3 ASPIRATION AND SILENT ASPIRATION ASPIRATION - passage of food or liquid through the vocal folds and into the lungsSILENT ASPIRATION - Aspiration occurring with no signs/symptoms (aka triggers)
4 LONG TERM CONSEQUENCES OF ASPIRATION PneumoniaLung DamageDeath
5 Cause of Death (MR/DD) in Indiana Nation wide, the leading cause of death in people with MR/DD is constipationIn 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.
6 ASPIRATION MAY OCCUR ANY TIME DAY OR NIGHT This includes:MealsOral CareMedication AdministrationBathingDressingSleepingSwallowing and the ability to tolerate saliva occurs throughout the day and night.
7 DYSPHAGIA DYSPHAGIA-Difficulty feeding or swallowing 3 types of DysphagiaOralPharyngealEsophagealOral 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.
11 DysphagiaTRIGGERS- Signs or symptoms associated with possible aspirationTrigger 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.
12 EXAMPLES OF DYSPHAGIA WARNING SIGNS OR TRIGGERS Coughing w/ signs of struggleWheezingWet Vocal Quality or RespirationsExcessive DroolingPocketing of food in the mouthSudden change of color around the lips and faceFever (24-48 hours post suspected incident)Refusal of foods or liquidsWatering eyesGaggingFacial GrimacingSmell of formula on breathIncreased ResidualsThe 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”.
13 Dysphagia Triggers TRIGGERS SHOULD BE INDIVIDUALIZED Examples: Vocalizing in a low wet sounding moanResidue in the mouth after liquid intakeFatigues before meal is completedIncreased vocalizations during oral intakeLeaning to the left in chairAs 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.
14 Coughing or Choking What’s the difference? Airway is not blockedKeeps your throat and airway clearMay be dry or productiveIf Coughing:Encourage coughingand clear airwayCHOKINGAirway is blockedMedical emergencyLack of oxygen to the brainIf Choking:Follow the provider’semergency protocolJOB 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.
15 Dysphagia Triggers What to do if you notice a Dysphagia trigger Check all Plans:Diet TextureFluid ConsistencyPositioningEating InstructionsAdaptive EquipmentPace of EatingBite or Drink SizeOther Dysphagia InterventionsINTERVENE AND SELF CORRECT IF ANY OF THE PLANS OR INSTRUCTIONS WERE NOT FOLLOWED CORRECTLY
16 Dysphagia Triggers What to do (cont) Resume meal or activity IF INDIVIDUAL HAS STOPPED EXHIBITING THE TRIGGERAND IS SAFE FROM HARM:Resume meal or activityIF INDIVIDUAL DEMONSTRATES THE TRIGGER AGAIN:Stop meal or activityCall for an evaluationDocument who was called and the time of the callDocument occurrence of trigger on the flow recordWait for further instructionsThe “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.
17 GASTROESOPHAGEAL DISEASE (GERD) GERD - Acidic stomach contents that move backward into the esophagus or mouthHeartburn is present in 80% of people with GERDOne of the most under-diagnosed conditions in the ID population60%f people with GERD have some sort of regurgitation
18 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.
19 GERD Who’s at risk? People with skeletal deformities People who smoke, drink coffee, or alcoholPeople who take relaxantsPeople with delayed stomach emptyingPeople who eat high fat dietsPeople who take medications that relax musclesPeople with seizure disorders that take medication that affects muscle toneMedications that increase GERD by decreasing lower esophageal tone:Anticholinergics such as cogentin, artane, atropineAlso, theophylline, benadryl, thorazine, mellaril, elevil, sinequan, tofranil, calcium channel blockers, caffeine, chocolate, aspirin, antibiotics such as tetracycline.
20 DYSPHAGIA IMPLICATIONS OF GERD Inhalation of stomach contents into the lungs (aspiration) resulting in possible pneumoniaEsophagitisStricturesUlcerationsEsophagitis is an inflammation of the lining of the esophagus
21 GERD SIGNS AND SYMPTOMS HoarsenessDroolingCoughingHand in mouthRepeated swallowingFrequent respiratory problems (i.e., coughing, wheezing, bronchitis, pneumonia)PICA“Sour” smelling or “Formula” burpsGERD should be considered as a possible cause in any person with severe asthma or recurrent pneumoniasGERD 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 discomfortThe 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.
22 TREATMENT FOR GERDPROTON PUMP INHIBITORS (Nexium, Prilosec, Prevacid are examples)Elevation – from top of head to at least hips, if not able to be totally uprightSupported so not curving sideways or slumping forwardElevated right sidelying or prone positioning may assist with stomach emptying and decrease reflux
23 TREATMENT FOR GERD (cont) Slow down eatingEncourage thorough chewingFrequent small mealsNo meals 2-3 hours before lying downSlowing 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 digestionVolume control in the stomach can decrease refluxing – rationale for 5-6 small meals per day.
