• The service aims to see patients within 2 working days of receipt of referral. In times of reduced staffing, the response time may be longer and patients will be prioritised in liaison with appropriate members of the MDT.

• Referrals will not be accepted for the following patient groups:

  • Patients with fluctuating levels of consciousness who may be too unwell or too drowsy to participate in assessment.

  • Patients who are eating and drinking normally but who have difficulty swallowing tablets.

  • Patients who are on a normal diet and fluids and presenting only with vomiting as a symptom.

• On the general wards, speech and language therapy service operates Monday to Friday with core hours of 8.30am – 4.00pm.

• FPH Stroke Unit: SLT service provides cover 6 days per week and on bank holidays. This service may be affected when there are vacancies in the team to ensure appropriate staffing Mon to Fri.

• All patients who fail a swallow screen will be referred to speech and language therapy for assessment.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition.

Print copies must be destroyed after use.

Abbreviations

1.1 Referrals are made on EPIC via patient orders. The team will check the EPIC ‘all SLT orders’ list for new referrals at least three times a day (morning, lunchtime and afternoon).

1.2 Following receipt of referral by the Speech and Language Therapy team, patients will be prioritised according to the level of risk posed to them:

1. New patients who are nil my mouth without any other form of nutrition/hydration in place and requests for reviews when there is concern that a patient’s condition may have deteriorated.

2. New patients who are nil by mouth but have IV/enteral nutrition in place, those who are eating and drinking but concerns have been raised about their swallowing ability and those who are imminently due for discharge.

3. Requests for reviews of patients already under SLT management when there are no new specific concerns.

The service level will be determined by the senior staff member working that day (usually Band 7)

1.3 New patients will be added to the current caseload whiteboard in the department with appropriate annotations that they are waiting to be seen. These patients will also be allocated on EPIC by the managing SLT. If a referral is rejected, a note will be created on EPIC using the ‘inappropriate referral option’ either explaining the reason for rejection or to request re-referral with more information.

1.4 An open referral system exists.

1.5 Referrals will not be accepted for the following patient groups:

• Patients with fluctuating levels of consciousness who may be too unwell or too drowsy to participate in assessment.

• Patients who are eating and drinking normally but who have difficulty swallowing tablets.

• Patients who are on a normal diet and fluids and presenting only with vomiting as a symptom.

1.6 For head and neck patients the following protocol should be followed.

• At FPH

  • 1. For those patients with a new diagnosis of head and neck cancer, liaise with H&N clinical nurse specialist to make aware of the patient, encourage transfer of patient to the Royal Surrey Hospital, inform the ward of above and document on patient’s EPIC notes

  • 2. For those patients with palliative management: review as inpatient (in the context of palliative management, discuss with James Martin (H&N SLT at WXH) cc in senior therapists) and refer to local community teams as required

  • 3. For those patients who are more than 3 months post treatment: Email Tracie Mansell (MARS SLT) to inform of admission and to allow her to follow up on their care, inform the ward of above and document on patient’s EPIC notes

• At WPH

  • Liaise with Senior Specialist Head and Neck SLT (James Martin)

2.1 The service aims to see patients within 2 working days of receipt of referral. In times of reduced staffing the response time may be longer and patients will be prioritised in liaison with appropriate members of the MDT.

2.2 New stroke patients who have failed a swallow screen will be seen within 72 hours of admission in line with national stroke guidelines.

3.1 On the general wards speech and language therapy service operates Monday to Friday with core hours of 8.30am – 4.00pm. An out of hours swallow screening service is provided at FPH outside of these hours as follows via the night nurse practitioners or HIT team.

3.2 FPH Stroke Unit: SLT service provides cover 6 days per week and on bank holidays. This service may be affected when there are vacancies in the team to ensure appropriate staffing Mon to Fri. All patients who have a confirmed or suspected stroke are screened by the stroke co-ordinator.

3.3 FPH and WPH Critical Care Units: Appropriately trained Nurses will complete the ICU swallow screen for all those patients that meet the criteria (as specified on the screen). Those that fail along with all patients that do not meet the criteria and/or have a tracheostomy will be referred directly to SLT.

3.4 All members of staff carrying out swallow screening will have completed the relevant e-learning module.

3.5 By agreement, the Stroke co-ordinators, NNP or HIT team (FPH) may ask each other to see a patient referred however the wards should always contact the correct team for the patient.

3.6 All patients who fail a swallow screen will be referred to speech and language therapy for assessment.

4.1 Verbal explanation will be given to the patient prior to SLT intervention.

4.2 Consent will be obtained verbally if possible, using supported communication as appropriate. If the patient is unable to give consent, the SLT may proceed in their best interests if the patient is compliant and does not seem in any distress.

