Overview

Background

• In 2019, an Australia-wide research project and scoping review on the prevalence of and factors contributing to the deaths of people with a disability was conducted by the National Disability Insurance Commission. 
• Respiratory disease was the primary underlying cause of death for people with a disability across the reviewed reports. 
  • Aspiration pneumonia was the most common underlying cause of respiratory death, accounting for under half of all respiratory deaths.
• The following factors were reported as contributors to these outcomes:
  • safe mealtime guidelines were not consistently being adhered to due to
  • lack of staff knowledge and understaffing of dysphagia; 
  • high rates of psychotropic prescriptions and polypharmacy; 
  • increasing risk of impaired swallowing function; 
  • sedation and hypersalivation; 
  • delays in diagnosis and treatment of respiratory-related illness; 
  • lack of timely access to influenza and pneumococcal vaccines, and lack of comprehensive
  • nutrition and swallowing assessments for at-risk groups.
• Across the reports, accidental choking was highlighted as the leading external cause of death for people with disabilities.
• People with lifelong health conditions or disabilities have a higher incidence of dysphagia. 
• The impacts of dysphagia are widely reported and can be severe, long-lasting and substantial (Bryant & Hemsley, 2018). 
• Dysphagia and mealtime interventions can impact a person’s quality of life, well-being, and participation.

Scope

• This policy applies to managing dysphagia at mealtimes of all HWH clients, including administering oral medication.

Desired Outcomes

• To maintain a quality and safe standard of service delivery support
• To proactively reduce the number of deaths attributed to choking and respiratory infections in persons with a disability, due to the lack of understanding in the identification and prevention of dysphagia related incidents, 
• early identification of a person at risk of dysphagia and implementing strategies to prevent their harm.

Strategies to Support Desired Outcomes

• Support staff to complete First Aid Training annually with a national training provider.
• Workplace training and education related to dysphagia management for staff working with clients with dysphagia including how to call for assistance and commence first aid measures.
• Support staff to have access to our Managing Dysphagia Processes.
• Support staff to follow the mealtime management plan for a client with dysphagia. 
• Support staff to read the dysphagia choking protocol process relevant to each client. 
• Support staff to achieve competency with the company choking protocol.

Definitions 

• Dysphagia is a medical term for any difficulty in the swallowing process of food or fluids.
• 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.
• A carer is a person that provides support to the client at no cost (generally family or friend).
• Community Supports and/or Services who provide paid services in a client's home or community.
• A 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.

Risks associated with dysphagia

Causes

• 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. 
• poor posture

• Stroke
• Traumatic Brain Injury 
• Cerebral Palsy 
• Parkinson’s Disease 
• Motor Neurone Disease and other degenerative diseases 
• people with intellectual disabilities or cognitive impairment can also have dysphagia 
• symptoms of dysphagia can worsen as people age and is associated with advanced dementia conditions.
• people experiencing varied levels of alertness

Signs and Symptoms

• coughing and throat clearing during and after swallowing, 
• coughing or choking on food or fluid while eating and drinking,
• difficulty biting or chewing on food, 
• difficulty controlling food and drink in the mouth
• painful chewing or swallowing, 
• gagging when eating or drinking, 
• food or drink falling from a person’s mouth
• Having a dry mouth and a gurgly voice
• The client states that they feel like "food or drink gets stuck in their throat or goes down the wrong way". This could mean the person is aspirating (see definition above), which can cause pneumonia. 

• eating takes longer than usual
• frequent complaints of heartburn
• shortness of breath when eating and drinking
• avoidance of some foods because they are hard to swallow
• Regurgitation of undigested food and poor oral hygiene
• babies that have difficulty sucking during breast or bottle feeding could have dysphagia

• repeated or unexplained chest infections and raised body temperature
• unexplained weight loss; dehydration
• weak or absent cough or swallow
• drooling.

Assessment

• 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.

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 oesophagus
• In some cases, enteral feeding may be indicated to augment or replace an oral diet.

NDIS Dysphagia Supports for the client

• low-cost assistive technology – this means equipment, technology, or devices to help the client eat and drink 
• thickener products 
• help to prepare specific foods which the client can safely eat 
• a support worker to help the client eat or drink safely if they can’t do this independently because of their disability. 

• make a mealtime management plan, sometimes called an oral eating and drinking care plan, which describes how the client can eat and drink safely 
• train the client's support workers, family or carers in the client's specific disability-related dysphagia support needs. 

The Service Provider Provides:

• 4. Provide care, supports and services safely and competently, with care and skill.
• 5. Act with integrity, honesty and transparency.
• 6. Promptly raise and act on concerns about matters that may impact the quality and safety of care, supports and services.
• 7. Provide care, supports and services free from violence, discrimination, exploitation, neglect, abuse and sexual misconduct.
• 8. Take all reasonable steps to prevent and respond to all forms of violence, discrimination,        exploitation, neglect and abuse and sexual misconduct.  

• provide supports and services in a safe and competent manner with care and skill 
• promptly take steps to raise and act on concerns about matters that might have an impact on the quality and safety of supports provided to people with disability.

• d) provide care, supports and services in a safe and competent manner, with care and skill
• e) act with integrity, honesty and transparency 
• f) promptly take steps to raise and act on concerns about matters that may impact the quality and safety of care, supports and services 
• g) provide care, supports and services free from all forms of violence, discrimination, exploitation, neglect and abuse, sexual misconduct 
• h) take all reasonable steps to prevent and respond to all forms of violence, discrimination, exploitation, neglect and abuse.

How do we support clients with dysphagia

• 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. 

• They have the right to actively make decisions and be supported in dignity of risk in decision making, and have times to review their options and seek advice in their decision making (NDIS)
• The client is treated with dignity and respect, and can maintain their identity. They can make informed choices about their care and services, and live the life they choose (Aged Care).

• Aged Care Quality and Safety Commission
• Aged Care Quality Standards - Fact Sheet
• Code of Conduct for Aged Care 
• NDIS Dysphagia supports 
• NDIS Practice Alert - Dysphagia, safe swallowing and mealtime management.
• NDIS Practice Standards and Quality Indicators
• Managing Dysphagia Processes
• Level of Consciousness in Training, Policy & Process>Docs & Files>Processes>Core>5. High Intensity Personal Care
• Choking Protocol Process