24 MINIMIZING THE RISK OF ASPIRATION AND MANAGING DYSPHAGIA I. GENERAL INFORMATIONEvaluationPreventive MeasuresDiet TextureMealtimeOral CareMedicationADLs ( personal care, dressing, bathing, toileting, and bedtime)PositioningTrainingMonitoring and TrackingII. Program Implementation
25 EVALUATION Physician and Nursing >>> Speech Pathologist>>>>>>Occupational Therapist>>>Physical Therapist>>>>>>>Dietary>>>>>>>>>>>>>>>>Behavior Clinician>>>>>>>Overall Health and Risk AssessmentDiet Texture and Swallow EvaluationAdaptive Equipment, PositioningPositioning, TransfersMeal and Nutritional PlanningBehavioral Food Issues
26 EVALUATION TEAM APPROACH Identify factors that increase the risk of aspirationDiscuss:Mealtime problemsPositioning issuesOral careMedication administrationRisk issues
27 PREVENTITIVE MEASURES DIET TEXTURE Our job is not to take variety away from individual but to ensure that people cansafely eat a variety of foods.Diet Textures are typically described as:RegularMechanical #1-Whole Sandwich MeatMechanical #1-ChoppedMechanical #2 Soft-GroundPureedNeed 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.
28 PREVENTITIVE MEASURES DIET TEXTURE REGULARThis diet includes all foods with no texturerestrictions.Peanut butter may be thinned with Syrup, Honey, or Jelly
30 PREVENTITIVE MEASURES DIET TEXTURE MECHANICAL #1-Whole Sandwich MeatFor 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).
32 PREVENTITIVE MEASURES DIET TEXTURE MECHANICAL (#1)-chopped meatFor 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).
34 PREVENTITIVE MEASURES DIET TEXTURE MECHANICAL (#2) SOFT-ground meatFor 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.
36 PREVENTITIVE MEASURES DIET TEXTURE PUREEDFor 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
40 PREVENTITIVE MEASURES DIET TEXTURE RESTAURANT FOODS CONSISTENCY CHARTAll 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 homePortable ChopperFork mashingCutting with knife
41 Restaurant Foods Consistency Chart Please refer to your handout.
42 PREVENTITIVE MEASURES DIET TEXTURE Things to Consider:The risk for malnutrition and dehydration increases when diet is altered.Formal Nutritional Assessment should be completed by a DieticianAlternative Nutritional ConsiderationsAirway is repeatedly assaulted regardless of supportive interventionsNutritionally compromisedImpairments consistently interfere with food/fluid intakeRespiratory Status is compromisedClients 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)
43 PREVENTITIVE MEASURES MEALTIME GENERAL FACTORSDining room should be quietMinimal distractionsConversations should not be encouraged when individual has food in their mouthEncourage individual to focus on swallowingPositioned appropriatelyMonitor food texturesMake 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.
44 PREVENTITIVE MEASURES MEALTIME GENERAL FACTORS cont…Straw decreases the level of oral sensationSmall amounts per bite and sip is easier to manipulate and tolerateAlternating sips and bites helps clear the oral cavityIf wearing dentures, they should be well-fittedRemain upright for at least minutes after oral intakeRegarding 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.
45 PREVENTITIVE MEASURES MEALTIME Things to Consider:The person may not be able to tolerate 3 large mealsLiquids that are thickened may change in consistency over timeRepositioning may be needed during the course of a mealPerson may fatigue through the meal and have more trouble swallowing safelyThe type of Adaptive equipment needed changes over timeSwallow strategies change over time
46 PREVENTITIVE MEASURES MEALTIME PositioningMake sure the person is properly elevated, aligned and supported.Head is maintained in midline with chin tucked unless otherwise specifiedToolsAdaptive mealtime equipment (coated spoon, divided plate, small bowled spoon, measured cups etc.)Adapted positioning equipmentCompensatory strategiesDiet texture modificationsEnvironmental modificationsA 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.
47 PREVENTITIVE MEASURES MEALTIME Common ErrorsBites that are TOO BIG and sips that areTOO MUCHWhat is too big? Any bite or sip that is unable to be safely handledin 1 swallowHow to CorrectFollow the dining planWatch the neck for signs of a swallowUse the correct utensilsDo not overload the eating utensilSpread food out over entire plateRemember 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”
48 PREVENTITIVE MEASURES MEALTIME Common Errors (cont)Giving bites and sips TOO FAST!!!What is too fast? When the person does not have time to swallowand breathe between bites or sips.How to CorrectFollow the dining plan for the number of swallows needed for each bite or sipKnow how to identify the person’s swallowWATCH for the swallow—DO NOT GUESS!Watch for distress signals that tell you the person needs to swallow again
49 PREVENTITIVE MEASURES MEALTIME Poor head alignmentWhat is Poor Head Alignment? When the head is not inmidline with a chin tuck (Not only when giving food/fluidbut during the swallow).How to CorrectFollow 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.
50 PREVENTITIVE MEASURES MEALTIME Poor placement of the food/fluidWhat is poor placement? When the food or fluid is placed wherethe person is unable to safely swallow or handle it.How to CorrectFollow the Dining PlanPlace food/fluid on the center of the tongue or an alternate place in the mouth as noted on the dining planUse the correct utensil as specified on the dining plan.
