COMPREHENSIVE DYSPHAGIA MANAGEMENT

COMPREHENSIVE DYSPHAGIA MANAGEMENT
INDIANA OUTREACH SERVICES Jamie Bailey MCD-CCC-SLP

FOUNDATIONS ASPIRATION SILENT ASPIRATION DYSPHAGIA TRIGGERS COUGHING
CHOKING GASTROESOPHAGEAL DISEASE(GERD)

ASPIRATION AND SILENT ASPIRATION
ASPIRATION - passage of food or liquid through the vocal folds and into the lungs SILENT ASPIRATION - Aspiration occurring with no signs/symptoms (aka triggers)

LONG TERM CONSEQUENCES OF ASPIRATION
Pneumonia Lung Damage Death

Cause of Death (MR/DD) in Indiana
Nation wide, the leading cause of death in people with MR/DD is constipation In Indiana, as you can see from the graphed information, the leading cause of death is from DYSPHAGIA issues. This information was summarized by BQIS (Bureau of Quality Improvement Services) in Indiana.

ASPIRATION MAY OCCUR ANY TIME DAY OR NIGHT
This includes: Meals Oral Care Medication Administration Bathing Dressing Sleeping Swallowing and the ability to tolerate saliva occurs throughout the day and night.

DYSPHAGIA DYSPHAGIA-Difficulty feeding or swallowing
3 types of Dysphagia Oral Pharyngeal Esophageal Oral Dysphagia—Difficulty with Oral manipulation of liquid, food, or saliva (chewing, clearance) Pharyngeal Dysphagia—reduced propulsion into the esophagus (airway protection) Esophageal Dysphagia—Difficulty passing food into the stomach (reflux) Trigger” is used to convey the practice that if any of the warning signs occur, it “triggers” staff to act immediately. SOMETHING HAS TO HAPPEN IMMEDIATELY WHEN A TRIGGER OCCURS.

DYSPHAGIA Swallowing Phases
Oral Prep Oral Phase

Pharyngeal Phase

Esophageal Phase

Dysphagia TRIGGERS- Signs or symptoms associated with possible aspiration Trigger is used to convey the practice that if any of the warning signs occur, it “triggers” staff to act immediately. SOMETHING HAS TO HAPPEN IMMEDIATELY WHEN A TRIGGER OCCURS.

EXAMPLES OF DYSPHAGIA WARNING SIGNS OR TRIGGERS
Coughing w/ signs of struggle Wheezing Wet Vocal Quality or Respirations Excessive Drooling Pocketing of food in the mouth Sudden change of color around the lips and face Fever (24-48 hours post suspected incident) Refusal of foods or liquids Watering eyes Gagging Facial Grimacing Smell of formula on breath Increased Residuals The triggers listed are just an example of what may be observed. It is the job of the treatment team to individualize the triggers. Wet Respirations may not be observed at the beginning of the meal. Respirations may become coarse or wet as the meal progresses. Wheezing may also be heard as the person continues to eat. Refusal of food and fluids – the saying goes that “if you have to choose between breathing and swallowing, you’ll choose breathing every time”.

Dysphagia Triggers TRIGGERS SHOULD BE INDIVIDUALIZED Examples:
Vocalizing in a low wet sounding moan Residue in the mouth after liquid intake Fatigues before meal is completed Increased vocalizations during oral intake Leaning to the left in chair As members of the treatment team begin to track the “generic” triggers, it will become obvious what symptoms that person usually displays –that is called “individualizing” the triggers. Staff need to know what specific signs to watch for so that the client doesn’t have to be critically ill before someone recognizes that they are having difficulty.

Coughing or Choking What’s the difference?
Airway is not blocked Keeps your throat and airway clear May be dry or productive If Coughing: Encourage coughing and clear airway CHOKING Airway is blocked Medical emergency Lack of oxygen to the brain If Choking: Follow the provider’s emergency protocol JOB NUMBER ONE, the first thing you do when a trigger is observed------ENSURE SAFETY!!!!! This best practice protocol does NOT conflict with your organization’s emergency response protocols. Severe coughing with struggling to get a breath is frightening – make sure the person knows you are there and are ready to help if they get in trouble.

Dysphagia Triggers What to do if you notice a Dysphagia trigger
Check all Plans: Diet Texture Fluid Consistency Positioning Eating Instructions Adaptive Equipment Pace of Eating Bite or Drink Size Other Dysphagia Interventions INTERVENE AND SELF CORRECT IF ANY OF THE PLANS OR INSTRUCTIONS WERE NOT FOLLOWED CORRECTLY

Dysphagia Triggers What to do (cont) Resume meal or activity
IF INDIVIDUAL HAS STOPPED EXHIBITING THE TRIGGER AND IS SAFE FROM HARM: Resume meal or activity IF INDIVIDUAL DEMONSTRATES THE TRIGGER AGAIN: Stop meal or activity Call for an evaluation Document who was called and the time of the call Document occurrence of trigger on the flow record Wait for further instructions The “trigger” occurs a second time, it is now a NON-CORRECTED trigger instead of a self-corrected trigger. When a trigger occurs a second time, that means that the plans that are already in place that you have implemented are NOT protecting that person from possible harm that could be caused by aspiration. This now requires further follow up and evaluation.

GASTROESOPHAGEAL DISEASE (GERD)
GERD - Acidic stomach contents that move backward into the esophagus or mouth Heartburn is present in 80% of people with GERD One of the most under-diagnosed conditions in the ID population 60%f people with GERD have some sort of regurgitation

CAUSES OF GERD Hiatal Hernia
Lower Esophageal Sphincter Incompetence (LES) Hiatal Hernia - When part of the stomach bulges upward out of the abdomen and into the chest cavity. LES- Acid reflux can occur when the ring of muscular tissue at the boundary of the esophagus and stomach is weak and relaxes too far. Sphincter incompetence is the most common cause of gastroesophageal reflux. The acid juices from the stomach are most likely to flow backward through a weak sphincter when a person bends, lifts a weight, or strains.

GERD Who’s at risk? People with skeletal deformities
People who smoke, drink coffee, or alcohol People who take relaxants People with delayed stomach emptying People who eat high fat diets People who take medications that relax muscles People with seizure disorders that take medication that affects muscle tone Medications that increase GERD by decreasing lower esophageal tone: Anticholinergics such as cogentin, artane, atropine Also, theophylline, benadryl, thorazine, mellaril, elevil, sinequan, tofranil, calcium channel blockers, caffeine, chocolate, aspirin, antibiotics such as tetracycline.

DYSPHAGIA IMPLICATIONS OF GERD
Inhalation of stomach contents into the lungs (aspiration) resulting in possible pneumonia Esophagitis Strictures Ulcerations Esophagitis is an inflammation of the lining of the esophagus

GERD SIGNS AND SYMPTOMS
Hoarseness Drooling Coughing Hand in mouth Repeated swallowing Frequent respiratory problems (i.e., coughing, wheezing, bronchitis, pneumonia) PICA “Sour” smelling or “Formula” burps GERD should be considered as a possible cause in any person with severe asthma or recurrent pneumonias GERD is one of the 3 most common causes of chronic cough in all age groups (asthma and post nasal drip are the others) Medications to treat asthma and breathing problems often make reflux worse. Pica may be seen as person attempts to “feed” their abdominal discomfort The muscular opening between the esophagus and the stomach depends on gravity and posture to help it work correctly, that is, open up when the food is ready to enter the stomach. The opening between the stomach and the small intestines also depends on correct posture and gravity – food has to put pressure on the lower part of the stomach to cause it to open and allow the food to pass on into the small intestines. If the spine is curved, food may not be able to empty out of the stomach. If person is lying down, the pressure on the lower part of the stomach that is needed does not occur and the opening action is prevented. This significantly delays stomach emptying. If food stays in the stomach longer, there is a greater chance that Reflux will occur.

