient
compared to feeding patients individually in consumption, new food products were
their rooms. Dining rooms were established added, and costs savings have continued.
for each unit in the Nursing Home Care
Unit. Daily Snack Costs: The dietary service
calculated the costs of serving individual
Patients fed meals in their room without snacks to patient rooms and costs of serving
assistance had an average weight loss of bulk snacks to the nursing station for Happy
1.38 lbs., compared with patients who were Hour.
fed by Silver Spoon volunteers at meals and
Happy Hour (+4.16 - +6.15 lbs.) during a 3- Participants: Food service manager,
month period. Patients with probable dietitian, nurses.
Alzheimer’s disease benefited from
volunteer feeding programs; 94% Outcome: The dietary service found that it
maintained or gained weight. was very efficient and cost-effective to
deliver snacks in bulk to each unit instead of
Additional benefits of the feeding programs serving individual snacks to patients in their
include more efficient use of staff and rooms. There was an average food cost
volunteer time, increased monitoring of savings of $3.32 per unit per day to deliver
patients with feeding/swallowing problems, the snacks in bulk.
Enteral Tube Feeding (Special Focus on quarterly basis. Table 3 provides an example
PEGS) of the data collected by the Dysphagia
Team. When appropriate the Team
Challenge: Alternate or supplemental recommended follow-up dysphagia
nutrition devices (e.g., intravenous [IV], evaluation and intervention.
nasogastric tube [NG], jejunostomy,
percutaneous endoscopic gastrostomy Participants: Dysphagia Team members.
[PEG], total parenteral nutrition [TPN]
provide hydration and nutrition if patients Outcome: Seventy-five (75%) of the patients
with disordered swallowing are unable to with PEGs gained weight, 8% maintained
digest a sufficient amount orally without risk weight, and 17% lost weight. There were no
of medical complications. Ciccon, deaths during the first quarter of data
Silverstone, Graver, and Foley (1988) collection. Initially 21% of the nursing home
observed 70 tube-fed patients aged 65-95 population had enteral tube feeding; the
years during an 11-month period to average has now decreased to 11% of the
determine indications, benefits, and residents. During the initial quarter of
complications of enteral alimentation. monitoring, 25% of the patients had the PEG
Twenty-eight (40%) of the 70 patients died removed after follow-up Dysphagia Team
during the study period. After this study evaluation. During the second quarter, 13%
various articles described the risks and of the patients with enteral tube feeding
benefits of enteral tube feeding, challenging were able to have the tube removed.
our Dysphagia Team to carefully consider
all options for patients with dysphagia. PEG Table 3. Dysphagia Team
feeding has become a common practice in
extended-care facilities, though little is High Risk Quality Management Monitor
known about long-term results. Percutaneous Endoscopic Gastrostomy
Patients reserve the right to refuse medical Patient I.D.:
treatment, including refusal of enteral tube Admission to ECU/NHCU:
feeding. No data are available to document Unit:
the risk and benefit of dysphagia Major medical/psychiatric diagnosis:
intervention in patients with documented Date of PEH placement:
aspiration who refuse tube feeding. Two Restraint required to maintain tube placement:
populations were selected for quality List any complication(s): (example: leaking at
improvement monitoring: (a) patients with PEG site)
PEGs placed before admission to the nursing Height:
home; and (b) patients who elected not to Ideal body weight:
have enteral tube feeding following the Actual weight:
Dysphagia Team evaluation. % Ideal body weight:
Initiative #1: Monitoring and re- Formula:
evaluation of patients with percutaneous Rate of formula:
endoscopic gastrostomies (PEG). Continuous/bolus:
The Dysphagia Team decided to monitor the Prescribed water:
weights of patients with PEGs on a monthly Head of bed:
basis and results were reviewed on a Other observations or notes:
Initiative #2: Monitor nutrition and specialist position within the medical center,
health status of patients who elect not to and an outpatient dysphagia clinic was
have enteral tube feeding. The Miami VA established to follow patients after discharge
Dysphagia Team respects the patient’s from the nursing home or hospital.
wishes and provides the safest diet and
compensatory strategies for maximum oral Outcome data have supported the need for
intake. The team monitors these patients for new policies, procedures, and programs
weight loss, dehydration, and complications within the medical center. For example, a
(infections). successful procedure for obtaining and
monitoring patient weights on a monthly
Participants: Dysphagia Team members. basis was introduced, a policy was
established for laboratory orders to monitor
Outcome: Initial data suggest that patients nutrition, and the gastroenterologists began
with progressive neurological diseases to require a dysphagia evaluation prior to
maintain oral intake with diet modification placement of a percutaneous endoscopic
and an assigned feeder for each meal. gastrostomy for alternate feeding. A member
Patients status post-head and neck surgery of the Dysphagia Team was selected as the
have an average of 2-3 instances of chair of the Medical Center Nutrition
aspiration pneumonia per year; when the Committee.