51 PREVENTITIVE MEASURES ORAL CARE Development of acomprehensive oral careProgram significantly:Improves quality of lifeDecreases risk of pneumonia
52 PREVENTITIVE MEASURES ORAL CARE Impact of PlaqueMethodology57 ICU patients3 month period assessed for dental plaqueResultsIncreased plaque on the teeth over the time periodCorrelation between dental plaque colonization and microorganism in respiratory secretions21 patients developed pneumoniaPlaque colonization significantly associated with pneumonia
53 PREVENTITIVE MEASURES ORAL CARE Pneumonias in enterally fed patients is oftenassociated with the aspiration of bacteria fromthe oropharynx and GI tract.Bacteria invade the lower respiratory tract by micro- or bolus aspiration of oropharyngeal organismsCDC, 1997Celis, Torres, Gatell, Almela, Rodriguez-Roisin, Agusti-Vidal 1994
54 PREVENTITIVE MEASURES ORAL CARE Chlorohexidine Antispeptic (CHG)Study tests CHG effectiveness in oropharyngeal decontaminationN=353Infection rate decreased by 65% in those treated with CHG69% reduction in total respiratory tract infectionsOropharyngeal rinse was “rigorously” applied to all oral cavity surfaces including the tongue and tooth surfacesExample of CHG--PeridexDeRiso (1996)Chlorhexidine destroys the bacteria that grow in the coating (plaque) that forms on your teeth between tooth brushingsChlorhexidine does not prevent plaque and tartar from forming; proper tooth brushing is still required
55 PREVENTITIVE MEASURES ORAL CARE Cetylpyrdinium Antiseptic (CPC)Study tests CPC effectiveness in decreasing oral bacteriaN=45Significant decrease in oral bacteria countExample of CPC—Oral-B Anti-Plaque WashKalaga et al, 1989Cetylpridinium chloride is an ingredient which inhibits plaque formation
56 PREVENTITIVE MEASURES ORAL CARE ChlorohexidineKills bacteria on contactProlonged effect after expectorationCetylpyrdiniumKills bacteria on contactLimited abilities after expectorationNo data directly comparing the two.
57 PREVENTITIVE MEASURES ORAL CARE Oral Care ProgramTooth 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 administrationApprox dose is 15ml 2 x dailyMay be diluted with water if ulcers are present or individual has sensitivity issuesWash should contain one of the two discussed ingrediates (CHG or CPC)
58 PREVENTITIVE MEASURES ORAL CARE Things to Consider:If the person is having difficulty swallowing, or is unable to spit the toothpaste or mouthwash out, then these should be avoidedBrush one quadrant of teeth, give a short break for person to get a breath and swallow, then brush another quadrantA toothette can be used to swab the mouth with diluted mouthwash or diluted toothpasteMAKE SURE THE EXCESS WATER, MOUTHWASH, OR TOOTHPASTE IS SQUEEZED OUTIf 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.
59 PREVENTITIVE MEASURES ORAL CARE Remember that the individual is required to swallow during tooth brushing.PositioningMake sure the person is properly elevated, aligned and supportedHead is maintained in midline with a chin tuckToolsSuctioning toothbrush may be helpfulCollis-Curve toothbrushToothette with fluoride washRegarding 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.
60 PREVENTITIVE MEASURES ORAL CARE Important to view oral hygiene as a priorityand not just a comfort measure.
61 PREVENTITIVE MEASURES ORAL CARE RISKS The technique of brushing the teeth can damage the gums and cause bleedingThere 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
62 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.
63 PREVENTITIVE MEASURES MEDICATION ADMINSTRATION Remember that the person is required to swallow during medication administrationPositioningMake sure the person is properly elevated, aligned and supportedHead is maintained in midline with a chin tuckThere is a direct relationship between the dining plan and safe medication administrationToolsPill crusherAdapted meal equipment
64 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.
65 PREVENTITIVE MEASURES ADLs Remember that the risk of aspiration is not limited to mealtimePositioningMake sure the person’s positioning program addresses dysphagia and GERD by specifying the position for dressing, toileting, personal care, bathing/showering and bedtime.ToolsWedgeHospital bed or elevated bed with bed blocksShower trolleyTilt in Space commode/shower chairMany 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.
66 PREVENTITIVE MEASURES POSITIONING Things to Consider:All activities require specific position methodsToileting and undergarment changesDressingOral careMedication administrationBathing or showeringSleepingEating, swallowing, drinking including those using G-tubeStomach emptyingBowel and bladder elimination
67 PREVENTITIVE MEASURES POSITIONING Things to Consider (continued):Variety of positions includeWheelchair or other mobility deviceLeft sidelyingRight sidelyingProne on forearms or quadrupedSupineStanding or kneeling
68 PREVENTITIVE MEASURES POSITIONING Things to Consider (continued):The best position for eating, oral care andswallowing……….May NOT be sitting upElevated right sidelying or elevated proneMay be a better position for safe swallowingand airway protectionMay be a better stomach emptying positionMay encourage better abdominal compressionto address lower GI problems such asconstipation
69 PREVENTITIVE MEASURES POSITIONING 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
70 PREVENTITIVE MEASURES POSITIONING Things to Consider:Positioning for constipation can includeprone on elbows or quadruped and elevatedleft sidelying.Positioning for stomach emptying todecrease reflux can include prone on elbowsor quadruped and elevated right sidelying.