TREATMENT FOR GERD PROTON PUMP INHIBITORS (Nexium, Prilosec, Prevacid are examples) Elevation – from top of head to at least hips, if not able to be totally upright Supported so not curving sideways or slumping forward Elevated right sidelying or prone positioning may assist with stomach emptying and decrease reflux

TREATMENT FOR GERD (cont)
Slow down eating Encourage thorough chewing Frequent small meals No meals 2-3 hours before lying down Slowing down eating gives food time to move through the GI system easier without “piling up” Thorough chewing decreases the time that food needs to stay in the stomach for digestion Volume control in the stomach can decrease refluxing – rationale for 5-6 small meals per day.

MINIMIZING THE RISK OF ASPIRATION AND MANAGING DYSPHAGIA
I. GENERAL INFORMATION Evaluation Preventive Measures Diet Texture Mealtime Oral Care Medication ADLs ( personal care, dressing, bathing, toileting, and bedtime) Positioning Training Monitoring and Tracking II. Program Implementation

EVALUATION Physician and Nursing >>>
Speech Pathologist>>>>>> Occupational Therapist>>> Physical Therapist>>>>>>> Dietary>>>>>>>>>>>>>>>> Behavior Clinician>>>>>>> Overall Health and Risk Assessment Diet Texture and Swallow Evaluation Adaptive Equipment, Positioning Positioning, Transfers Meal and Nutritional Planning Behavioral Food Issues

EVALUATION TEAM APPROACH
Identify factors that increase the risk of aspiration Discuss: Mealtime problems Positioning issues Oral care Medication administration Risk issues

PREVENTITIVE MEASURES DIET TEXTURE
Our job is not to take variety away from individual but to ensure that people can safely eat a variety of foods. Diet Textures are typically described as: Regular Mechanical #1-Whole Sandwich Meat Mechanical #1-Chopped Mechanical #2 Soft-Ground Pureed Need to be aware and vigilant in making sure that everytime, everywhere a client eats or drinks, s/he is getting foods and drinks that are appropriate for their health and safety. If there are specific “favorite” foods for a client, it is our job to assess and plan how that person can have some of their favorite foods. Refer to the “Restaurant Foods – By Consistency” sheets that list some of the typical eating out foods and what modifications need to be done to ensure the appropriateness and safety of that food item.

REGULAR This diet includes all foods with no texture restrictions. Peanut butter may be thinned with Syrup, Honey, or Jelly

PREVENTITIVE MEASURES DIET TEXTURE Regular

MECHANICAL #1-Whole Sandwich Meat For individuals who have mild chewing and swallowing deficits. They have increased difficulty tolerating certain types of meats, fresh fruit, and raw vegetables, however they are able to tolerate specific sandwich items. Meat is cut in ½” cubes except hamburgers, fish fillets, lunchmeat, meatballs, meatloaf, ham loaf, hot dogs, sausage, shaved turkey, ham, roast beef and chicken patties which are left whole for sandwiches. No meat sent on bone. Hard cooked eggs are sent quartered. Peanut butter thinned (with syrup, honey or jelly). Bread is whole. Whole fresh fruit that is soft such as bananas, melons, berries and oranges, other fruit cut into pieces. Raw vegetables are grated (i.e. carrot and lettuce salads, coleslaw) or soft pieces (i.e. tomato slices).

PREVENTITIVE MEASURES DIET TEXTURE Mech #1 – Whole Sandwich Meat

MECHANICAL (#1)-chopped meat For individuals who have mild chewing and swallowing deficits. They have increased difficulty tolerating certain types of meats, fresh fruit, and raw vegetables. These individuals are unable to tolerate whole sandwich items. All meat cut into ½” cubes. Hard cooked eggs sent quartered. Meatballs are ground. Hot dogs and Polish sausage are cut lengthwise, then into ½” pieces. Peanut butter thinned (with syrup, honey or jelly). Bread is whole. Whole fresh fruit that is soft such as bananas and melons, other fruit cut into 1/2 “ pieces. Fibrous and tough skinned fruit may need further modification (ie canned apricots to puree). Raw vegetables are grated (i.e. carrot and lettuce salads, coleslaw) or soft pieces (i.e. tomato slices).

PREVENTITIVE MEASURES DIET TEXTURE Mech #1 (Chopped meat)

MECHANICAL (#2) SOFT-ground meat For individuals who have limited chewing or swallowing mobility but are able to tolerate a greater variety and texture of foods than the pureed diet offers. Meat is ground and moistened with gravy or meat juice (meat should be ground after it has been cooked). Hard cooked eggs are ground and moistened. Cheese is grated. No peanut butter except in baked items. Bread is broken in approximately 1” squares. Cookies, cake, crackers, biscuits, buns, Pop Tarts, etc. are broken at table side. These items may need to be soaked. Fruits and vegetables are soft and cut into small ½” pieces or chopped. Canned fruit allowed if diced and soft, other items should be pureed. Soft mashed fresh fruit. Corn is cream style. Beets are pureed. Broccoli, brussel sprouts, cooked cabbage, cauliflower and sauerkraut are ground. Salads are finely chopped and coated with salad dressing. Gelatin is blenderized to ease getting it on a spoon. Tough foods such as nuts, popcorn, French fries, tater tots, potato chips or other chips need modification to soft consistency. Coconut must be finely chopped. No raisins or prunes unless pureed in recipes.

PREVENTITIVE MEASURES DIET TEXTURE Mech #2 Soft (Ground Meat)

PUREED For individuals who have severe difficulty chewing or swallowing. All foods are pureed/blended. Foods should have a smooth, pudding-like consistency. Gelatin is blenderized to ease getting it on a spoon. Cookies and cakes are broken, soaked in liquid (milk or fruit juice) and stirred until smooth. Thickening agents: Breadcrumbs are the usual pureed food thickening agent used in food preparation. Dry baby cereal is available at table side for thickening pureed food. Commercial thickeners and gels are agents for thickening fluids or foods

PREVENTITIVE MEASURES DIET TEXTURE Pureed

Drink (Fluid) textures are generally described as: Thin-any fluid texture is allowed Nectar-tomato juice, prune juice, buttermilk Honey-honey, milkshake Pudding-spoon thick

PREVENTITIVE MEASURES DIET TEXTURE (Nectar)

RESTAURANT FOODS CONSISTENCY CHART All foods whether at the individual’s home or away on trips must be modified to fit their specific diet texture. How to modify foods outside of the home Portable Chopper Fork mashing Cutting with knife

Restaurant Foods Consistency Chart
Please refer to your handout.

Things to Consider: The risk for malnutrition and dehydration increases when diet is altered. Formal Nutritional Assessment should be completed by a Dietician Alternative Nutritional Considerations Airway is repeatedly assaulted regardless of supportive interventions Nutritionally compromised Impairments consistently interfere with food/fluid intake Respiratory Status is compromised Clients are at risk of dehydration due to decreased liquid intake once fluids are thickened. Make sure that if the person requires 8 oz of water they receive 8 oz of water before the thickener is added (Thickener adds volume)

PREVENTITIVE MEASURES MEALTIME
GENERAL FACTORS Dining room should be quiet Minimal distractions Conversations should not be encouraged when individual has food in their mouth Encourage individual to focus on swallowing Positioned appropriately Monitor food textures Make sure that you allow time before or after the meal for socializing so the person with swallowing problems does not miss out on the chance to interact with others.