patients tire of acute illnesses, they
reconsider PEG placement. Less than 20% Transition From Quality Improvement to
of the population died within a 3-month Clinical Research and Treatment Efficacy
The American Speech-Language-Hearing
Transition From Quality Improvement Association (1990) and the Veterans
Data to Clinical Improvement Administration (1986) have stressed the
importance of maintaining careful records
The Miami Dysphagia Team continuous on each patient referred for evaluation to
quality improvement data demonstrated facilitate data collection for future use. Data
improved nutrition and hydration status, should be organized to specifically describe
along with weight gain of nursing home the patient population, including age,
residents, less food waste, and less need for etiology of dysphagia, and pertinent medical
supplements when an appropriate diet is history. Evaluation techniques and results
supplied and consumed. Subjectively, should be coded for each patient. These
patients and volunteers benefit from the one- basic data may eventually demonstrate the
on-one socialization and attention during impact of dysphagia intervention for
meals and modification of the dining colleagues and administrators, serve as
environment. program evaluation, and provide
retrospective descriptive data for scientific
Educational programs have assisted in early investigation.
identification and intervention of high-risk
elderly individuals, and essentially initiated Retrospective Descriptive Review (1987-
a preventive approach to the management of 1990)
patients with feeding and swallowing
disorders. An increased number of referrals A retrospective review of the Dysphagia
offered support for a full-time dysphagia Team database and patient medical records
was undertaken to obtain information stone for future prospective pilot data and
regarding (a) the incidence and type of quality improvement monitors.
feeding or swallowing disorder(s) identified
in geriatric long-term care patients; and (b) Selected References
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required feeding assistance in order to providing services to dysphagic
maintain oral intake and 62% presented with patients/clients. Asha, 32(Suppl. 2),
oral preparatory stage delays. Oral 7–12.
(transition) stage dysphagia was identified in
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dysphagia in 42%, and esophageal stage & Foley, C. J. (1988). Tube feeding
dysphagia in 8%. Cognitive decline was in elderly patients: Indications,
identified in 68%. Patterns of feeding benefits and complications. Archives
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Dysphagia Team’s treatment Hillarp, B. (1988). Interobserver
recommendations included NG or PEG variability in cineradiographic
placement for 29%, food modification for assessment of pharyngeal function
59%, liquid modification for 45%, feeding during swallow. Dysphagia, 3, 46–
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Checklist for Observation of Feeding
Observer:_________________________________________ Time In________________ Time Out_____________
Feeder: RN Family Volunteer Other
Patient’s Diagnosis: 1)_______________________________________________________________
Meal: Breakfast Lunch Dinner
Yes No N/A Comments
1) Patient was positioned correctly and comfortably
2) Tray was positioned correctly
3) Sensory motor aids were in place (glasses, hearing aid)
4) Feeder was positioned correctly
5) Feeder verbally identified foods and meal to patient
6) Feeder used patient’s name
7) Feeder demonstrated conversation with patient
8) Feeder had eye contact with patient during feeding
9) Feeder complimented patient
10) Feeder demonstrated positive facial expression to patient
11) Feeder offered to add condiments to food
12) Feeder was aware of the patient’s nutritional needs
(Feeder asked what kind of diet is patient on?)
13) Information about patient’s dysphagia needs was available to feeder
(e.g., charts, notes near patient’s bed)
14) Feeder offered patient choices during feeding (e.g., order of foods)
15) Feeder demonstrated awareness of any of the following dysphagia
symptoms: (a) poor chewing; (b) difficulty swallowing; (c) pocketing
food; (d) coughing
16) Feeder demonstrated attention to patient’s eating behavior
17) Feeder arranged environment for patient (e.g., TV, lights, curtain)
18) TV was on and potentially distracting
19) Feeder provided after-the-meal care (e.g., check mouth, wash face and
hands, reposition patient)
20) Feeder offered assistance with appearance during meal (e.g., drooling,
food residue on clothes)
21) Feeder reported attending the Dysphagia Team in-service or Silver
If yes, How many? _____1 or 2 _____3 or more