71 PREVENTITIVE MEASURES POSITIONING Head PositionAt midlineNeutral or chin tucked4 fingers flat against the nape of the neck
72 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 trainingCategory 2: Client Specific competency based training
73 PREVENTITIVE MEASURES TRAINING This training is General or Foundational training.
74 PREVENTITIVE MEASURES 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.
75 PREVENTITIVE MEASURES MONITORING AND TRACKING It is “best practice” to monitor an individual’s dysphagia triggers 24/7Provides the caregivers with the information needed to be proactive in minimizing the risks associated with dysphagiaTrackingProvides information on whether or not the Dysphagia plan is protecting the individual from harm.Provides data regarding the severity and # of dysphagia related occurrences.
76 PROGRAM IMPLEMENTATION Interdisciplinary ApproachRisk AssessmentEvaluation and Follow-UpInterventionMonitoringTrackingTraining
77 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 loss2) Coughing on Thin Liquids3) Vomiting after mealsIdentified goals or outcomes:1) weight maintenance or weight gain2) No vomiting3) No coughingCauses: 1) not eating enough, getting tired during the meal, non-preferred staff2) eating too much, eating too fast, laying down too soon3) only coughs on koolaid and water but not tomato juice or milkshakes
78 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 planThis is going to give you your documentation component1) weight consistently2) chart vomiting3) chart incidents of coughing
79 Staying Connected To Your Team One to OneGroup MeetingPhoneVoic
80 PROGRAM IMPLEMENTATION RISK ASSESSMENT General Risk Factors AssessmentRisk Assessment for Choking for Individuals who eat by mouthAssessment of Pneumonia RiskSkin Assessment ToolBraden Scale for Predicting Pressure Sore RiskMobility Screenings for Persons with Visual Impairments
81 PROGRAM IMPLEMENTATION RISK ASSESSMENT General Risk Factors AssessmentPurpose: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
82 PROGRAM IMPLEMENTATION RISK ASSESSMENT Risk Plan should include:Interventions to be providedMonitoring and Tracking mechanismStaff trainedImplementation of the plan as part of the Individual Support Plan (ISP)Completed:Annually and Reviewed Quarterly by members of the IDTIf selected items are checked in the Dysphagia orPhysical Management section, additional riskassessment forms are to be completed and sent toOutreach
83 PROGRAM IMPLEMENTATION RISK ASSESSMENT ADDITIONAL RISK FORMS:RISK ASSESSMENT FOR CHOKING FOR PERSONS WHO EAT BY MOUTHCompleted by IDTASSESSMENT OF PNEUMONIA RISKSKIN ASSESSMENT TOOLBRADEN SCALE FOR PREDICTING PRESSURE SORE RISKMOBILITY SCREENINGS FOR PERSONS WITH VISUAL
84 PROGRAM IMPLEMENTATION RISK ASSESSMENT Choking and Pneumonia Assessment-must be completed at least annually or as determined by General Risk Factors AssessmentSkin and Pressure Sore Assessments- must be completed at least annually or as determined by General Risk Factors AssessmentMobility Screenings for Persons with Visual Impairments- must be completed at least annually or as determined by General Risk Factors AssessmentCompleted originals are to remain on site and a copy mailed or faxed to Southeastern Indiana Outreach Services
85 PROGRAM IMPLEMENTATION RISK ASSESSMENT Identifying the Individual‘s DysphagiaRisk 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.
86 PROGRAM IMPLEMENTATION RISK ASSESSMENT DYSPHAGIA RISK LEVELSLEVEL 1Residents enterally fedResidents with a risk of Aspiration as determined by MBSResidents with a history of Aspiration PneumoniaResidents with AsthmaResidents with a risk score of 70 or greater as determined by the Choking Assessment FormResidents with a risk score of 70 or greater as determined by the Pneumonia Risk Assessment Form
87 PROGRAM IMPLEMENTATION RISK ASSESSMENT DYSPHAGIA RISK LEVELSLEVEL 2Residents with a risk score of 50-60% as determined by the Choking Assessment FormResidents with a risk score of 50-60% as determined by the Pneumonia Risk Assessment FormResidents with pharyngeal and esophageal phase dysphagia
88 PROGRAM IMPLEMENTATION RISK ASSESSMENT DYSPHAGIA RISK LEVELSLEVEL 3Residents with a risk score of 30-40% as determined by the Choking Assessment FormResidents with a risk score of 30-40% as determined by the Pneumonia Risk Assessment FormResidents with oral phase dysphagia, GERD, hiatal hernia, reflux, rumination, erosive esophagitis or gastritis.
89 PROGRAM IMPLEMENTATION RISK ASSESSMENT DYSPHAGIA RISK LEVELSLEVEL 4All other residentsThis level has no diagnosis of dysphagia, GERD, or choking risk.
