The International Dysphagia Diet Standardisation Initiative (IDDSI) has published international definitions for food that has been modified for people with swallowing difficulties (dysphagia). Caroline Quilty, Head of Quality at Royal Trinity Hospice in London, and Juliet Lawson, Senior Speech & Language Therapist at Princess Alice Hospice in Surrey, explain the benefits and challenges of implementing the terminology in hospices.
The IDDSI has published the standardised terminology in response to numerous patient safety incidents where patients have been placed at risk from being given the incorrect diet/fluids.
The framework consists of a continuum of eight levels (0-7, picture above) and includes descriptors, testing methods and evidence for both drink thickness and food texture levels. The framework aims to improve clinical safety and efficiency by offering healthcare providers standardised terminology to assist in the development of international collaborative clinical research, and to standardise the terminology and consistency of different food providers in order to reduce risk.
In the UK, all healthcare settings are required to be fully IDDSI compliant by April 2019.The IDDSI framework replaces the Royal College of Speech and Language Therapist (RCSLT) and the British Dietetic Association (BDA) Dysphagia diet food texture descriptors which described fluids in terms such as honey, nectar, custard-thick and foods in terms of soft etc. The new framework is objective with very specific descriptions of what each level should look like.
At Royal Trinity Hospice, a Task and Finish group has been set up to implement the IDDSI Framework. The group consists of a registered Dietitian, Senior Nurse Manager, Senior Pharmacy Technician and Head of Catering. The first task for the group was to develop a local implementation plan which identified the following actions:
- Identify staff and volunteer training needs
- Develop staff and volunteers knowledge through an awareness-raising and education programme
- Identify any changes needed to the electronic patient record (Crosscare)
- Revise systems for ordering meals/snacks including the use of communication boards in the main kitchen and the ward kitchen
- Review guidelines for use of thickeners and oral nutritional supplements (manufacturers’ instructions)
- Liaise with local community Dietetic and SLT services to understand local implementation plans for patients at home
- Update relevant hospice policies, procedures and guidelines including audit as indicated.
The implementation group will report to the hospice Clinical Risk Management group.
While reviewing staff training needs, we took the opportunity to develop a comprehensive workshop for key staff covering:
- The physiology of the normal swallow
- Identification of dysphagia/ deteriorating swallow
- Management of dysphagia/ deteriorating swallow
- Management of risks associated with deteriorating swallow in a palliative care setting
- The impact of IDDSI
This is particularly important as the hospice does not have an on-site Speech & Language therapist (SLT); patients with an identified swallowing or communication difficulty who require SLT assessment and treatment are referred to their local community/acute service.
At Princess Alice Hospice, IDDSI implementation has been led by their on-site Speech & Language therapist, supported by the hospice Nutrition & Hydration Group. The Speech & Language therapist is a member of a Surrey -wide IDDSI action group, a multi-professional group that has come together to discuss and disseminate consensus- agreed IDDSI information and documentation across Surrey. A training pack was developed and training sessions led by the Speech & Language therapist were delivered to key staff groups involved in patient eating and drinking.
The IDDSI framework has been implemented in two stages. At stage one, the IDDSI fluid framework was implemented followed by IDDSI food framework at stage two. This two-stage process ensured that the new terminology was properly embedded and all paperwork was adapted. A practical training session was carried out with the hospice catering team led by Gary Brailsford from Dining with Dignity who demonstrated the new food descriptors in the hospice kitchen.
Benefits and challenges
Some patients may have already been converted to the new IDDSI descriptors by their community or acute unit therapists and it is important that we all use the same terminology to provide a seamless transition between settings. This will ensure clear understanding between practitioners and patients no matter which setting they are being supported by.
Other benefits that have been identified include increased resources around modified diets/fluids, increased confidence as all health professional following same guidance, and greater choice for some patients as there is an increased number of food/fluid descriptors.
At Princess Alice Hospice where IDDSI is now fully implemented, there have been various challenges along the way including ensuring all staff attended training; adoption of new terminology; adoption of practical catering changes to food preparation; change to paperwork; different scoop size/instructions with the different thickeners used; and ensuring clear menu guidelines.
Staff are very familiar with the “old” definitions so it takes time to get used to using new terminology. Furthermore, there may be only a very small number of patients on texture modified diets at any one time, so familiarity with the new descriptors may take some time to embed.
Roll-out to more hospices
Many hospices do not have their own on-site Speech and Language Therapist or Dietitian therefore they will need to identify their own implementation plan according to their local situation.
Each hospice will need to implement IDDSI according to their own locality resources. For those that do not have an SLT or Dietitian, we would recommend they get in touch with their local community SLT or Dietetic services to find out what is being done for implementation in the community and to join in any local training. This can then be disseminated across the organisation in a cascade:
- Identify a specific person/group who will lead on IDDSI implementation
- awareness raising through posters, emails, local intranet;
- specific training for key hospice staff which can then support their team in implementation;
- use of resources IDDSI website.
For more information visit IDDSI