GENERAL FACTORS cont… Straw decreases the level of oral sensation Small amounts per bite and sip is easier to manipulate and tolerate Alternating sips and bites helps clear the oral cavity If wearing dentures, they should be well-fitted Remain upright for at least minutes after oral intake Regarding straw – we must protect clients from the “generic health care system” What is the first thing that happens when a person enters the hospital? They are put in bed, possibly not elevated or sitting up, given a glass of ice water WITH A STRAW. We must be diligent about providing protection from harm in all settings. It takes 1-2 HOURS for the stomach to digest the food to a liquid that can pass in to the small intestines. This is why you would not want to lay down flat while the stomach is still processing the food.

Things to Consider: The person may not be able to tolerate 3 large meals Liquids that are thickened may change in consistency over time Repositioning may be needed during the course of a meal Person may fatigue through the meal and have more trouble swallowing safely The type of Adaptive equipment needed changes over time Swallow strategies change over time

Positioning Make sure the person is properly elevated, aligned and supported. Head is maintained in midline with chin tucked unless otherwise specified Tools Adaptive mealtime equipment (coated spoon, divided plate, small bowled spoon, measured cups etc.) Adapted positioning equipment Compensatory strategies Diet texture modifications Environmental modifications A person cannot eat, breath, swallow or digest food effectively if s/he is not in a good position. If the bottom is scooted forward so that the person is sitting on the tailbone instead of their buttocks, then the person’s entire body is poorly positioned. If there is a gap between the back of the person’s buttocks and the back of the chair or wheelchair, that is incorrect positioning and the person is at a higher risk for swallowing problems. The saying goes “what you want in the lips, begins at the hips”. A way to check if the person’s head is in a chin tuck, place the open palm of your hand gently against the back of the person’s neck. If you can get all 4 fingers flat on the neck, the head is in a chin tucked position. If you can only get 3 or 2 fingers flat on the neck, the head is back too far and is not in a safe swallowing position. Check throughout the meal to make sure the head stays in a safe position. Also, person assisting client should be seated at eye level. If a person has to look up for the next bite, the head is in an unsafe position. Bring the spoon up from below chin level to encourage the person to look down at the next bite or drink.

Common Errors Bites that are TOO BIG and sips that are TOO MUCH What is too big? Any bite or sip that is unable to be safely handled in 1 swallow How to Correct Follow the dining plan Watch the neck for signs of a swallow Use the correct utensils Do not overload the eating utensil Spread food out over entire plate Remember respect and dignity – an adult’s meal utensils should not be referred to as the baby spoon for example. It can be called a “small bowled spoon” or a “short tined fork” A spoon full of food should not be bigger than a LEVEL MEASURING TEASPOON and should be easily swallowed in one swallow without any struggle. A sip is no more than 2 measuring teaspoons full that can easily be swallowed in one swallow with no “Gulping”

Common Errors (cont) Giving bites and sips TOO FAST!!! What is too fast? When the person does not have time to swallow and breathe between bites or sips. How to Correct Follow the dining plan for the number of swallows needed for each bite or sip Know how to identify the person’s swallow WATCH for the swallow—DO NOT GUESS! Watch for distress signals that tell you the person needs to swallow again

Poor head alignment What is Poor Head Alignment? When the head is not in midline with a chin tuck (Not only when giving food/fluid but during the swallow). How to Correct Follow the dining plan for instructions on supporting or cueing the person for midline with a chin tuck or as specified. A safe practice is maintaining the head in midline with a chin tuck from presentation until after the swallow. Remember to use the open palm gently against the back of the neck fingers flat is a chin tuck. It is never appropriate to assist someone to hold their head up by pushing backwards on the person’s forehead. This is a VERY HIGH RISK practice. If there are problems with head positioning, get an occupational or physical therapy assessment from a therapist who has experience in seating and mobility. Remember that staff assisting should be seated at eye level with the client and bring bites or drinks up from below chin level. Adaptive equipment such as a nosey cut out glass can also be helpful.

Poor placement of the food/fluid What is poor placement? When the food or fluid is placed where the person is unable to safely swallow or handle it. How to Correct Follow the Dining Plan Place food/fluid on the center of the tongue or an alternate place in the mouth as noted on the dining plan Use the correct utensil as specified on the dining plan.

PREVENTITIVE MEASURES ORAL CARE
Development of a comprehensive oral care Program significantly: Improves quality of life Decreases risk of pneumonia

Impact of Plaque Methodology 57 ICU patients 3 month period assessed for dental plaque Results Increased plaque on the teeth over the time period Correlation between dental plaque colonization and microorganism in respiratory secretions 21 patients developed pneumonia Plaque colonization significantly associated with pneumonia

Pneumonias in enterally fed patients is often associated with the aspiration of bacteria from the oropharynx and GI tract. Bacteria invade the lower respiratory tract by micro- or bolus aspiration of oropharyngeal organisms CDC, 1997 Celis, Torres, Gatell, Almela, Rodriguez-Roisin, Agusti-Vidal 1994

Chlorohexidine Antispeptic (CHG) Study tests CHG effectiveness in oropharyngeal decontamination N=353 Infection rate decreased by 65% in those treated with CHG 69% reduction in total respiratory tract infections Oropharyngeal rinse was “rigorously” applied to all oral cavity surfaces including the tongue and tooth surfaces Example of CHG--Peridex DeRiso (1996) Chlorhexidine destroys the bacteria that grow in the coating (plaque) that forms on your teeth between tooth brushings Chlorhexidine does not prevent plaque and tartar from forming; proper tooth brushing is still required

Cetylpyrdinium Antiseptic (CPC) Study tests CPC effectiveness in decreasing oral bacteria N=45 Significant decrease in oral bacteria count Example of CPC—Oral-B Anti-Plaque Wash Kalaga et al, 1989 Cetylpridinium chloride is an ingredient which inhibits plaque formation

Chlorohexidine Kills bacteria on contact Prolonged effect after expectoration Cetylpyrdinium Kills bacteria on contact Limited abilities after expectoration No data directly comparing the two.

Oral Care Program Tooth brushing x 3 daily (Utilize suction toothbrush for individuals who have difficulty tolerating thin liquids) Oral Swab Care x 2 daily with an anti-plaque solution (i.e., Peridex, Oral-B Anti-Plaque Wash) Food and Drinks should be held for approx 1 hour after administration Approx dose is 15ml 2 x daily May be diluted with water if ulcers are present or individual has sensitivity issues Wash should contain one of the two discussed ingrediates (CHG or CPC)

Things to Consider: If the person is having difficulty swallowing, or is unable to spit the toothpaste or mouthwash out, then these should be avoided Brush one quadrant of teeth, give a short break for person to get a breath and swallow, then brush another quadrant A toothette can be used to swab the mouth with diluted mouthwash or diluted toothpaste MAKE SURE THE EXCESS WATER, MOUTHWASH, OR TOOTHPASTE IS SQUEEZED OUT If a toothette or “mouth swab” is used, make sure you rinse the flavoring out and squeeze the water out. Some toothettes have a powdery, white, minty flavoring on them that can be sucked into the airway like the powdered sugar off a powdered donut. This can cause a severe coughing episode.

