Managing Dysphagia

Deanne York Douglas
Deanne York Douglas
Last updated 
The process we use to manage dysphagia and mealtimes safely.

About
These processes aim to assist HWH and clients, other stakeholders, and funders in identifying and managing swallowing difficulties - Dysphagia the client has so that mealtimes are safe and effective use "best practices" to minimise choking risk for persons who have Dysphagia in the community setting.

With the client’s consent, a doctor will diagnose dysphagia. Appropriately qualified health practitioners assess severe dysphagia management needs. Each participant is involved in developing their own individual and unique mealtime management plan.

The Mealtime Management Plan is a document created from the dysphagia assessment process and provided to the client by a qualified professional such as a speech pathologist. The speech pathologist collaborates with other allied professionals, such as a dietitian who ensures enough nutrition and hydration in the modified meals or enteral food, and an occupational therapist for positioning techniques. Language pathologists are involved as an extension to the quality of life for a person with dysphagia, prescribing exercises to maintain language and swallowing skills.

Our Role
  • To ensure staff have access to our Dysphagia Management Policy
  • To ensure that a client with signs and symptoms of dysphagia has access to their GP for a dysphagia diagnosis. 
  • If a dysphagia diagnosis is confirmed and the client consents to dysphagia assessment, the company logistically and emotionally supports the client's referral to an allied health professional(s) such as, a speech pathologist, speech therapist, or speech and language therapist for dysphagia assessment. They will assess the client's swallowing capacity and outline strategies to manage the dysphagia in a safe manner and that may include a mealtime management plan - MMP.
  • To ensure staff and support workers understand their duty of care to closely follow a client's mealtime management plan. Special Note: It is beyond the support workers' scope of practice to alter a client's MMP. All changes to a client's swallowing capacity are to be reported to the CCM or HWH 24/7 number 1800 717 590 for further assessment and modifications to the MMP. 
  • To ensure all staff working with a client with dysphagia are familiar and have achieved competency in the first aid response to choking
    1. Try to keep the person calm. 
    2. Ask them to cough to try to remove the object. 
    3. If coughing doesn't work, call triple zero (000) for an ambulance. 
    4. Bend the person forward and give them up to 5 sharp blows on the back between the shoulder blades with the heel of one hand. 
    5. After each blow, check if the blockage has been cleared.
    6. If the blockage still hasn’t cleared after 5 blows, place one hand in the middle of the person’s back for support. Place the heel of the other hand on the lower half of the breastbone (in the central part of the chest). Press hard into the chest with a quick upward thrust, as if you’re trying to lift the person up.
      After each thrust, check if the blockage has been cleared.
    7. If the blockage has not cleared after 5 thrusts, continue alternating 5 back blows with 5 chest thrusts until medical help arrives.
    8. If the patient becomes blue, limp or unconscious, start CPR immediately.
Dysphagia is a medical term for any difficulty in the swallowing process of food or fluids. It may include: 
  • weakened muscles or lack of muscle coordination which makes managing food or fluid in the mouth difficult;
  • poor initiation of the swallow; 
  • slowed or absent reflexes such as cough;
  • reduced or no sensation in the airway; 
  • incoordination of the swallow
  • structures in the pharynx or larynx. 
  • A person may have dysphagia due to poor posture, varied levels of alertness, cognitive impairment, or ageing.
  • Dysphagia can be caused by neurological conditions such as Stroke, Traumatic Brain Injury, Cerebral Palsy, Parkinson’s, Motor Neurone, and other degenerative diseases. People with intellectual disabilities can also have dysphagia.
  • Early signs of dysphagia may be coughing, throat clearing, gagging, or choking while eating and drinking. This could mean the person is aspirating (see definition), which can cause pneumonia.
  • Other signs of dysphagia are repeated or unexplained chest infections and/or raised temperature; unexplained weight loss; dehydration; weak or absent cough or swallowing; or drooling.
  • Further signs and symptoms of potential dysphagia are
    • eating takes longer than usual; 
    • the need to cough or clear the throat during or after eating and drinking; 
    • frequent complaints of heartburn; 
    • shortness of breath when eating and drinking; 
    • avoidance of some foods because they are hard to swallow. 
    • Babies that have difficulty sucking during breast or bottle feeding could have dysphagia.
  • Instrumental swallowing assessment: While the above signs and symptoms of dysphagia are important and should be reported immediately, they are not always reliable indicators of aspiration. 
    • Instrumental swallowing assessment is the gold standard for aspiration detection, such as a videofluoroscopic swallow study (a moving x-ray of swallow function). 
    • Persons with a disability should be referred for instrumental swallowing assessment by a treating medical practitioner where appropriate. 
    • A speech pathologist and radiologist should conduct the instrumental swallowing assessment.
  • Dysphagia Treatment
    • The most appropriate treatment for dysphagia will depend on its cause and presentation. Treatment and management plans should be tailored to individual service users by a specialist in dysphagia management who can assist with:
      • modifying textures of foods or drinks
      • swallowing techniques or strategies focusing on positioning or placement of food
      • exercises or stimulation
      • medication to reduce stomach acid reflux or relax the esophagus
      • In some cases, enteral feeding may be indicated to augment or replace an oral diet.