90 PROGRAM IMPLEMENTATION EVALUATION AND FOLLOW UP Dysphagia EvaluationPositioning EvaluationNutritional Evaluation
91 PROGRAM IMPLEMENTATION EVALUATION AND FOLLOW UP DYSPHAGIA EVALUATIONCompleted by a Speech Language Pathologist with expertise in the area of swallowing and the ID populationEvaluations and reviews are based on individual’s dysphagia risk level.Level 1-Annual Evaluation, Monthly Review, and PRNLevel 2-Annual Evaluation, Quarterly Review and PRNLevel 3-Annual Evaluation, 6 Month Review and PRNLevel 4-Annual Evaluation and PRN
92 PROGRAM IMPLEMENTATION EVALUATION AND FOLLOW UP DYSPHAGIA EVALUATION (cont)If there is a significant change, a review should be completed immediatelyvisit to ER,unplanned weight loss of 10% in 6 months or more than 5 pounds in one monthchange in daily scheduleany lab work indicating nutritional deficits or dehydrationobservation of dysphagia triggersDining Plan updates, Dysphagia Plan updates, and Trigger Responses should be completed PRN
93 PROGRAM IMPLEMENTATION EVALUATION AND FOLLOW UP POSITIONING EVALUATIONCompleted by a Therapist with expertise in positioningIndividual’s should be evaluated annually and reviewed quarterly and PRN
94 PROGRAM IMPLEMENTATION EVALUATION AND FOLLOW UP POSITIONING EVALUATION (cont)If there is a significant change, individual and positioning program should be reviewed immediatelyvisit to ERunplanned weight loss of 10% in 6 months or more than 5 pounds in one monthany existing pressure area that worsens, any pressure area discoveredany change to positioning program or equipmentchange in daily scheduleany lab work indicating nutritional deficits or dehydration
95 PROGRAM IMPLEMENTATION EVALUATION AND FOLLOW UP NUTRITIONAL EVALUATIONCompleted by a DieticianIndividuals are evaluated as needed (i.e., BMI under 18 or over 30)
96 PROGRAM IMPLEMENTATION EVALUATION AND FOLLOW UP NUTRITIONAL EVALUATIONIf there is a significant change, individual should be reviewed immediatelyunplanned weight loss of 10% in 6 months or more than 5 pounds in one monthBMI (Body Mass Index) under 18BMI (Body Mass Index) greater than 30any lab work indicating nutritional deficits or dehydration
97 PROGRAM IMPLEMENTATION INTERVENTION Dining PlansDysphagia PlansPositioning ProgramsDysphagia Triggers Process
98 PROGRAM IMPLEMENTATION INTERVENTION DINING PLANSWhat is a Dining Plan?Who needs one?Development of the planUse of the planReview and Revision
99 PROGRAM IMPLEMENTATION INTERVENTION DINING PLANSWhat is it?A dining plan provides staff with vital information regarding the individual’s mealtime structureRisk factorsFood and Fluid textureDiet considerations (MD ordered)Behavioral precautionsEating and Drinking strategiesSpecific mealtime goalsCommunication strategiesDysphagia triggersAdaptive equipmentEating positionPosition of staff assisting
100 PROGRAM IMPLEMENTATION INTERVENTION DINING PLANSWho needs one?All individuals who are determined to have difficulties during mealtimeBehaviorsDysphagiaModified textureSpecial dietsPositioning issuesAdaptive equipmentEven 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).
101 PROGRAM IMPLEMENTATION INTERVENTION DINING PLANSDevelopment of the planDeveloped 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 informationShould include pictures of adaptive equipment and position during eatingIndividualizedTeam approach
102 PROGRAM IMPLEMENTATION INTERVENTION DINING PLANS-ExampleASPIRATION RISK CHOKING RISKBehavioral Precautions – [including special table or environment]:Occasionally stomps feet and bites fingers when upsetwill shake head “no” to refuses food/activity;self-stimulatory behavior-able to verbally redirect.FOOD TEXTURE:PureedFLUID 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 cupIf using pudding or gel thickness, offer them in a coated spoon
103 PROGRAM IMPLEMENTATION INTERVENTION Dining Plans-Example (cont)CALORIE RESTRICTION: low cholesterolSUPPLEMENTS:Applesauce and bran at breakfastPrunes every meal [no other fruit or desert]EATING:Requires total set-up and assistance for meals.Wears neck napkinStaff should be seated at eye-levelPresent food at level of lips and say “take a bite”. Once he takes a bite say “good bite”.
104 PROGRAM IMPLEMENTATION INTERVENTION Dining Plan-ExampleEating (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.
105 PROGRAM IMPLEMENTATION INTERVENTION Dining Plan-Example (cont)DRINKING:No fluids on tray; Gels per memoGels are preferred method of fluids, however, he can tolerate honey-thick liquids.DO NOT discourage coughingSPECIFIC SKILLS TO MAINTAIN/ACQUIRE:Encourage Choice MakingCOMMUNICATION:VocalizationsFacial expressions, behavioral; head shakes yes/no are not always communicative.
106 PROGRAM IMPLEMENTATION INTERVENTION Dining Plan-Example (cont)TRIGGERS to Notify Nursing Staff:Bottom not back in wheelchairCoughing with signs of struggle (watery eyes, drooling, facial redness)Wet vocal qualityVomitingSudden change in breathingWatery eyes
107 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
108 Dining Plan OutlinePlease refer to the sample Dining Plan provided in your packet
109 PROGRAM IMPLEMENTATION INTERVENTION DINING PLANSUse of the PlanShould be available wherever the individual may be eatingDining Plan should be located at tableside for easy referenceStaff 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.