Remember that the individual is required to swallow during tooth brushing. Positioning Make sure the person is properly elevated, aligned and supported Head is maintained in midline with a chin tuck Tools Suctioning toothbrush may be helpful Collis-Curve toothbrush Toothette with fluoride wash Regarding positioning: If a person has difficulty controlling their own saliva and food or fluids, it makes sense that if the person’s head is back or the person is reclined or laying down, whatever is in his/her mouth is going to run to the back of their throat and cause aspiration. Most people have had the experience during a dental visit of having the dentist’s hand and tools in their mouth too long and you feel that you are going to cough on your own saliva. Poor positioning can make that worse for a client and can lead to resistance to tooth brushing.

Important to view oral hygiene as a priority and not just a comfort measure.

PREVENTITIVE MEASURES ORAL CARE RISKS
The technique of brushing the teeth can damage the gums and cause bleeding There is the potential that during the process of oral care cleaning that debris may be loosened that can be aspirated into the lower airways. Damage to the gums can provide an entry site for bacteria

PREVENTITIVE MEASURES MEDICATION ADMINSTRATION
Things to Consider: The size pill an individual can swallow is the same as their diet texture. The consistency of the medication may need to be altered so it can be swallowed safely. Runny liquids may need to be altered, and dry medications may need to be added to moist foods so the person can safely swallow it. Administration of the medication should be the same as the dining plan, using the same placement techniques, size of presentations, number of swallows etc. Utensils must be the same unless otherwise noted on the dysphagia plan. Remember that some people without dysphagia have trouble swallowing pills or get pills “stuck” in their throat. Staff must be very attentive to signs and symptoms that a client is struggling with trying to get pills down. If significant problems are suspected a Modified Barium Swallow can test swallowing on barium pills.

PREVENTITIVE MEASURES MEDICATION ADMINSTRATION
Remember that the person is required to swallow during medication administration Positioning Make sure the person is properly elevated, aligned and supported Head is maintained in midline with a chin tuck There is a direct relationship between the dining plan and safe medication administration Tools Pill crusher Adapted meal equipment

PREVENTITIVE MEASURES ADLs
Things to Consider: The person may benefit from being elevated at all times when being changed, bathed or in bed. Lying flat during personal care or dressing increases the risk of reflux aspiration. If a person is unable to tolerate thin liquids, care should be taken to ensure that water is not swallowed during baths or showers. A plan may call for HOB elevation. Remember that we are NOT elevating the head of the bed, we are elevating the person. The person needs to be checked in bed on a frequent basis (every 15 minutes) to make sure that s/he has not slid down in bed and is no longer elevated correctly.

PREVENTITIVE MEASURES ADLs
Remember that the risk of aspiration is not limited to mealtime Positioning Make sure the person’s positioning program addresses dysphagia and GERD by specifying the position for dressing, toileting, personal care, bathing/showering and bedtime. Tools Wedge Hospital bed or elevated bed with bed blocks Shower trolley Tilt in Space commode/shower chair Many times a person, if incontinent, needs personal care shortly after a meal because his/her bowels have moved. This is a particularly risky time because the stomach may still have food in it. During these laying down times, elevated positioning from the top of the head to at least the level of the hips should be considered as an intervention to make the person safer.

PREVENTITIVE MEASURES POSITIONING
Things to Consider: All activities require specific position methods Toileting and undergarment changes Dressing Oral care Medication administration Bathing or showering Sleeping Eating, swallowing, drinking including those using G-tube Stomach emptying Bowel and bladder elimination

Things to Consider (continued): Variety of positions include Wheelchair or other mobility device Left sidelying Right sidelying Prone on forearms or quadruped Supine Standing or kneeling

Things to Consider (continued): The best position for eating, oral care and swallowing………. May NOT be sitting up Elevated right sidelying or elevated prone May be a better position for safe swallowing and airway protection May be a better stomach emptying position May encourage better abdominal compression to address lower GI problems such as constipation

Things to Consider: If the lower GI tract is not working well, is constipated or has poor motility, then the upper part of the GI system will also not be able to work very well. This may lead to increases in reflux, vomiting, dehydration, and unplanned weight loss so the positioning intervention plans have to address constipation and reflux

Things to Consider: Positioning for constipation can include prone on elbows or quadruped and elevated left sidelying. Positioning for stomach emptying to decrease reflux can include prone on elbows or quadruped and elevated right sidelying.

Head Position At midline Neutral or chin tucked 4 fingers flat against the nape of the neck

PREVENTITIVE MEASURES TRAINING
Competency based training is “best practice”. Competency based training can be divided into 2 categories: Category 1: General or Foundational competency based training Category 2: Client Specific competency based training

This training is General or Foundational training.

Client specific competency based training regarding dysphagia is in the correct implementation of the client’s plans and programs. The trainer should visually observe the staff performing the correct techniques outlined in the individual's program.

PREVENTITIVE MEASURES MONITORING AND TRACKING
It is “best practice” to monitor an individual’s dysphagia triggers 24/7 Provides the caregivers with the information needed to be proactive in minimizing the risks associated with dysphagia Tracking Provides information on whether or not the Dysphagia plan is protecting the individual from harm. Provides data regarding the severity and # of dysphagia related occurrences.

PROGRAM IMPLEMENTATION
Interdisciplinary Approach Risk Assessment Evaluation and Follow-Up Intervention Monitoring Tracking Training

Interdisciplinary Approach to Risk Management
What are the observable and measurable things that are risks and concerns? What would you like to see related to this problem? What are the suspected causes? Examples of identified risks: 1) Unplanned weight loss 2) Coughing on Thin Liquids 3) Vomiting after meals Identified goals or outcomes:1) weight maintenance or weight gain 2) No vomiting 3) No coughing Causes: 1) not eating enough, getting tired during the meal, non-preferred staff 2) eating too much, eating too fast, laying down too soon 3) only coughs on koolaid and water but not tomato juice or milkshakes

Interdisciplinary Approach to Risk Management
What intervention are you going to try first and why? What information do you need to show that the person is improving or getting worse? Who will look at the gathered information, how often will it be looked at, how will the team be notified, and under what circumstances will the plan be reviewed by the team? This gives you your intervention plan This is going to give you your documentation component 1) weight consistently 2) chart vomiting 3) chart incidents of coughing

Staying Connected To Your Team
One to One Group Meeting Phone Voic

PROGRAM IMPLEMENTATION RISK ASSESSMENT
General Risk Factors Assessment Risk Assessment for Choking for Individuals who eat by mouth Assessment of Pneumonia Risk Skin Assessment Tool Braden Scale for Predicting Pressure Sore Risk Mobility Screenings for Persons with Visual Impairments

General Risk Factors Assessment Purpose: To identify the individual’s level of risk in 5 identified areas (Behavior, Health, Dysphagia, Safety, and Physical Management) All checked items should be discussed by the Interdisciplinary Team (IDT) and a corresponding Risk Plan developed

Risk Plan should include: Interventions to be provided Monitoring and Tracking mechanism Staff trained Implementation of the plan as part of the Individual Support Plan (ISP) Completed: Annually and Reviewed Quarterly by members of the IDT If selected items are checked in the Dysphagia or Physical Management section, additional risk assessment forms are to be completed and sent to Outreach

ADDITIONAL RISK FORMS: RISK ASSESSMENT FOR CHOKING FOR PERSONS WHO EAT BY MOUTH Completed by IDT ASSESSMENT OF PNEUMONIA RISK SKIN ASSESSMENT TOOL BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK MOBILITY SCREENINGS FOR PERSONS WITH VISUAL

Choking and Pneumonia Assessment-must be completed at least annually or as determined by General Risk Factors Assessment Skin and Pressure Sore Assessments- must be completed at least annually or as determined by General Risk Factors Assessment Mobility Screenings for Persons with Visual Impairments- must be completed at least annually or as determined by General Risk Factors Assessment Completed originals are to remain on site and a copy mailed or faxed to Southeastern Indiana Outreach Services

Identifying the Individual‘s Dysphagia Risk Level: Dysphagia Risk Level is assigned by Indiana Outreach. Risk level is assessed upon completion of the choking and pneumonia assessment forms by provider and receipt of these forms at Outreach.