Aspiration

To ensure support staff receive knowledge of the signs and symptoms of Aspiration. Aspiration is when food, fluid or saliva enters the airway and/or lungs before, during or after swallowing. This can occur with apparent signs and symptoms or silently.

Signs and Symptoms of Aspiration
  • fever
  • headache 
  • nausea
  • vomiting
  • anorexia
  • myalgia
  • weight loss
  • chest pain
Aspiration of food or drink can cause aspiration pneumonia. A proportion of people (20–25%) who aspirate may develop bacterial pneumonia (aspirational pneumonia) 48–72 hours after an aspiration event. It is generally treated with antibiotic therapy. If it is undetected the aspiration pneumonia can become fatal.

Signs and Symptoms of Aspirational Pneumonia
  • worsening shortness of breath
  • cough
  • purulent phlegm (white, yellow, or brown fluid and might be slightly thick in texture, it is a sign of infection)
  • fevers
  • sweats
  • fatigue 
  • drowsiness

Mealtime Management Plan - this is the result of a mealtime management review. The mealtime management plan is a document that outlines for clients: 
  • food and drink that is safe to swallow (e.g. texture modified diet or thickened fluids)
  • timing of meals and feeding (e.g. allowing a suitable time for the client to complete their meal)
  • the best environment for meals (e.g. may need a quiet environment with minimal distraction)
  • level of assistance or supervision (e.g. promote and support independence)
  • positioning and posture during eating and drinking (e.g. to reduce coughing and swallowing issues)
  • equipment and aids (e.g. modified cutlery and cups) 
  • clients’ preferences for foods, tastes, and flavours  
  • Speech Pathologist/ Speech Therapist/Speech Language Therapist is a health professional trained to assess, diagnose, and treat communication, swallowing, speech, language or voice disorders.
  • (Home) A Support Worker is an individual who assists or supervises a client to perform tasks of daily living to support and maintain general well-being and enable meaningful involvement in social, family and community activities in the person’s home and community. The Support Worker is a paid person with access to education, support and advice from the Service Provider line manager or team leader. 
    • A support Worker is commonly known as an attendant care worker, disability worker, aged care worker, community worker, home care worker, care worker or paid carer. 
  • Support Worker Competency means a support worker trained and assessed as competent by a skilled registered nurse, allied health professional, or a person deemed competent by HWH to safely and appropriately perform a specified task as a support worker.
Safe Mealtime Guidelines
  • HWH Care Managers address the issue of persons with a disability who are at risk of choking and/or dysphagia through our risk management program while also acknowledging client-directed care and dignity of risk.
Identifying Clients at Risk
New Clients
  • People with a disability can have an increased risk of swallowing difficulties. We should screen for swallowing and choking risks when a new client is assessed using service-specific processes or a Nutrition & Swallow Risk Checklist.
Existing Clients
  • All our clients must have an annual health review where swallowing, choking, respiratory risks and issues can be identified and assessed. 
  • A review of medications and their impact/side effects should also be completed annually.
  • It is recommended that all clients with dysphagia have a current and accessible mealtime management plan (MMP).
  • Mealtime Management Reviews If there are any concerns about clients’ ability to swallow or meet their nutritional needs, it is recommended that the client be assessed by their Medical/General Practitioner or directly referred to specialised services. They may then refer the client to one or all of the following specialists for support:
    • A speech pathologist can assess swallowing and develop a treatment plan and mealtime management plan. 
    • A dietitian can assess the nutritional requirements and support.
    • An occupational therapist who can assess the environment for mealtimes, positioning, and feeding and recommend equipment and aides if needed.
  • Oral Hygiene: There is a clear link between dysphagia, poor oral health and increased risk of aspiration pneumonia. It is recommended that clients are supported to maintain good oral hygiene and regular dental checks.
  • Medication Management: There is an increased risk of choking in clients medicated with sedatives, antidepressants and antipsychotics due to their impact on alertness and saliva production. 
    • It is recommended that side effects and interactions of all medications are monitored concerning their impact on swallowing and choking. This should be part of the annual health review.
  • Training and Education: Regular training and education of all support workers, carers and family are essential to safely managing dysphagia and mealtimes. It has been shown that a bystander’s awareness and knowledge of swallowing difficulties and choking can impact the outcome of an incident. HWH Support Workers and CCMs must have a current First Aid Certificate. If they are assigned a client with Dysphagia, they must complete the two Talent LMS courses: Dysphagia - Outcomes, Indicators, Policy and Processes, and Dysphagia Management. In addition, they will need to pass the Severe Dsyphagia - Choking Competency Assessment:
    • Training should include: 
      • dysphagia
      • general mealtime management
      • individual education on each service user’s MMR, risks of choking and/or aspiration and oral hygiene care
        • Preparation of modified food and drinks following the IDDSI Framework (if applicable)
      • responding to choking, including cardiopulmonary resuscitation, emergency procedures
      • signs and symptoms of aspiration of food or drink
      • How to report incidents through a reporting system to reduce future risks
      • How to refer to specialised services
    • The client should be involved in all training and education if they can participate.
Severe Dysphagia - Choking Competency.pdf 80.4 KB View full-size Download


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