4.3 If a patient does not consent to SLT intervention, this will be recorded on their records on EPIC and discussed with the MDT. It may be appropriate to return at a later date to attempt further intervention.

5.1 In line with RCSLT guidelines, the SLT will determine if the patient is appropriate to be assessed. Contra-indications, for example, would be if the patient had a low GCS, or were too medically unstable.

5.2 The following areas are recommended to ensure a comprehensive assessment although not all areas may be feasible or appropriate:

• Background information including indicators of pre-existing and/or chronic swallowing difficulty – obtained from patient’s medical notes, patient/carer report and other MDT members;

• Current status – relevant details on recent medical history, respiratory status, cognitive status, communication impairment, level of consciousness, positioning issues, oral hygiene;

• Neurological examination – including cranial nerve function and voluntary reflexes.

5.3 Bolus administration – a risk assessment should be made to determine if it is appropriate to administer a bolus. Clinical judgement should then be used to determine the safest consistency of food/fluid to administer.

5.4 Non-oral feeding – the recommendation for non-oral feeding (temporary or

long term) should be discussed with the medical team as soon as possible.

5.5 Medication – nursing staff should be advised to discuss suitable routes for administration of medication with the medical team and/or ward pharmacist.

5.6 Referral for other investigations - where appropriate, SLTs will recommend referral for further objective/instrumental investigations of dysphagia, for example Videofluroscopy, FEES, Barium swallow, OGD. These will be discussed with the patient’s medical team.

5.7 Specialist assessments, such as cervical auscultation, pulse oximetry, FEES and assessment of a patient with a tracheostomy, will only be undertaken by suitably trained and/or experienced therapists. Relevant training/experience in these areas will be monitored through supervision and individual performance and development reviews.

5.8 The outcome of the assessment will be handed over verbally to a qualified nurse in charge of the patient’s care.

5.9 The outcome of the assessment will be discussed with the patient and/or relative when appropriate.

6.1 Once assessed, the patient review date and plan, e.g., R-D/F P3 (review diet and fluids- priority 3) will be updated on the departmental whiteboard, on the relevant flowsheet and priority column on EPIC. Where appropriate they will be put down for review on a specific day following the initial assessment based on clinical judgement. This board is updated daily.

6.2 Ward staff can request the review of an existing patient by telephone or via the EPIC orders. It is the responsibility of ward staff to inform the SLT team if there is a significant change in the patient’s condition that might affect their dysphagia risk.

6.3 If recommendations change after a review, notices over the patient’s bed, diet order (for food and fluid) and discharge summary on EPIC will be updated to reflect this change and the bedside nurse/ medical team (if indicated) informed.

6.4 The SLT will use clinical judgement to determine whether a full mealtime review is needed to upgrade a patient’s diet, or whether a smaller amount of the appropriate consistency can be used.

6.5 Checks – a ward check will be undertaken if it is necessary to review the patient’s EPIC notes or speak directly to a member of the MDT without the need to see the patient. Other checks will be carried out by telephone.

6.6 Any changes to recommendations made for patients as a result of a review/check, will be communicated verbally to a trained nurse responsible for the patient’s care.

7.1 SLTs may offer the following interventions, where appropriate:

• advice and education;

• recommendations for modifying food / fluid consistencies, with reference to the International Dysphagia Diet Standardisation Initiative (IDDSI) (2016) compensatory strategies;

• environmental modifications to facilitate safe eating and drinking;

• advice regarding adaptive equipment (in liaison with Occupational Therapy, where appropriate);

• advice regarding safe positioning for eating and drinking (in liaison with Physiotherapy, where appropriate);

• education for carers and people involved in assisting patients at mealtimes.

• Onward referrals.

7.2 Where direct swallowing therapy is indicated, the SLT will be fully conversant with the range of therapy approaches available and be clear as to the rationale of the approach adopted. In these instances, a videofluoroscopy should be considered before commencing therapy.

7.3 SLTs may delegate tasks related to dysphagia interventions to other professionals, the patient and/or carer. The decision to delegate must be clinically motivated. Written and verbal instructions will be given. Delegated tasks may include giving food/fluids for trials of oral intake or carrying out oral exercises.

7.4 If a disagreement exists between the multidisciplinary team relating to planned dysphagia intervention, every effort will be made to resolve it through discussion. Where the patient and/or the patient’s medical team choose a course of action contrary to the advice of the SLT, and the SLT believes that such action may cause the patient harm, the SLT will clearly record his/her assessment findings and opinion in writing to his/her manager and the medical practitioner involved and withdraw input.