DYSPHAGIA RISK LEVELS LEVEL 1 Residents enterally fed Residents with a risk of Aspiration as determined by MBS Residents with a history of Aspiration Pneumonia Residents with Asthma Residents with a risk score of 70 or greater as determined by the Choking Assessment Form Residents with a risk score of 70 or greater as determined by the Pneumonia Risk Assessment Form

DYSPHAGIA RISK LEVELS LEVEL 2 Residents with a risk score of 50-60% as determined by the Choking Assessment Form Residents with a risk score of 50-60% as determined by the Pneumonia Risk Assessment Form Residents with pharyngeal and esophageal phase dysphagia

DYSPHAGIA RISK LEVELS LEVEL 3 Residents with a risk score of 30-40% as determined by the Choking Assessment Form Residents with a risk score of 30-40% as determined by the Pneumonia Risk Assessment Form Residents with oral phase dysphagia, GERD, hiatal hernia, reflux, rumination, erosive esophagitis or gastritis.

DYSPHAGIA RISK LEVELS LEVEL 4 All other residents This level has no diagnosis of dysphagia, GERD, or choking risk.

PROGRAM IMPLEMENTATION EVALUATION AND FOLLOW UP
Dysphagia Evaluation Positioning Evaluation Nutritional Evaluation

DYSPHAGIA EVALUATION Completed by a Speech Language Pathologist with expertise in the area of swallowing and the ID population Evaluations and reviews are based on individual’s dysphagia risk level. Level 1-Annual Evaluation, Monthly Review, and PRN Level 2-Annual Evaluation, Quarterly Review and PRN Level 3-Annual Evaluation, 6 Month Review and PRN Level 4-Annual Evaluation and PRN

DYSPHAGIA EVALUATION (cont) If there is a significant change, a review should be completed immediately visit to ER, unplanned weight loss of 10% in 6 months or more than 5 pounds in one month change in daily schedule any lab work indicating nutritional deficits or dehydration observation of dysphagia triggers Dining Plan updates, Dysphagia Plan updates, and Trigger Responses should be completed PRN

POSITIONING EVALUATION Completed by a Therapist with expertise in positioning Individual’s should be evaluated annually and reviewed quarterly and PRN

POSITIONING EVALUATION (cont) If there is a significant change, individual and positioning program should be reviewed immediately visit to ER unplanned weight loss of 10% in 6 months or more than 5 pounds in one month any existing pressure area that worsens, any pressure area discovered any change to positioning program or equipment change in daily schedule any lab work indicating nutritional deficits or dehydration

NUTRITIONAL EVALUATION Completed by a Dietician Individuals are evaluated as needed (i.e., BMI under 18 or over 30)

NUTRITIONAL EVALUATION If there is a significant change, individual should be reviewed immediately unplanned weight loss of 10% in 6 months or more than 5 pounds in one month BMI (Body Mass Index) under 18 BMI (Body Mass Index) greater than 30 any lab work indicating nutritional deficits or dehydration

PROGRAM IMPLEMENTATION INTERVENTION
Dining Plans Dysphagia Plans Positioning Programs Dysphagia Triggers Process

DINING PLANS What is a Dining Plan? Who needs one? Development of the plan Use of the plan Review and Revision

DINING PLANS What is it? A dining plan provides staff with vital information regarding the individual’s mealtime structure Risk factors Food and Fluid texture Diet considerations (MD ordered) Behavioral precautions Eating and Drinking strategies Specific mealtime goals Communication strategies Dysphagia triggers Adaptive equipment Eating position Position of staff assisting

DINING PLANS Who needs one? All individuals who are determined to have difficulties during mealtime Behaviors Dysphagia Modified texture Special diets Positioning issues Adaptive equipment Even if a person is NPO, nothing by mouth, s/he still needs to have a dining plan and dysphagia care plan that clearly indicates that the client takes everything by tube. It should also specify what position person is in for meals and individualized triggers to monitor for (people, all people, aspirate their own saliva, for example).

DINING PLANS Development of the plan Developed by Speech Pathologist with input and assistance from members of the IDT with knowledge of swallowing disorders and who have attended the Comprehensive Dysphagia Training Program or have been trained by someone who has attended the Training Program (Nurse, OT, PT, RD, and Direct Care Staff) Should identify key mealtime information Should include pictures of adaptive equipment and position during eating Individualized Team approach

DINING PLANS-Example ASPIRATION RISK CHOKING RISK Behavioral Precautions – [including special table or environment]: Occasionally stomps feet and bites fingers when upset will shake head “no” to refuses food/activity; self-stimulatory behavior-able to verbally redirect. FOOD TEXTURE: Pureed FLUID TEXTURE: Thick-it to fluids to Honey Consistency if gel not available. Gels are preferred method of fluids, however, can tolerate honey-thick liquids. If using honey-thick liquids, offer them in a small Nosey cup If using pudding or gel thickness, offer them in a coated spoon

Dining Plans-Example (cont) CALORIE RESTRICTION: low cholesterol SUPPLEMENTS: Applesauce and bran at breakfast Prunes every meal [no other fruit or desert] EATING: Requires total set-up and assistance for meals. Wears neck napkin Staff should be seated at eye-level Present food at level of lips and say “take a bite”. Once he takes a bite say “good bite”.

Dining Plan-Example Eating (cont) Ignore negative behavior “head shaking”, reward positive behavior “taking a bite”. Has a tendency to bite the spoon. Apply gentle downward pressure on the tongue with the bowl of the spoon during each bite to reduce biting. If he tilts head backward during meal, staff should reposition his head, and check to assure mouth is cleared prior to offering more food. Respect his refusal. Staff may touch his chin while verbally cueing him to take a bite, however, he SHOULD NOT be forced in any way to eat.

Dining Plan-Example (cont) DRINKING: No fluids on tray; Gels per memo Gels are preferred method of fluids, however, he can tolerate honey-thick liquids. DO NOT discourage coughing SPECIFIC SKILLS TO MAINTAIN/ACQUIRE: Encourage Choice Making COMMUNICATION: Vocalizations Facial expressions, behavioral; head shakes yes/no are not always communicative.

