|
Article Excerpt
Abstract
Thickened fluids and texture-modified foods are provided for the therapeutic treatment of dysphagia. Review of the literature indicated that numerous labels are applied to a small number of food textures and fluid thickness levels. The consequences of inconsistent terminology affect patient safety and the efficiency of communication. A joint project of the Dietitians Association of Australia and The Speech Pathology Association of Australia Limited (Speech Pathology Australia) was undertaken to develop consensus standards for number of levels, labels and definitions of thickened fluids and texture-modified foods within the Australian context. A project officer and multidisciplinary advisory committee were appointed by competitive process to carry out and oversee the project. The project determined that there were 39 different labels in use for thickened fluids and 95 different labels in use for texture-modified foods used in Australia. Dietitians and speech pathologists demonstrated overwhelming support for a standardised labelling and terminology system (99.2% of respondents). A national consultative process encompassing the views of more than 580 clinicians helped to formulate the final standards. A scale for modified fluids and a scale for texture-modified foods were developed and consensus was achieved between the Dietitians Association of Australia and Speech Pathology Australia. The standards are now recommended for use throughout Australia.
Key words: dysphagia diet, food and fluid standards, standardised diet, thickened fluid.
INTRODUCTION
Texture modification of foods and thickening of fluid forms a routine part of the assessment and treatment of swallowing difficulties (dysphagia). (1-6) Dysphagia contributes to reduced dietary intake, and potentially malnutrition, aspiration and asphyxiation. (7,8) Regular fluids require excellent muscle control and accurate timing between the swallowing system and the breathing system. Thickened fluids slow the act of swallowing and by doing so, enhance safe swallowing. (9) Modified diets use alterations to food texture to reduce the need to chew or orally prepare food. (10) When an individual has dysphagia, there is a breakdown in the swallowing process that can result in food or fluids entering the lungs (aspiration). If enough food or fluid is aspirated, severe infections such as aspiration pneumonia may develop leading to hospitalisation and even death. Consequently, thickened fluids and texture-modified foods is rarely a diet of choice, but a diet of necessity if an individual is to maintain their nutritional needs orally.
The provision of texture-modified foods and fluids is a prescription for individuals with dysphagia. By determining the cause and severity of the dysphagia, health professionals can determine the food texture and fluid thickness safest for an individual to swallow. If the prescription is not followed, the individual may face serious health consequences. Inconsistency in the labelling and definitions of foods and fluids adds an unnecessary and potentially dangerous layer of confusion. Confusion regarding food textures and labels was formally recorded as a contributing factor in the coroner's notes into the death of a South Australian nursing home resident. (11) To reduce the likelihood of adverse events, professional consensus on language for texture-modified foods and fluids is needed.
A lack of standard labels and definitions has a number of implications aside from patient safety. Comparison of research studies is difficult because of the lack of a common language for texture-modified foods and fluids. Research into the role of texture-modified foods and fluids in dysphagia management is an area needing greater focus to promote evidence-based practice. It is anticipated that national consensus on standardised terminology will provide a direct benefit to research in this area.
Standardisation of food and fluid terminology will also facilitate product development from the commercial sector. In Australia, there are four commercial companies that currently supply pre-packaged thickened fluids. There is variability in the number of fluid thickness levels offered between the companies. Clear descriptions of different levels of fluid thickness and their labels will improve communication between commercial, consumer and professional sectors. Although there are some similarities in the names chosen for each level of thickness, there are also differences between companies. Companies who supply 'shelf ready' thick fluids will have greater confidence in developing product ranges if institutions across Australia are using a consistent language. A common language will also reduce errors in product selection in hospitals and at home. Standardisation will ensure that individuals with dysphagia have consistent access to the food and fluid textures that are safest for them.
Global variability in the names provided for texture-modified foods and thickened fluids is well noted in the literature. (10) An American task force identified 40 different names used to label solid food and 18 different names to describe thickened fluids. (12) An Australian study from the city of Brisbane (population 1.6 million) found there to be 12 different names for three different levels of fluid thickness sampled from only 10 major hospitals. (13,14)
Penman and Thomson conducted a detailed review of terminology, definitions and levels of dysphagia diets for the period 1981-1996. (10) They, and others, found there were wide variations in the degree of modification and numerous descriptions of textures. (1,10) Texture-modified diets typically ranged from two to five categories of altered food consistency. (10,15) There were typically three levels of fluid thickness. The most commonly described model of progression for food and fluid texture modification is noted in Tables 1 and 2.