7.5 In some cases it may be agreed amongst the MDT that a patient should continue to ‘eat and drink at acknowledged risk’ (EDAR) despite a risk of aspiration, e.g., patients with end stage dementia. There is a protocol to guide decision making in these cases which is available on the intranet. In these cases, the SLT team will provide advice on consistencies, positioning etc and will then monitor the patient. Advice will be provided on discharge as appropriate.

8.1 Patients will be discharged from the SLT service when:

• Their symptoms have resolved.

• They have returned to their pre-admission baseline.

• They are not expected to improve further and have a new baseline.

8.2 Patients will be discharged from the SLT caseload when all previous review dates are removed from EPIC flowsheets.

8.3 Once a patient is stable on their current intake and could be safely discharged into the community the SLT will input information into the ‘individual requirements’ section of the discharge summary, tick the ‘SLT readiness’ box by putting ‘yes’ in the ‘discharge from SLT box’ at the end of the flowsheet and take appropriate advice leaflets/information to the ward to go out with the patient.

8.4 Prior to discharge, wards must ensure that patients who require modified food/fluid consistencies have the relevant information with them for ongoing management (available from the speech and language therapy department) as well as an adequate supply of thickener (recommend 2 tubs) until a prescription can be filled for more.

8.5 Any patient being discharged who requires ongoing SLT input for dysphagia management will be referred to the appropriate community SLT service.

9.1 SLT’s will keep comprehensive notes of all contact with patients according to Professional and Trust guidelines. These are completed on the notes section on EPIC.

9.2 A standard flowsheet on EPIC is used to document the results of the initial dysphagia assessment and subsequent reviews.

9.3 A summary of assessment and review, with all relevant information will be documented on the patient’s EPIC notes.

9.4 Any SLT recommendations for the patient will be placed above the patients’ bed using standard information sheets.

9.5 Once a patient is placed on thickener, the therapist will request a prescription via the ‘orders’ tab on EPIC by typing in ‘Resource’. The prescription is available under the ‘after visit’ tab. The SLT will only be able to save the request therefore the smartphrase ‘.doc’ should be added to the recommendations section of the notes to prompt the discharging Doctor to sign the request ahead of discharge.

9.6 A discharge letter outlining recommendations for oral intake will be sent with the patient to the patient/carers/manager of care home and automatically via EPIC to the GP as appropriate.

10.1 If the community SLT team are aware of a patient being admitted to FPH they will inform the inpatient SLT team and handover information on the patient’s recommendations for eating and drinking.

10.2 If a referral is made to the inpatient team the SLT will contact the community team and /or the specialist liaison nurse to gain information about the patient to inform the assessment. Carers should be present where possible. Where appropriate the community SLT may attend an assessment / review on the ward.

10.3 The SLT team will use the information in a patient’s hospital communication book / communication passport where it is available.

10.4 On discharge the inpatient SLT team will liaise further with the community SLT team to highlight changes to recommendations and to refer for follow up as indicated.

10.5 All choking incidents involving people with a learning disability should be reported via the Serious Incident procedure/safeguarding and investigated properly (NPSA guidelines 2007).

11.1 All staff attending will be up to date with mandatory infection control, manual handling and basic life support training.

11.2 All staff will adhere to current infection control policies regarding PPE.

11.3 All food/fluid trials are prepared for single use with disposable utensils.

11.4 Handwashing will be carried out between patients.

International Dysphagia Diet Standardisation Initiative [IDDSI] (2019) The IDDSI framework. Available at: https://iddsi.org/framework/ (Accessed: 12 September 2023)

Department of Health (2009) Reference guide to consent for examination or treatment. 2nd ed. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_103653__1_.pdf (Accessed: 12 September 2023)

Royal College of Speech and Language Therapists [RCSLT] (2014) Dysphagia training and competency framework. Available at: https://www.rcslt.org/wp-content/uploads/media/dysphagia-training-and-competency-framework-2014-pdf.pdf (Accessed: 12 September 2023)

National Institute for Health and Clinical Excellence [NICE] (2016) Stroke in adults. QS2. Available at: https://www.nice.org.uk/guidance/qs2 (Accessed: 12 September 2023)

National Institute for Health and Care Excellence [NICE] (2018) Dementia: assessment, management and support for people living with dementia and their carers. NG97. Available at: https://www.nice.org.uk/guidance/ng97 (Accessed: 12 September 2023)

National Patient Safety Agency [NPSA] (2007) Ensuring safer practice for adults with learning disabilities who have dysphagia. Available at: https://webarchive.nationalarchives.gov.uk/ukgwa/20180501173844/http://www.nrls.npsa.nhs.uk/resources/clinical-specialty/learning-disabilities/?entryid45=59823%26p=2 (Accessed: 12 September 2023)

National Clinical Guideline for Stroke for the UK and Ireland (2023) Intercollegiate Stroke Working Party

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version History

Related Documents

None