Dining Plan-Example (cont) TRIGGERS to Notify Nursing Staff: Bottom not back in wheelchair Coughing with signs of struggle (watery eyes, drooling, facial redness) Wet vocal quality Vomiting Sudden change in breathing Watery eyes

DINING PLAN ASPIRATION RISK CHOKING RISK
Behavioral Precautions – [including special table or environment]: FOOD TEXTURE: FLUID TEXTURE: CALORIE MODIFICATION: SUPPLEMENTS: EATING: DRINKING: SPECIFIC SKILLS TO MAINTAIN/ACQUIRE: COMMUNICATION: TRIGGERS To Notify Nursing Staff: (These should be individualized) IF APPROPRIATE EQUIPMENT IS NOT AVAILABLE OR YOU ARE UNSURE OF HOW TO IMPLEMENT THIS PLAN CONTACT YOUR SUPERVISOR ·Bottom not back in wheelchair ·Coughing with signs of struggle (watery eyes, drooling, facial redness) ·Wet vocal quality ·Vomiting · Sudden change in breathing · Watery eyes · Total meal refusals (X 2)-nursing notified · Pocketing of food in mouth · Hyper extends neck despite use of compensatory strategies ·Weight loss/gain of 5lbs in a month

Dining Plan Outline Please refer to the sample Dining Plan provided in your packet

DINING PLANS Use of the Plan Should be available wherever the individual may be eating Dining Plan should be located at tableside for easy reference Staff should refer to the dining plan prior to and during meal. Notify Nurse and/or House Manager if a non-corrected trigger is identified and document on flow sheet or trigger sheet.

DINING PLANS Review and Revision Should be updated as changes occur Review quarterly at IDT meeting or in the occurrence of a significant change (unplanned weight loss or gain , hospitalization, observation of triggers)

Dysphagia Plans What is a Dysphagia Plan? Who needs one? Development of the plan Use of the plan Review and Revision

Dysphagia Plans What is a Dysphagia Plan? Provides Vital information regarding the individual’s physical and nutritional health. Risk areas Dysphagia triggers Nutrition and Mealtime Oral Care and Medication Administration General positioning Covers all areas of the individual’s daily life

Dysphagia Plans Who needs one? Diagnosis of Oral, Pharyngeal, or Esophageal Dysphagia Diagnosis of GERD, Reflux Esophagitis, History of Pneumonia or Aspiration Pneumonia All individuals who are determined by Outreach to be at a level 1, 2, or 3 dysphagia risk.

Dysphagia Plans Development of the plan Developed by Speech Pathologist with input and assistance from members of the IDT with knowledge of swallowing disorders and who have attended the Comprehensive Dysphagia Training Program or have been trained by someone who has attended the Training Program (Nurse, OT, PT, RD, and Direct Care Staff) Should identify key information (diagnoses, triggers, mealtime, oral care and medication administration, & general positioning) Individualized Team approach

_______Client’s Name_______
AGENCY DYSPHAGIA CARE PLAN _______Client’s Name_______ Date Level of Risk ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Diagnoses related to Dysphagia (i.e., GERD, Oral, Pharyngeal, Esophageal Dysphagia, Aspiration or Choking risk etc…) TRIGGERS: In this section you will include specific triggers (aka signs or symptoms) that are related to the individual having increased difficulty swallowing, tolerating tube feedings, tolerating their own secretions or positioning triggers during mealtme) IF YOU NOTICE ONE OR MORE OF THE ABOVE TRIGGERS, ATTEMPT TO SELF CORRECT (make sure dysphagia plan is being followed correctly) IF TRIGGER IS OBSERVED AGAIN, DOCUMENT ON FLOW CHART AND NOTIFY NURSE OR House MANAGER.

NUTRITION AND MEALTIME
This section includes information on the client’s food textures, fluid textures and supplements. If NPO, this should be listed here as well as the client’s rate and frequency of feedings. Any adaptive equipment, positioning information (during and after meals) and dining strategies (small bites, alternating liquids/solids etc…) should be included. ORAL CARE and MEDICATION ADMINISTRATION Oral Care Guidelines (suctioning or non-suctioning), positioning, and fluid texture information are included in this section GENERAL POSITIONING Positioning as it relates to bathing, attends changes, and showering are included in this section. Remember that an individual should be positioned in an upright manner when performing these activities. Refer to Positioning Plan for specifics. Quarterly Review: IT IS HELPFUL TO USE A BULLET FORMAT FOR EASY REFERENCE ASPIRATION CAN OCCUR AT ANY TIME 1st Quarter 2nd Quarter 3rd Quarter

Dysphagia Care Plan Please refer to the handout

Dysphagia Plans Use of the plan Plan should be located in a place that is easily accessible to all staff. Staff should refer to the Dysphagia Plan prior to participating in any identified areas addressed by the plan (oral care, medication administration etc..) Notify Nurse and/or House Manager if a non-corrected trigger is identified and document on flow sheet or trigger sheet

Dysphagia Plans Review and Revision Should be updated as changes occur Review quarterly and annually at IDT or in the occurrence of a significant change (unplanned weight loss or gain , hospitalization, observation of triggers) Review Date and Reviewer should be documented in Grid on Care Plan

Positioning Programs What is a Positioning Program? Who needs one? Development of the program Use of the program Review and Revision

Positioning Programs What is a Positioning Program? Includes optimal positions for: Eating and Swallowing Medication Administration Stomach Emptying Bowel and Bladder Elimination Oral Care ADLs (personal care, dressing, bathing/showering)

Positioning Programs Who needs one? Person who is unable to move themselves INDEPENDENTLY into or out of a variety of positions throughout a 24 hr day Person who spends >2 hrs out of a 24 hr day in a wheelchair Person who spends > 12 hrs out of a 24 hr day in a recumbent position (time in bed, recliner, lying down on mat etc..) Person who has a Braden scale of 18 or lower History of any skin breakdown related to: pressure, poor nutrition or hydration, shear or friction, moisture, contractures or poorly fitting equipment with the last 3 yrs.

Positioning Programs Who needs one? (cont) Unable to sit upright for any reason Requires support of head, trunk, upper or lower extremities to maintain an upright or near upright position Demonstrates obligatory primitive postural, obligatory movement reflexes or unmanageable postural tone such as extensor tone in supine position Demonstrates postural or skeletal deformities related to an inability to resist forces of gravity such as scoliosis, kyphosis, windswept or frog leg pelvic deformity. Requires adapted supportive or positioning equipment to complete ADLs Person who has 2 or less positions they can tolerate Diagnosis of GERD, Reflux Esophagitis, History of pneumonia or Aspiration Pneumonia, and Asthma

Positioning Programs Development of the program Developed by an Occupational or Physical Therapist with input and assistance from other members of the IDT (Nurse, SLP, RD, and Direct Care Staff) Should include specific positioning methods (written and photographed) Bathing/Showering Toileting and Personal Care Dressing Oral Care and Medication Administration Degree of elevation for each position

Positioning Programs Use of the Program Program should be located in a place that is easily accessible to all staff. Staff should refer to the Positioning Program prior to participating in any identified areas addressed by the plan (i.e., oral care, medication administration etc..)

Positioning Programs Review and Revision Should be updated as changes occur Review quarterly at IDT or in the occurrence of a significant change (unplanned weight loss or gain , worsening or discovery of a pressure area, hospitalization, observation of triggers etc..) Review should be documented and dated using the review grid at the bottom of each position intervention

Dysphagia Trigger Process It is “best practice” that all clients living in the community setting with the diagnosis of Dysphagia have a Dysphagia Care Plan (DCP) All clients should have a Dining Plan Direct Support Staff ensures proper implementation of Plan (positioning, diet texture, etc.). Direct Support Staff identifies that triggers has occurred and immediately assist If triggers occur and plan is not being followed, follow plan and notice if triggers continue.