110 PROGRAM IMPLEMENTATION INTERVENTION DINING PLANSReview and RevisionShould be updated as changes occurReview quarterly at IDT meeting or in the occurrence of a significant change (unplanned weight loss or gain , hospitalization, observation of triggers)
111 PROGRAM IMPLEMENTATION INTERVENTION Dysphagia PlansWhat is a Dysphagia Plan?Who needs one?Development of the planUse of the planReview and Revision
112 PROGRAM IMPLEMENTATION INTERVENTION Dysphagia PlansWhat is a Dysphagia Plan?Provides Vital information regarding the individual’s physical and nutritional health.Risk areasDysphagia triggersNutrition and MealtimeOral Care and Medication AdministrationGeneral positioningCovers all areas of the individual’s daily life
113 PROGRAM IMPLEMENTATION INTERVENTION Dysphagia PlansWho needs one?Diagnosis of Oral, Pharyngeal, or Esophageal DysphagiaDiagnosis of GERD, Reflux Esophagitis, History of Pneumonia or Aspiration PneumoniaAll individuals who are determined by Outreach to be at a level 1, 2, or 3 dysphagia risk.
114 PROGRAM IMPLEMENTATION INTERVENTION Dysphagia PlansDevelopment of the planDeveloped 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)IndividualizedTeam approach
115 _______Client’s Name_______ AGENCYDYSPHAGIA CARE PLAN_______Client’s Name_______DateLevel of Risk________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Diagnoses related to Dysphagia (i.e., GERD, Oral, Pharyngeal, EsophagealDysphagia, Aspiration or Choking risk etc…)TRIGGERS:In this section you will include specific triggers (aka signs or symptoms) thatare related to the individual having increased difficulty swallowing, toleratingtube feedings, tolerating their own secretions or positioning triggers duringmealtme)IF YOU NOTICE ONE OR MORE OF THE ABOVE TRIGGERS, ATTEMPT TOSELF CORRECT (make sure dysphagia plan is being followed correctly)IF TRIGGER IS OBSERVED AGAIN, DOCUMENT ON FLOW CHART ANDNOTIFY NURSE OR House MANAGER.
116 NUTRITION AND MEALTIME This section includes information on the client’s food textures, fluidtextures and supplements. If NPO, this should be listed here as well asthe 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 ADMINISTRATIONOral Care Guidelines (suctioning or non-suctioning), positioning, and fluidtexture information are included in this sectionGENERAL POSITIONINGPositioning as it relates to bathing, attends changes, and showering areincluded in this section. Remember that an individual should bepositioned in an upright manner when performing these activities. Referto Positioning Plan for specifics.Quarterly Review:IT IS HELPFUL TO USE A BULLET FORMAT FOR EASY REFERENCEASPIRATION CAN OCCUR AT ANY TIME1st Quarter2nd Quarter3rd Quarter
117 Dysphagia Care PlanPlease refer to the handout
118 PROGRAM IMPLEMENTATION INTERVENTION Dysphagia PlansUse of the planPlan 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
119 PROGRAM IMPLEMENTATION INTERVENTION Dysphagia PlansReview and RevisionShould be updated as changes occurReview 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
120 PROGRAM IMPLEMENTATION INTERVENTION Positioning ProgramsWhat is a Positioning Program?Who needs one?Development of the programUse of the programReview and Revision
121 PROGRAM IMPLEMENTATION INTERVENTION Positioning ProgramsWhat is a Positioning Program?Includes optimal positions for:Eating and SwallowingMedication AdministrationStomach EmptyingBowel and Bladder EliminationOral CareADLs (personal care, dressing, bathing/showering)
122 PROGRAM IMPLEMENTATION INTERVENTION Positioning ProgramsWho needs one?Person who is unable to move themselves INDEPENDENTLY into or out of a variety of positions throughout a 24 hr dayPerson who spends >2 hrs out of a 24 hr day in a wheelchairPerson 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 lowerHistory 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.
123 PROGRAM IMPLEMENTATION INTERVENTION Positioning ProgramsWho needs one? (cont)Unable to sit upright for any reasonRequires support of head, trunk, upper or lower extremities to maintain an upright or near upright positionDemonstrates obligatory primitive postural, obligatory movement reflexes or unmanageable postural tone such as extensor tone in supine positionDemonstrates 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 ADLsPerson who has 2 or less positions they can tolerateDiagnosis of GERD, Reflux Esophagitis, History of pneumonia or Aspiration Pneumonia, and Asthma
124 PROGRAM IMPLEMENTATION INTERVENTION Positioning ProgramsDevelopment of the programDeveloped 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/ShoweringToileting and Personal CareDressingOral Care and Medication AdministrationDegree of elevation for each position
125 PROGRAM IMPLEMENTATION INTERVENTION Positioning ProgramsUse of the ProgramProgram 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..)
126 PROGRAM IMPLEMENTATION INTERVENTION Positioning ProgramsReview and RevisionShould be updated as changes occurReview 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
127 PROGRAM IMPLEMENTATION INTERVENTION Dysphagia Trigger ProcessIt 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 PlanDirect Support Staff ensures proper implementation of Plan (positioning, diet texture, etc.).Direct Support Staff identifies that triggers has occurred and immediately assistIf triggers occur and plan is not being followed, follow plan and notice if triggers continue.
