We recently read an article written by Veronica Giudice – a Specialist Dietitian; about making sure dysphagia recommendations are clearly communicated across the patient team.

As we are sure it will prove useful we asked her to let us share it with you…

Introduction
Dysphagia is defined by any difficulties experienced with positioning, controlling and manipulating food or drink within the mouth, and difficulties achieving prompt, timely and coordinated muscle movements required for food and drink to be swallowed safely (RCSLT CQ3, 2006). Dysphagia is a potentially life-threatening condition and can have a significant impact on the person’s physical health and well-being, potentially resulting in weight loss, food refusal, chest infections and aspiration pneumonia.

Various incidents have been reported over a 2 year period within this NHS Trust surrounding dysphagia recommendations including; 20 reports of patients being provided with the incorrect texture or consistency of food or fluid and 3 reports of nil by mouth patient being given oral diet and fluids. The major factors contributing to the reported incidents were poor communication, inconsistent documentation and unclear recommendations. With the launch of IDDSI, it was seen as a good time to improve nutritional care of dysphagia patients across this Trust and to limit confusion that may occur with the introduction of new descriptors.

It was thought it would be quite a challenge to implement IDDSI within NHS Fife within the given timeframe so a dysphagia short life working group (SLWG) was set up including acute and community based members of the multidisciplinary team who met on a monthly basis to roll out IDDSI across Fife and improve nutritional care across Fife in terms of dysphagia. The members of the dysphagia SLWG split up into various sub groups to look at different aspects of nutritional care surrounding dysphagia including a subgroup developing inpatient documentation in the form pictorial meal mats (an example of which, can be found here).

Methods
A Dietitian and two Speech and Language Therapists collaborated to produce meal mats to highlight dysphagia recommendations and nutritional needs of individual patients. Once completed, the draft meal mats were then piloted in acute and community hospitals within Fife. They were positioned above the patients beds as this was thought to be the most visible location. Evaluation forms of the meal mats were then completed by various ward staff including trained and untrained staff, SLT, Dietitians and Occupational Therapists. The main positive feedback provided was; the meal mats were a good way to highlight SLT recommendations, it was helpful to have a visual aid of what the patients food and fluid should look like and it acted as a reminder for families bringing in food. The constructive feedback received was that writing was too small – ward staff felt they had to walk round the bed to read the information on the meal mat rather than being able to see the patients nutritional recommendations at a glance. The meal mats looked ‘messy’ as any information that did not apply to the patient was scored off with a pen. The meal mats did not stand out compared to anything else on the patients white board. Additionally, there was no option to personalise information on meal mats such as snack information.

Final meal mats were developed based on feedback received. They were doubled in size to make them more visible and to allow them to stand out amongst other paperwork on the board above the patients bed. Blank spaces were left on the meal mats for personalisation of information and the meal mats were laminated so that personalised information could be written on and wiped off as recommendations changed throughout the patient’s journey. Finalised meal mats were then rolled out across the acute hospital in this Trust and are available for use within community hospitals also. It is the sole responsibility of Dietitians and SLT to implement and keep these meal mats up-to-date which will reduce the risk of inaccurate recommendations being documented on the meal mats. On the patients discharge, the meal mats transfer across wards and sites with patients which limits the risk of miscommunication of recommendations between ward staff on transfer.

To ensure the efficacy of the meal mats in setting out to achieve our aims of improving communication of dysphagia recommendations at ward level and ensuring the safe transition to IDDSI, evaluation forms were provided to ward staff to analyse the improvement in service since implementation of meal mats.

Results
Of the ward staff who completed the evaluation form following implementation of the meal mats; 100% agreed that the meal mats are a beneficial way of highlighting patients with dysphagia. 100% agreed that the meal mats make SLT recommendations and nutritional needs of patients with dysphagia clear. 90% agreed that the meal mats are likely to improve their confidence when providing diet and fluid for patients with dysphagia. 70% agreed that the meal mats have improved their understanding of the new dysphagia descriptors.

Conclusion
This resource has been very well received across the acute setting within this Trust. The meal mats are seen as a useful visual aid for raising awareness and understanding of dysphagia descriptors among ward staff, patients, families and carers.

References
Royal College of Speech and Language Therapists (RCSLT). 2019. Dysphagia Overview. <https://www.rcslt.org/speech-and-language-therapy/clinical-information/dysphagia> [Accessed July 24 2019].