Dysphagia Trigger Process (cont) 6. If triggers continue, stop meal or activity, document on flow chart or trigger sheet and notify Nursing and/or House Manager. 7. Person notified should immediately Verify that the Dysphagia Care Plan is being followed If not, ensure proper implementation Checks pulse, respirations, and breath sounds Check O2 sats if there is distress noted or congestion is present 8. Determines if client’s health is compromised and is in need of immediate evaluation.

Dysphagia Trigger Process (cont) 9. If client’s health is compromised and is in need of immediate evaluation, client is sent to ER/Hospital. 10. After assessing the client’s status and providing immediate care, Determine if modifications to the plans are temporarily needed to ensure safety and what evaluations are needed.

Dysphagia Trigger Process (cont) Recommended Response to Incident It is recommended that the Nurse or House Manager notify the appropriate therapist of client’s condition by the next business day. 12. Therapist schedules evaluation upon client’s return home from the ER/Hospital within 3 business days for Dysphagia Level 1 5 business days for Dysphagia Level 2 7 business days for Dysphagia Level 3 14 business days for Dysphagia Level 4 If ER/Hospital visit is not required, Nurse or House Manager notifies the appropriate community therapist (OT, PT, SLP, or RD) the next business day and therapist schedules an in-home evaluation to be conducted within:

Dysphagia Trigger Process (cont) Recommended Response to Incident 13.Once the client is evaluated, Therapist from the community should make recommendations and provide follow through within: 3 business days for Dysphagia Level 1 5 business days for Dysphagia Level 2 7 business days for Dysphagia Level 3 14 business days for Dysphagia Level 4

Dysphagia Trigger Process (cont) An IDT should be held within 5 days of the completed evaluation to discuss the incident and ensure recommendations of all involved disciplines have been implemented and trained. Pneumonia and Choking Assessment will be conducted by members of the IDT and a copy will be sent to the Primary Outreach Team and the level of Dysphagia Risk will be reviewed and Risk Level will be modified as needed. 15. If a client does not currently have a Dysphagia Care Plan and triggers are identified—start at step #6. Dysphagia and other Plans will be developed based on the therapist’s review. Review: Dysphagia Care Plans Dining Plans Positioning Programs

Dysphagia Issues requiring Immediate evaluation (ER/Hospital visit): choking Decreased pulse or respirations coarse or wet breath sounds client distress or congestion Actions: Client is sent to ER/Hospital Nurse or House Manager notifies therapist the next business day Therapist evaluations are provided based on risk schedule upon client’s return home. Dysphagia Issues not requiring immediate evaluation: coughing w/ signs of struggle wet vocal quality excessive drooling pocketing of food in mouth behavior issues during mealtime (chugging of liquids, large bites) facial grimacing increased residuals refusal of food or fluids x2 improper positioning Actions: Nurse or House Manager assesses situation Immediate evaluation (ER) is not needed Temporary modifications are made to plans Nurse or House Manager contacts Therapist the next business day Therapist evaluations are provided based on risk level

Aspiration Protocol (Sample)
Please refer to your handout at this time.

PROGRAM IMPLEMENTATION MONITORING
Dysphagia Schedule Positioning Schedule Monitoring Forms It is “best practice” to monitor an individual’s dysphagia triggers and positioning

Dysphagia Schedule Serves as a guide to assist the provider through the monitoring process Provides information on the type of monitor and frequency of monitoring sessions Frequency of monitors are based on the individual’s dysphagia risk level Covers all areas where the individual is determined to be at risk

AGENCY DYSPHAGIA MONITORING SCHEDULE
Number, Type, and Frequency of Monitoring Type of Monitor Level types per month Level type per month Level type per quarter Level at ISP Update Dental 1/year annual eval Oral Care 4/year Bathing 3/year Dressing Documentation Review 1/quarter 1/6 months Med-Pass 2 a.m./year 2 p.m./year Mealtime/Snack 8/year 6/year Total Doc Reviews/year 4 2 Total Monitors/year 24 12

Positioning Schedule Name of Client, revision date and individual who revised the schedule Beginning and ending time for the position Specific position including amount of elevation Schedule should cover 24 hrs day Data collection for each position Staff initials responsible for the positioning program Schedule includes position for : Bathing/Showering, Toileting and Personal Care, Oral Care and Medication Administration, and need to be elevated at all times)

MONITORING FORMS Dysphagia Plan Monitor Dysphagia Documentation Review

Dysphagia Plan Monitor Serves as a general and client specific dysphagia and dysphagia positioning review Monitors all areas of the client’s day Mealtime med pass Dressing oral care Bathing dental Frequency of monitors are based on client’s dysphagia risk level. Follow dysphagia schedule Should be completed by members of the IDT who have completed Indiana Outreach’s Comprehensive Dysphagia Training Program

Dysphagia Plan Monitor
Please refer to the sample provided in your packet

Dysphagia Plan Monitor Directions
Insert the name of the resident being monitored, location and provider, staff member working with resident and the date and time of the monitor. Place a check in the situation (breakfast, lunch, med pass, changing etc…) being monitored. Answer Yes, No, or N/A to the provided 24 questions. If the answer is “No” to questions 1-14; the monitor must train the individual on the spot and answer “Yes” to question 23. If training was needed, the training section should be filled out by the monitor stating the area and question # that was trained. Observed staff member and monitor must both sign the form verifying that training occurred regarding the observed deficit. In the space “Actions Taken To Address Identified Issues” , Briefly summarize all steps that were taken to address questions 1-14 that were answered “NO” Keep forms on site

Dysphagia Documentation Review Provides structure to the process of reviewing a client’s dysphagia plan, monitoring, and tracking processes Frequency of documentation reviews is based on the client’s dysphagia risk level Follow dysphagia schedule Should be completed by members of the IDT who have completed Indiana Outreach’s Comprehensive Dysphagia Training Program

Dysphagia Documentation Review
Please refer to the sample provided in your packet

Dysphagia Documentation Review Directions
Insert the name of the resident being reviewed, the dysphagia plan date, and documents reviewed. Documents reviewed should include the Nursing Flow Chart, Med Sheet, Dietary Notes, Consult Notes and any other documents that provide pertinent medical information. If the answer is “NO” to questions 1-5, a plan should be in place that addresses the issue. Keep forms on site

PROGRAM IMPLEMENTATION TRACKING
Flow Record

Flow Record Please refer to the sample provided in your packet

Flow Record Provides a way for staff to document and track dysphagia triggers as well as other pertinent medical information Additional information on the “flow record” replaces many existing forms Vitals Meals (I/O) GI Triggers G-Tube Skin Oral Care Data can be easily viewed and analyzed

Flow Record Directions
Direct Support Staff Vitals Record Monthly/Daily on Flow Record Use Vita Sign Record if vital signs are taken more frequently than daily If O2 Sat is taken more than once a day, utilize Progress Notes entry. Meals For all clients record % of Meals/Snacks eaten and fluid intake GI Suppository – Y or N Enema – F-Fleets, SS – Soap Suds Chart results in Progress Notes as well as on Flow Record BM Utilize Code: I – Soft M – Medium II – Hard L – Large X – Liquid XL – Extra Large Last Void (time) Vomitus – Y for Yes, N for No

Direct Support Staff (cont) Triggers For each trigger, if it did not occur or was corrected by staff intervention (self-corrected), put a dash (-) in the space. If trigger did occur and intervention did not work (non-corrected), mark the number of times it occurred G-Tube Formula – Identify type of feeding and amount Residual – Amount: if > 25cc, chart a progress note Site Care – Y/N: if redness or drainage present, chart until Resolved (R) with progress note entry

Direct Support Staff (cont) Skin Abrasion/Scratch – Location (Progress Note Entry) Bruise – Location, R-resolved (Progress Note Entry) Other – Chart location on Flow record and document in Progress Notes if a skin breakdown is noted. Documentation to occur until Resolved (R). For example: if redness is noted, indicate location under Other. Mark R when resolved, (Progress Note Entry) Oral Care Suction Tooth Brushing – Check mark for completion Oral swab – Check mark for completion Toothbrush – Check mark for completion

Nurse Should initial each Flow Record after data is reviewed. Perform appropriate follow-up.

