The South West Region Speech and Language Therapy Managers have unanimously agreed the following responses to questions about Standard 5, ensuring that the nutrition and hydration needs of people with a dementia are well met. We hope that our response will help the South West Dementia Partnership and Acute Trusts in successfully implementing the Standard across the region.
The South West Region Speech and Language Therapy Managers have unanimously agreed the following responses to the questions you asked us to consider:
1. Is Standard 5, level 2, needed?
It was agreed that this standard was required, but needed further definition and clarification regarding tasks, roles, training, and competencies
2. Is there agreement to the objectives underpinning Standard 5 Level 2?
Yes, in that the person’s status regarding nutrition, eating, drinking, and swallowing needs to be identified as soon as possible following admission with subsequent appropriate care plans. However, it needs to be sufficiently broad so as to include functional eating and drinking (in comparison with a specific swallowing disorder or dysphagia).
3. What is the problem with the way it is currently stated?
Clarity is required regarding definitions so that eating and drinking, and nutritional needs are apparent and, where necessary, referrals for specific swallowing problems are made as soon as appropriate, following admission. These activities are parts of the overall objective, requiring different management approaches and competencies to implement.
The standard refers to ‘nurse led specialist assessment’ however current evidence suggests that there are few nurses in the country who have the level of dysphagia training required to fully assess a person’s swallow. Most dysphagia training for nurses has been based on swallow screening protocols for stroke, as opposed to full swallow assessments, and would not be applicable to this population.
If specialist assessment refers to a full specialist swallowing assessment it would need to be undertaken by a professional with the relevant recognised knowledge, skills and expertise in dysphagia and dementia. For dysphagia currently this is usually a Speech and Language Therapist due to the different aetiologies that can result in dysphagia, their effect on the physiology of the swallow, and the affect of communication and cognition on the use of strategies / interventions for swallowing.
Clarification is needed on whether the standard wants to achieve a full specialist assessment within 12 hours or to identify the presence of any eating, drinking, or swallowing problem and that appropriate management action is taken within that timeframe? For example, referrals for specialist swallow assessment by a speech and language therapist or recognition by nursing staff of a pre-existing eating and drinking problem and implementation of the existing management plan to support those activities.
The 12 hour timescale conflicts with the Royal College of Speech and Language Therapists Professional Guidelines on response times to swallowing referrals. In addition, there may be medical reasons why a specialist swallow assessment may not be appropriate within 12 hours on initial admission to the acute hospital
4. How can the standard promote a proactive approach in identifying need / appropriate referral and timely response?
The standard can promote a proactive response by being clear regarding definitions.
As the Hospital Standards document already states the National Audit checklist for this standard would include as part of initial assessment that “patients are weighed on admission and protected mealtimes established in all wards that admit frail elderly people” this group recommends that as part of the initial admission eating, drinking or swallowing disorders, including information on any previous difficulties/existing management decisions, highlighted in the community, should be identified
Identification of previously known and current management plans regarding eating / drinking and swallowing difficulties could be done as part of the clerking in procedure with the person and or relative/carer either by nursing staff or by the admitting medical team and could include checking the person’s GP practice health records and other agencies involved.
A structured observation of the person eating and drinking during the first 12 hours of admission would enable a screen of any self feeding or environmental issues affecting nutrition / hydration intake and any overt signs of swallowing difficulty. It needs to be identified who would do this observation, although nursing care plans should include this information as well as the MUST scores, and these could act as the triggers for referrals.
Other screening / prioritisation could be carried out as in the accompanying ‘Triage’ documentation from Gloucestershire.
Where the ‘screen’ indicated a problem then appropriate specialist referrals e.g. to Occupational Therapy, Dietetics, could be triggered and appropriate care plans implemented i.e. eating and drinking best practice guidelines.
Where swallowing problems are identified referral for specialist assessment for dysphagia for a full diagnostic swallowing assessment in order to identify aetiology and a management would be undertaken but should form part of the medical plan. It may not be appropriate for the referral to be made or the timing of the referral may need to be considered.
5. Is the problem one of resources available to implement the standard?
This would need to be audited following final agreement and implementation of the standard (including response times following referral to Speech and Language Therapy for a specialist swallowing assessment) but it is highly likely that for seven day a week and twenty four hour cover there would be resource issues.
6. If the standard is appropriate what new or alternative approaches are recommended to deliver the spirit of this standard?
The need to gather information regarding the person’s eating, drinking status prior to admission to hospital is most important, both in order to ensure safe swallowing during admission and to provide information to support diagnosis of any identified dysphagia.
This is of particular importance if the person does not have carers to help provide details of current management plans regarding eating/drinking and swallowing difficulties, and when previous community advice may have been provided by Speech and Language Therapists working within a different Trust e.g. a Mental Health Trust, or from other agencies.
It is suggested that doctors need to be involved in the development of further approaches, to help shape the standard in relation to how their initial clerking of patients might identify potential eating, drinking and swallowing problems. Also helpful would be the development of an observational framework / screening tool for acute or hospital ward staff that supports best practice in helping people with dementia to eat and drink. This should include identifying the impact of any functional, social and environmental considerations and individual patient needs.
Additionally, greater Speech and Language Therapy involvement in training is seen as a need, regarding both communication and eating, drinking and swallowing disorders. This may have a resource implication.
7. Is there a need for an agreed protocol based on a ‘decision tree’ or other tool?
A ‘decision tree’ or other tool may be helpful and should be developed in conjunction with medical, dietetic and speech and language therapy staff.
8. What are the implications (patient care/resources) of implementing this standard which leaders will need to understand and endorse?
Clarity regarding this will become evident following agreement of the standard.
9. What are the recommendations for ensuring consistent delivery?
The specificity of training will need to be addressed, with functional, social and environmental considerations (as well as the actual medical focus on the swallowing disorder).
Expectation of the development of competencies and specialist skills following the training, and update training at agreed intervals.
The availability of snacks between meals is very important for people with dementia, to maintain nutritional sufficiency.
Review of the measures and indicators, with revision as required.
The view of patients and carers is required.
Multidisciplinary agreement to the standard and its definitions is necessary. Dysphagia screening tools in acute hospital are evidence based on STROKE and cannot necessarily be applied to dementia. Also, whereas NBM may be acceptable for CVA this could raise ethical issues and would not be evidence based for much of this population of people with dementia.