128 PROGRAM IMPLEMENTATION INTERVENTION 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 immediatelyVerify that the Dysphagia Care Plan is being followedIf not, ensure proper implementationChecks pulse, respirations, and breath soundsCheck O2 sats if there is distress noted or congestion is present8. Determines if client’s health is compromised and is in need of immediate evaluation.
129 PROGRAM IMPLEMENTATION INTERVENTION 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.
130 PROGRAM IMPLEMENTATION INTERVENTION Dysphagia Trigger Process (cont)Recommended Response to IncidentIt 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 within3 business days for Dysphagia Level 15 business days for Dysphagia Level 27 business days for Dysphagia Level 314 business days for Dysphagia Level 4If 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:
131 PROGRAM IMPLEMENTATION INTERVENTION Dysphagia Trigger Process (cont)Recommended Response to Incident13.Once the client is evaluated, Therapist from the community should make recommendations and provide follow through within:3 business days for Dysphagia Level 15 business days for Dysphagia Level 27 business days for Dysphagia Level 314 business days for Dysphagia Level 4
132 PROGRAM IMPLEMENTATION INTERVENTION 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 PlansDining PlansPositioning Programs
133 PROGRAM IMPLEMENTATION INTERVENTION Dysphagia Issues requiringImmediate evaluation(ER/Hospital visit):chokingDecreased pulse or respirationscoarse or wet breath soundsclient distress or congestionActions:Client is sent to ER/HospitalNurse or House Manager notifies therapist the next business dayTherapist evaluations are provided based on risk schedule upon client’s return home.Dysphagia Issues not requiringimmediate evaluation:coughing w/ signs of strugglewet vocal qualityexcessive droolingpocketing of food in mouthbehavior issues during mealtime (chugging of liquids, large bites)facial grimacingincreased residualsrefusal of food or fluids x2improper positioningActions:Nurse or House Manager assesses situationImmediate evaluation (ER) is not neededTemporary modifications are made to plansNurse or House Manager contacts Therapist the next business dayTherapist evaluations are provided based on risk level
134 Aspiration Protocol (Sample) Please refer to your handout at this time.
135 PROGRAM IMPLEMENTATION MONITORING Dysphagia SchedulePositioning ScheduleMonitoring FormsIt is “best practice” to monitor an individual’s dysphagia triggers and positioning
136 PROGRAM IMPLEMENTATION MONITORING Dysphagia ScheduleServes as a guide to assist the provider through the monitoring processProvides information on the type of monitor and frequency of monitoring sessionsFrequency of monitors are based on the individual’s dysphagia risk levelCovers all areas where the individual is determined to be at risk
137 AGENCY DYSPHAGIA MONITORING SCHEDULE Number, Type, and Frequency of MonitoringType of MonitorLevel types per monthLevel type per monthLevel type per quarterLevel at ISP UpdateDental1/yearannual evalOral Care4/yearBathing3/yearDressingDocumentation Review1/quarter1/6 monthsMed-Pass2 a.m./year 2 p.m./yearMealtime/Snack8/year6/yearTotal Doc Reviews/year42Total Monitors/year2412
138 PROGRAM IMPLEMENTATION MONITORING Positioning ScheduleName of Client, revision date and individual who revised the scheduleBeginning and ending time for the positionSpecific position including amount of elevationSchedule should cover 24 hrs dayData collection for each positionStaff initials responsible for the positioning programSchedule includes position for : Bathing/Showering, Toileting and Personal Care, Oral Care and Medication Administration, and need to be elevated at all times)
139 PROGRAM IMPLEMENTATION MONITORING MONITORING FORMSDysphagia Plan MonitorDysphagia Documentation Review
140 PROGRAM IMPLEMENTATION MONITORING Dysphagia Plan MonitorServes as a general and client specific dysphagia and dysphagia positioning reviewMonitors all areas of the client’s dayMealtimemed passDressingoral careBathingdentalFrequency of monitors are based on client’s dysphagia risk level.Follow dysphagia scheduleShould be completed by members of the IDT who have completed Indiana Outreach’s Comprehensive Dysphagia Training Program
141 Dysphagia Plan Monitor Please refer to the sample provided in your packet
142 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
143 PROGRAM IMPLEMENTATION MONITORING Dysphagia Documentation ReviewProvides structure to the process of reviewing a client’s dysphagia plan, monitoring, and tracking processesFrequency of documentation reviews is based on the client’s dysphagia risk levelFollow dysphagia scheduleShould be completed by members of the IDT who have completed Indiana Outreach’s Comprehensive Dysphagia Training Program
144 Dysphagia Documentation Review Please refer to the sample provided in your packet
145 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
147 Flow RecordPlease refer to the sample provided in your packet
148 PROGRAM IMPLEMENTATION TRACKING Flow RecordProvides a way for staff to document and track dysphagia triggers as well as other pertinent medical informationAdditional information on the “flow record” replaces many existing formsVitalsMeals (I/O)GITriggersG-TubeSkinOral CareData can be easily viewed and analyzed
149 Flow Record Directions Direct Support StaffVitalsRecord Monthly/Daily on Flow RecordUse Vita Sign Record if vital signs are taken more frequently than dailyIf O2 Sat is taken more than once a day, utilize Progress Notes entry.MealsFor all clients record % of Meals/Snacks eaten and fluid intakeGISuppository – Y or NEnema – F-Fleets, SS – Soap SudsChart results in Progress Notes as well as on Flow RecordBMUtilize Code:I – Soft M – MediumII – Hard L – LargeX – Liquid XL – Extra LargeLast Void (time)Vomitus – Y for Yes, N for No
150 Flow Record Directions Direct Support Staff (cont)TriggersFor 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 occurredG-TubeFormula – Identify type of feeding and amountResidual – Amount: if > 25cc, chart a progress noteSite Care – Y/N: if redness or drainage present, chart until Resolved (R) with progress note entry
151 Flow Record Directions Direct Support Staff (cont)SkinAbrasion/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 CareSuction Tooth Brushing – Check mark for completionOral swab – Check mark for completionToothbrush – Check mark for completion