REMEMBER: A “TRIGGER” can occur at any time, 24/7 A “SELF-CORRECTED TRIGGER” means that it occurred one time and the intervention you provided was successful in preventing it from happening again A “NON-CORRECTED TRIGGER” means that the intervention was not successful and the trigger occurred a second time. A “NON-CORRECTED TRIGGER” must be documented on the flow record and reported to Nurse

PROGRAM IMPLEMENTATION TRAINING
All staff should be provided with Client-Specific Competency Based Training Competency in: Dysphagia Mealtime Oral Care and Medication Administration Positioning for dressing, bathing, personal care, toileting and sleeping Must be trained and verified Trainers should have completed Indiana Outreach’s Comprehensive Dysphagia Training Program Refer to the Competency based checklists for Dysphagia, Mealtime, Oral Care and Medication Administration . “Read and sign” inservices are NOT recognized as training that ensures competence of staff in implementing plans and in protecting people from harm. It is vital that everyone who provides competency based training adheres to a high ethical standard. These completed competency training checklists indicate that a staff person is trained and has been observed by the TRAINER to complete the objectives competently without additional prompting needed to achieve competency. Our job is to train people until they each are competent, not to document that someone is incompetent. Some people may need more time and training to achieve competence. That additional support and training is the trainer’s responsibility. The staff person who was trained and the person completing the training sign and date when all learning objectives are completed as competent. Anyone who completes this training and indicates that a staff person is competent must be ready to indicate, in a court of law if needed, and swear that this training was completed to these standards. If only one person calls into question the validity of this training, then the training done by people throughout the state can be dismissed as “unreliable data”.

PROGRAM IMPLEMENTATION TRAINING
Competency Based Training Competency is verified as trained (T), competent (C) or needs further training (N=not correct or requires prompting) Refer to sample Dining Plan and sample Dysphagia Care Plan in Training Packet. Also refer to the sample Competency sheets for implementation of dining plan, positioning plan, oral care and medication administration as examples.

MythBusters Myth or Fact ?
It is normal for some people to cough throughout their meal. It is a good sign for someone to cough up a lot of phlegm first thing in the morning or after a drink of juice (for example) because they are getting that junk out of their lungs. Milk and Milk products should be avoided by people who have swallowing problems because it makes them produce more mucous. Even though a person is getting only pureed food, it is okay for them to have chocolate pieces or other foods that “melt in your mouth”. If a person is coughing during meals, that means they are okay and are not aspirating. If a person is not coughing during meals, that means they are okay and are not aspirating.

MythBusters Myth or Fact ? (cont)
A straw is always helpful in providing liquids to an individual, especially if they show signs of oral spillage. If a person has dysphagia and is supposed to sit upright when eating but is able to say that they want to lay back in the recliner to eat, that is their right to eat there. I like to eat in my bed and recliner so it should be okay for a person with dysphagia to eat in their recliner or bed. If nothing bad has happened up until now, it isn’t going to happen. If you are not concerned, maybe even a little nervous about someone’s safety at meals, you SHOULD NOT be assisting them. THINK: Are you willing to bet someone’s life on a myth? KNOW THE FACTS ABOUT DYSPHAGIA

Benefits of Physical and Nutritional Management
Dining Plans Provides staff with the information needed to safely assist individuals with mealtime issues Minimizes the risk of choking Minimizes the risk of aspiration Minimizes the risk of dehydration and malnutrition Dysphagia Plans Serves as a guideline for staff regarding the individual's physical and nutritional health Provide specific information on risk areas, dysphagia triggers, nutrition and mealtime, oral care and medication administration, and general positioning recommendations

Positioning Programs Improves GI, urinary and respiratory functioning Minimizes current and prevents further deformity Improves safety, health and comfort of client Prevents skin breakdown and decubitus Improves client's ability to use functional skills in meaningful activities Dysphagia Trigger Process Assists in removing the guesswork that staff may face when a trigger occurs Increases the level of awareness Provides a standard of care Increases communication between IDT members

Dysphagia Schedule Covers all areas where the individual is determined to be at risk of aspiration Serves as a guide to assist the provider through the monitoring process Dysphagia Plan Monitor Provides a general and client specific dysphagia and dysphagia positioning review Assists in the updating of care plans and identification of dysphagia issues

Dysphagia Documentation Review Ensures monitors and tracking are being conducted and triggers are responded to by the appropriate IDT member Flow Record Provides structure for staff to document and track dysphagia triggers as well as other important information Helps staff become more aware and proactive in the protection of our clients Minimizes risk of aspiration Minimizes risk of choking

Persons with Intellectual Disabilities are healthier and safer Deaths are prevented Less pain and suffering by clients Improved quality of life for clients By being proactive, issues will identified before they become problematic Fewer non-routine medical visits, emergency room visits, and hospitalizations Less staff time spent preparing for and accompanying person on medical visits Reduced reactionary interventions by IDT members Improved communication and knowledge base of staff and members of the IDT Fewer crisis situations Fewer incident reports to complete Fewer regulatory surveys and monitors following up on crisis situations

In Closing Know the Facts Protect the Individual Assess Risk Areas
Develop 24/7 Dysphagia Plans Develop Dining Plans Develop Positioning Plans Monitor and Track Triggers Implement Competency Based Training

References Celis R, Torres A, Gatell JM, Almela M, Rodriguez-Roisin R, Agusti-Vidal A. Nosocomial pneumonia: a multivariate analysis of risk and prognosis. Chest 1988;93:318-24 Kalaga, A, Addy M. HunterB (1989) Comparison of Chlorhexidine Delivery by Mouthwash and Spray on Plaque Accumulation. J. Peridontal 1989; 60(3): Logemann JA (1995). Dysphagia: evaluation and treatment. Folia Phoniatr Logop, 47(3): Logemann JA (1994). Multidisciplinary management of dysphagia. Acta Otorhinolaryngol Belg, 48(2):235-8. Murry, T., and R. L. Carrau. Clinical Manual for Swallowing Disorders. Albany, NY: Delmar, 2001 Orlando, R. Gastroesophageal Reflux Disease. New York, NY: Marcel Dekker, 2000. O'Sullivan, N. (1995). DYSPHAGIA CARE: TEAM APPROACH WITH ACUTE AND LONG TERM PATIENTS. (2nd edition). California, Cottage Square

Special Thanks Dr. Hal E. Bailey DDS Karen Green-McGowan RN
Becky Smitha OTR Southeast Indiana Outreach Jan Powers PhD, RN, CCRN Hilda Pressman CCC-SLP Joan Shepard CCC-SLP

Websites of Interest www.asha.org www.dysphagiaonline.com

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COMPREHENSIVE DYSPHAGIA MANAGEMENT

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COMPREHENSIVE DYSPHAGIA MANAGEMENT

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