SOCIAL CARE
DYSPHAGIA: IDDSI IMPLEMENTATION IN HIGHLAND CARE HOMES Delivering safe, nutritious and appetising mealtimes is essential for care home residents, especially those who suffer from dysphagia. This article looks at how this is being successfully managed in The Highlands. Since the 1st of April 2019, NHS Highland has fully implemented the new texture classifications across all health and social care settings. The International Dysphagia Diet Standardisation Initiative (IDDSI)1 describes texture modified food and thickened liquids used for individuals of all ages, living with dysphagia. The framework allows for consistent management, production and adherence to a texture modified diet (see Figure 1 overleaf). WHAT IS IDDSI?
IDDSI is a global standardised framework that provides terminology and definitions for texture modified foods and thickened liquids. It consists of a continuum of eight level (0-7) and provides an easy-touse colour-coded model. It includes descriptors, testing methods and evidence for both drink thickness and food texture levels. FOCUSING ON SUPPORT FOR CARE STAFF
Increasing numbers of care home residents are living longer with conditions such as dementia, stroke, Parkinson’s disease and other neurological conditions. All have an increased propensity for developing dysphagia, where symptoms increase in tandem with disease progression. It is our duty, as health and social care professionals, to support these vulnerable people to access safe enjoyable nutritious meals and drinks. This requires a greater awareness
and understanding of both carers and cooks about how they can deliver this practically, in a way that ensures food is varied, tasty and well presented. Gone are the days (I hope) when a diet for swallowing problems was a liquidised, unrecognisable brown/grey mass of whatever composite meal was on offer that day. Equally, attempts at presenting food well in the kitchen were often thwarted by carers who then proceeded to mix everything together on the plate. In the Highlands, we have focused a great deal of effort on supporting care staff and cooks to deliver high quality, safe and nutritious food and fluids for people who have an identified swallowing difficulty. Support includes: • extensive opportunities for learning and development; • one-to-one support for care chefs.; • access to online and printed resources, recipes and professional expertise. Unfortunately, not all cooks have had the experience of previously working in care homes, never mind preparing texture modified diets. So, in Highland, we are currently working with the University of Highlands and Islands (UHI) to deliver a new SVQ course, which supports care cookery as a career. Investment in care chefs is also championed by the National Association of Care Caterers (NACC),2 while the Care Inspectorate Food, Fluid and Nutrition hub 3 offers practical information, YouTube demonstrations and web links for anyone looking for evidence-based information and advice.
Evelyn Newman Nutrition and dietetics advisor: care homes NHS Highland Award winning dietitian, Evelyn Newman, is well known throughout the profession for her writing, volunteering with the BDA and innovative work. She currently holds a unique role in The Highlands. @evelynnewman17
REFERENCES Please visit the Subscriber zone at NHDmag.com
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SOCIAL CARE Figure 1: The International Dysphagia Diet Standardisation Initiative (IDDSI) framework
PURCHASING SYSTEM FOR PREPREPARED MEALS
Across Highland we noticed that when care cooks went on holiday, or were absent for any reason, it was not uncommon for a general member of care staff to step in and do the cooking instead, especially in the smaller homes. The risk to residents with dysphagia has become increasingly clear in this situation, particularly when there are several different textures required. They may not have access to a suitable, safe and varied diet, which could lead to greater risk of aspiration (or worse!), malnutrition and dehydration. An alternative solution to mitigate against these risks is now more accessible for them through a Board-wide contract with a preprepared meals company. This is often only needed on a short-term basis. Following a tendering exercise, led by the procurement team, 40
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this service is offered to care homes and care home managers can, if they choose, now order a wide range of frozen texture modified meals via the internal purchasing system. This provides an assurance that food provided to people during the absence of the chef, is both nutritious and safe to meet individual needs. Of course, many care home residents and service users also struggle to eat standard meal portions and appetite is often diminished. Staff are normally encouraged to offer small, regular meals and snacks to promote increased nutritional intake. However, this requires a greater level of effort and imagination for people with dysphagia. Breakfasts can become quite monotonous if all that is offered is porridge or yoghurt (and what happens if you don’t like either?). I wonder what snacks are available to service users where you work. There are of course some great examples of well-presented,
SOCIAL CARE varied and appetising texture modified meals: you only have to look on the IDDSI website or the care inspectorate hub for examples and links to YouTube clips and recipe sites.
IDDSI posters and other resources have been widely shared and updates have been routinely provided through a quarterly social care newsletter.5
TRAINING PROGRAMME FOR CARE HOME STAFF
A MDT APPROACH TO DYSPHAGIA
Our care home training programme includes an afternoon of practical demonstrations of texture modified cooking and meal presentation from a professional chef.4 Hundreds of care staff have now attended the quarterly full-day events and evaluations of each day have been unanimously positive. There has been a transformational impact on many aspects of the meal service for people with dysphagia and a far greater awareness of nutrition as a health and safety rather than just a practical issue. Here are some of the outcomes: • More varied menus with texture modified options. • Care home managers have invested in more suitable equipment for cooks to prepare and present texture modified meals correctly. • More appropriate and timely referrals to speech therapy and dietetic staff. • Happier residents: “I like that I can still choose from a normal menu like everyone else, but have it adapted to suit my needs with the right textures.”- Resident with Parkinson’s disease.
The year-long implementation of IDDSI has been planned and led by a multidisciplinary group of health and social care staff, resulting in a gradual, risk-managed transition. A wide variety of communication methods have supported this and we plan to continue to monitor how well this has progressed. Using a small grant, speech therapy colleagues, in conjunction with care staff and myself, will be objectively assessing and reporting on the impact of the implementation process in Highland care homes. To conclude, I encourage colleagues to work with care staff and cooks to ensure that this growing group of elderly people who are living with dysphagia – or those who just prefer to have a softer diet – receive safe, well-prepared and presented texture modified food. Our residents and service users deserve the best that we can give them.
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IDDSI IMPLEMENTATION BY SPEECH THERAPY STAFF
Speech therapy staff in Highland have led the transitional implementation of IDDSI and have also changed their practice, moving away from routine use of thickened drinks. There is an increasing awareness that the risk to individuals of aspirating thickened fluid is greater than if they aspirate a conventional drink. SLTs are therefore more likely to suggest that fluids are offered on teaspoons, straws or in small sips. There is a 70% chance that people with dysphagia will be at risk of dehydration, so robust person-centred care planning and proactively offering fluids is central to avoiding complications such as urinary tract infections, dizziness, confusion and constipation.
Staff training tool for health and social care teams – learn about managing dysphagia and implementing the IDDSI framework. Already using The Dysphagia Game? Order an IDDSI add-on pack. www.dysphagiagame.com
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