152 Flow Record Directions NurseShould initial each Flow Record after data is reviewed. Perform appropriate follow-up.
153 PROGRAM IMPLEMENTATION TRACKING REMEMBER:A “TRIGGER” can occur at any time, 24/7A “SELF-CORRECTED TRIGGER” means that it occurred one time and the intervention you provided was successful in preventing it from happening againA “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
154 PROGRAM IMPLEMENTATION TRAINING All staff should be provided with Client-Specific Competency Based TrainingCompetency in:DysphagiaMealtimeOral Care and Medication AdministrationPositioning for dressing, bathing, personal care, toileting and sleepingMust be trained and verifiedTrainers should have completed Indiana Outreach’s Comprehensive Dysphagia Training ProgramRefer 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”.
155 PROGRAM IMPLEMENTATION TRAINING Competency Based TrainingCompetency 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.
156 MythBusters Myth or Fact ? It is normal for some people to cough throughouttheir meal.It is a good sign for someone to cough up a lot ofphlegm first thing in the morning or after a drinkof juice (for example) because they are gettingthat junk out of their lungs.Milk and Milk products should be avoided by peoplewho have swallowing problems because it makesthem 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.
157 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 aboutsomeone’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
158 Benefits of Physical and Nutritional Management Dining PlansProvides staff with the information needed to safely assist individuals with mealtime issuesMinimizes the risk of chokingMinimizes the risk of aspirationMinimizes the risk of dehydration and malnutritionDysphagia PlansServes as a guideline for staff regarding the individual's physical and nutritional healthProvide specific information on risk areas, dysphagia triggers, nutrition and mealtime, oral care and medication administration, and general positioning recommendations
159 Benefits of Physical and Nutritional Management Positioning ProgramsImproves GI, urinary and respiratory functioningMinimizes current and prevents further deformityImproves safety, health and comfort of clientPrevents skin breakdown and decubitusImproves client's ability to use functional skills in meaningful activitiesDysphagia Trigger ProcessAssists in removing the guesswork that staff may face when a trigger occursIncreases the level of awarenessProvides a standard of careIncreases communication between IDT members
160 Benefits of Physical and Nutritional Management Dysphagia ScheduleCovers all areas where the individual is determined to be at risk of aspirationServes as a guide to assist the provider through the monitoring processDysphagia Plan MonitorProvides a general and client specific dysphagia and dysphagia positioning reviewAssists in the updating of care plans and identification of dysphagia issues
161 Benefits of Physical and Nutritional Management Dysphagia Documentation ReviewEnsures monitors and tracking are being conducted and triggers are responded to by the appropriate IDT memberFlow RecordProvides structure for staff to document and track dysphagia triggers as well as other important informationHelps staff become more aware and proactive in the protection of our clientsMinimizes risk of aspirationMinimizes risk of choking
162 Benefits of Physical and Nutritional Management Persons with Intellectual Disabilities are healthier and saferDeaths are preventedLess pain and suffering by clientsImproved quality of life for clientsBy being proactive, issues will identified before they become problematicFewer non-routine medical visits, emergency room visits, and hospitalizationsLess staff time spent preparing for and accompanying person on medical visitsReduced reactionary interventions by IDT membersImproved communication and knowledge base of staff and members of the IDTFewer crisis situationsFewer incident reports to completeFewer regulatory surveys and monitors following up on crisis situations
163 In Closing Know the Facts Protect the Individual Assess Risk Areas Develop 24/7 Dysphagia PlansDevelop Dining PlansDevelop Positioning PlansMonitor and Track TriggersImplement Competency Based Training
164 ReferencesCelis R, Torres A, Gatell JM, Almela M, Rodriguez-Roisin R, Agusti-Vidal A. Nosocomial pneumonia: a multivariate analysis of risk and prognosis. Chest 1988;93:318-24Kalaga, 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, 2001Orlando, 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
165 Special Thanks Dr. Hal E. Bailey DDS Karen Green-McGowan RN Becky Smitha OTRSoutheast Indiana OutreachJan Powers PhD, RN, CCRNHilda Pressman CCC-SLPJoan Shepard CCC-SLP
166 Websites of Interest www.asha.org www.dysphagiaonline.com