Residential Care Speech Pathology Service Successful Swallowing

1. Residential Care Speech Pathology ServiceSuccessful Swallowing

2. Residential Care Speech Pathology ServiceSuccessful Swallowing: Provision and Preparation of Thickened Fluids in Residential Care Facilities: Greater Newcastle Region Presented by Project Supervisor Selena McCaig, Speech Pathologist Project Coordinators, Speech Pathologists -Jessica Passmore, Kellie Meredith Acknowledgement for contributions: - Paula Machin, Maree Herzog, Larissa Mason, Amanda Bailey, Renae Mannix, Elisha Cooper

3. Overview of presentation • Scope of Project • Methodology • Results • Conclusions • Recommendations for future management and development

4. Who we are and what we do • Residential Care Speech Pathology Service • Compensable - utilising Federal funding for Allied Health services for high care residents in RCFs • Provide assessment/treatment for communication and swallowing (Dysphagia) in RCFs • Our mission: to prevent hospital readmission due to aspiration

5. Problems for solving • Initial Findings: • limited knowledge: preparation and provision of thickened fluids • only one consistency provided • no consistency in viscosity of fluids • used as ‘quick fix’ for dysphagia • no SP consult

6. Scope of project • Initial Goals: 2008 • Encourage trial of pre-packaged thickened fluids - ideal consistency • Limited shelf life / costly Most RCFs were not willing to trial

7. Scope of project – revised March 2011 • Review current knowledge and practices • Provide free educational inservice • Increase use of three consistent levels of thickened fluids • Impact referrals

8. Methodology • Approached 50 RCFs : telephone interviews • 18 facilities participated: • 62 individuals interviewed: • 44 nursing staff, 18 kitchen staff • Subjective rating: • allocated colour for perceived level of knowledge/current practice • ‘Green’, ‘Yellow’, ‘Red’

9. Methodology • Educational inservices (over 9 weeks) • Questionnaires assessed knowledge pre and post inservice • Interview data analysed qualitatively • Quantitative data analysis undertaken

10. Colour Codes for Perceived Knowledge and Current Practices Green • Managing current system well. • Good knowledge of purpose / function of thickened fluids • Consistent & monitored approach to preparing thickened fluids • Three levels of thickened fluids available (if required) • Thickened water available • Staff have good knowledge of warning signs for swallowing issues • Facility consistently uses speech pathologist to provide swallowing assessments Yellow • Knowledge around current system is inconsistent • Reasonable knowledge of purpose / function of thickened fluids • Inconsistent approach to preparing thickened fluids • Three levels of thickened fluids available (if required) • Thickened fluids may not be consistent on a day-to-day basis • Thickened water available • Staff have some knowledge of warning signs for swallowing issues • Facility consistently uses speech pathologist to provide swallowing assessments Red • Knowledge around current system is inconsistent and/or poor • Poor knowledge of purpose / function of thickened fluids • Inconsistent approach to preparing thickened fluids with no monitoring system in place • Less than three levels available of thickened fluids • Limited knowledge of warning signs for swallowing issues • Facility may or may not use a speech pathologist to provide ‘swallowing assessments’ and prescribe thickened fluids

11. Results 4 green, 8 yellow and 6 red Most using thickening powder only RCFs not monitoring hydration levels RNs assessing and modifying variation with terminology used feel they have adequate knowledge of dysphagia/modified diet fluids Not all facilities offering 3 levels! Some did not offer thickened water at all! Consistently inconsistent

12. Results The current level of knowledge of preparation and provision is not sufficient Resident safety breeched due to inability to provide modified diets/fluids to National Standards SP input redundant if RCFs unable to follow our recommendations

13. Results: pre/post education Comparison of nursing staff pre-test/ post-test scores Comparison of kitchen staff pre-test post-test scores

14. Results % change % change by colour classification

15. Results % change in key areas of education

16. Results - 1: • RCF education significantly improved: • Awareness of dysphagia and aspiration • Awareness of consequences of inadequate management. i.e. infection, dehydration, malnutrition • Awareness of standard terminology and definitions for texture modified diets/fluids • Understanding of the rationale for prescription of thickened fluid regimes

17. Results - 2: • Greatest change in knowledge for ‘Red’ category facilities • Knowledge remains relatively low despite improvement being measured Need for ongoing education!!!

18. Results - 3: • Kitchen/catering staff attendance – approx. 20%. - Kitchen staff complete most of the preparation of thickened fluids (up to 86%). • Need to target kitchen staff responsible for preparation of thickened fluids

19. Conclusions • Findings largely reflect available literature: thickened fluids  consistently inconsistent • Overall increased awareness - identified current weaknesses in provision of thickened fluids in Newcastle region • Ongoing consultation and education within RCFs is required! Specifically, education of kitchen staff Greater input from speech pathologists to ensure that each facility is able to implement changes

20. Were goals achieved? …1 • Thorough review of current knowledge/practices re thickened fluids and dysphagia management within the Newcastle Region • Provide free education to those RCF who participated

21. Were goals achieved? …2 • Knowledge and rationales for need for three consistent levels of thickened fluids however…. • Unable to determine if this education has led to%RCFs offering three consistent levels of thickened fluids • Timeframe has not allowed for review of appropriateness of RCSPS referralsas a result of education provided

22. Successful outcomes • Open and ongoing dialogue between RCSPS and RCFs • Increased awareness within RCFs of need for three levels of fluid thickness • Increased awareness of importance of referral to SP for dysphagia management

23. Feedback • RCF feedback • SP need to provide clear guidance re: how to mix fluids. Suggested that “recipe” would be helpful • RCFs identified need to change: ‘where to start?!?’

24. Now what? Measuring long-term outcomes: • ?Measure impact of training on patient outcomes • Further questionnaire 3-6 months post education - are RCFs using 3 consistencies? • ?Obtain feedback from nursing and kitchen staff re: impact of education on daily performance at mealtimes and confidence with feeding • Measure any change in nature and quantity of referrals to the RCSPS

25. Where to next….? • The thick fluid ready reckoner!?! • Stay tuned for project 2012

26. Questions or Comments? Residential Care Speech Pathology Service - 2011