The Australian Dysphagia Working Party was convened in 2003. It is a voluntary multidisciplinary leadership group with representation from speech pathology, dietetics, medicine, nursing, food services and industry. One of the aims of the group was to review current dysphagia management practices. Issues surrounding inconsistency in labelling and definitions for texture-modified foods and fluids in Australia were identified as a key area in need of resolution. The working party commenced work towards national standards but it became clear that the process would be better managed as a more formalised project by relevant Associations. The Dietitians Association of Australia and Speech Pathology Australia agreed to manage the project and develop consensus standards. An initial project plan was proposed and funding was provided by a company with commercial interest in production of texture-modified fluids to support the process.
Time and resource limitations restricted the scope of this project. The project was not intended to address the nutritional adequacy nor patient acceptability of texture-modified foods or fluids. Objective measurement of thickened fluid is a complex and multifactorial task. (5,16-23) Thus, it was not considered within the scope of the study to address objective measurement issues in relation to the definitions. Finally, the project was not intended to develop evidence-based practice guidelines.
The specific aims of the project were to, in an Australian context:
1 Determine the number of food texture levels to be used in a standardised scale.
2 Determine the number of fluid levels to be used in a standardised scale.
3 Determine standard names/identifiers for each food and fluid level.
4 Identify examples of foods appropriate for each food texture level.
5 Gain consensus from Dietitians Association of Australia and Speech Pathology Australia membership and other key stakeholders regarding points 1-4.
6 Commence communication of the new standards to stakeholders and commence education of speech pathologists and dietitians.
METHODS
The project commenced with a development of a Memorandum of Understanding between the Dietitians Association of Australia and Speech Pathology Australia. The Associations jointly developed a final project plan. A project officer and advisory committee were appointed after calling for expression of interest. The project officer had a professional qualification in speech pathology, a doctoral degree in dysphagia and had published nationally and internationally in the area of viscosity and thickened fluids. The advisory committee comprised individuals with professional qualifications in dietetics (x2), speech pathology (x2), nursing (x1) and food services (x2). The project was overseen by professional officers from the Dietitians Association of Australia and Speech Pathology Australia, reporting to the Board of the Dietitians Association of Australia and the Speech Pathology Australia Council.
Ethical issues were considered by the professional officers. It was determined that participation in the project would be voluntary, the purpose of the project would be communicated at the time of requesting participation and individuals or organisations providing information for the use of the project would not be identifiable in reports arising from the project. The funding organisation was not to be involved in the design of the project, its conduct or the writing and interpretation of the results. A summary of the results of the project would be made easily accessible to participants in the project.
Communication between the officers of the Associations, the project officer and the advisory committee was via regular teleconferences. The project officer position was paid, while the advisory committee provided honorary support. The project commenced in June 2006, with a six-month time frame for completion.
Key project stakeholders were: Dietitians Association of Australia and Speech Pathology Australia, speech pathologists, dietitians, consumers, industry (i.e. commercial companies that provide thickened fluids), non-government and community-based organisations, food service staff, food service professional bodies, and training institutions for speech pathology and dietetics. The training institutions were identified as stakeholders because they would provide an avenue for education of the new standards to new professionals. A dedicated website for the project was constructed as a conduit of information accessible by any person with an interest in the area.
A series of six steps were identified to meet the aims of the project. These steps are presented below.
Step 1 -- Literature review
Step 1 involved collation of any existing Australian scales, investigation of current international scales and a review of the literature pertaining to texture-modified foods and thickened fluids. The literature review sought to identify any evidence for the number of levels of food modification or fluid thickness. In addition, evidence was sought for recommendations regarding food particle size and rationale for inclusion or exclusion of identified contentious food or fluid items (e.g. bread). An extensive literature search was conducted. The Medline, Cinahl, Web of Science and Cochrane Library databases were searched. The following search terms were used for food texture modification used with individuals with dysphagia: 'deglutition disorders + food', 'dysphagia diet and deglutition', 'dysphagia diet', 'dysphagia and foods' and 'texture modification'. The search terms for thickened fluids were: 'viscosity and deglutition disorders', 'viscosity and thick fluids', 'dysphagia and fluids', 'thick fluids' and 'dysphagia and viscosity'.
Step 2 -- Survey of key stakeholders
A survey of key stakeholders, as identified earlier, was undertaken to determine support for national standardisation and to provide preliminary benchmarking for the number of food and fluid levels required for the final scales. Speech pathologists and dietitians were identified as one of the largest stakeholder groups for the project and a critical group to ensure the implementation of standards. A questionnaire was devised in consultation with the advisory committee. The questionnaire was available online via a dedicated website for the project for a three-week period. The online survey was publicised to members of...
|
