Quick Death, Slow Death, Hopefully No Death

Transcription

1 Quick Death, Slow Death, Hopefully No Death Collaborative presentation on learning from choking and nutrition incidents in RWT. Introduction of IDDSI for food and fluids Why there is an NPSA Alert Safe & Effective Kind & Caring Exceeding Expectation

2 Quick Death Choking in Adults Office for National Statistics data 286 Deaths by choking in this period This is an increase of 17% on the previous 2 years 85 per cent of choking deaths are caused by food. 91 % of the recorded deaths were adults over the age of 45 - despite children being deemed most at risk of choking hazards Increased incidence in men BMJ Pavitt et al 2017 LAS incidents in a calendar year. Highest incidence over 90 yrs. Peak at Sunday lunchtimes, and 19.00hrs on Weds. Most common food related causes of choking?

3 Quick Death B E Aged 92yrs Admitted from nursing home following 7/7 treatment for chest infection.frail with kyphosis, but fully orientated. Later diagnosed with bilateral pleural effusions, viral chest infection, new diagnosis of heart failure, hyponatremia secondary to fluid overload. Managing normal diet softer options, and normal fluids until chest infection During her hospital stay Day 1 and 2 NBM as coughing and choking. IV fluids. Noticed confusion not normal for patient. 3/4 th day. Patient eating and drinking, much more confused,iv fluids stopped

4 B E Aged cont 5th SLT assessed, Rec NBM consider NGT 6/7th Transferred to medical ward. Review swallow after NBM overnight diet and fluid tolerated as swallow no problem 8th SLT reviewed, NBM high risk of aspiration discussed with patient NGT recommended. NG Inserted. 12/13th SLT reviewed reduced cough NBM. NG in situ 15th referred to neurology? Cause for dysphagia. 16th SLT review, started on yoghurt trials,but refuses further investigations. NGT continues. 18th. Need long term feeding plan. SLT review.trials of yoghurt continue. 19th NG pulled out 20(Sun). Pt alert. Encourage oral fluids and thickened diet.nurses assume this is feeding at Risk 21st Bilateral crepitations. Pt needing 6 litreso2 Aspiration pneumonia likely. Sudden deterioration. RIP.

5 B E Aged 92yrs Swallow assessment by SLT: Day 5 unsafe swallow, wet voice, recommended NBM, NGT PT. Day 8 high risk of aspiration, NBM NGT inserted. Day 12/13 trialled with Yoghurt and level 3 fluids. Continues NBM Patient fatigued very quickly. Day 16 assessed swallow weak but improved trials start NGT in situ Day 18 trials continue (no chest deterioration) Management Decisions: Two occasions pt re-started on oral intake ( day3/4, 6/7) Patient tolerated NG feeding day Day 20, Risk feeding decision taken.

6 Learning from RCA for BE Poor communication between MDT which left a decision open to a weekend without MDT involvement. Use of variable terminology to describe appropriate diet and fluid modification Non-availability of Feed at Risk guidelines No clear discussion and documentation of the patient s wishes specifically with regard to long term feeding and risk feeding Actions SLT to escalate to medical team directly following ward reviews when concerns. Implement IDDSI Build on the current dysphagia guidelines- RWT Dysphagia policy in progress Any patient with an NG tube should have an MDT discussion at the earliest opportunity and short/ long term plan documented

7 Slow Death Malnutrition.how long can we last without food? Patients with dysphagia are at increased nutritional risk.

8 Slow Death Around 1 in 3 patients admitted to hospital or who are in care homes are malnourished or at risk of becoming so. NHS England (2015) Telegraph News Record numbers of patients dying malnourished in NHS hospitals with nearly one case a day 351 patients in England and Wales had malnutrition on their death certificate as an underlying cause or contributory factor in 2016 Record numbers of patients are dying malnourished in NHS hospitals, with almost one case a day, new figures show. The figure is 18 % higher than the 297 total recorded the year before and 31 % increase on the 268 figure a decade earlier. Over the past decade, a total of 3,022 people died with malnutrition listed as a factor.

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10 Why are patients with dysphagia at increased nutritional risk? (1) NBM Delays in decisions RE NG feeding Delays in placing an NGT/ confirming position Building up a regime to full requirements may take a few days Frequently pulling out NGTs Pre-existing nutritional issues/ medical conditions

11 Why are patients with dysphagia at increased nutritional risk? (2) Modified texture Anything that restricts menu choice can have impact on nutrition, particularly with fussy eaters Disliked Less appetising/ looks the same Decreased supplement choice/ snack choice Nutritional dilution Larger portion size not always appropriate/ tolerated well, e.g. fatigue/ positioning

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15 Increased risk of dehydration Thickened fluids Disliked ( Gum based more acceptable) Taste change Texture/ appearance Vessel choice (if have to use beaker/ straw/ spoon) Restricted fluid choice if certain fluids not suitable Fatigue/ positioning

16 What can we do? Diet & Food Fortification + Oral Nutritional Supplements + Enteral Feed Nutritional screening is particularly important in this patient group Is there potential for an inpatient to go ~45+ days without nutrition?

17 EM Age 97yrs Admitted with Fractured Neck of Femur Pre-admission frail elder, managing pureed diet and normal drinks; struggled with sticky food During her hospital stay: Given pureed diet and normal fluids. Food charts recorded minimal amount taken (2 5 teaspoons) for 23 days Given mash and gravy NGT / alternative feeding not considered Delayed referral to SLT

18 EM continued Swallow assessment by SLT: Level of risk of aspiration: high with thin and thickened drinks; Low to medium with smooth, non-sticky semi-solid. Patient fatigued very quickly. Management Decisions: Need to consider prior dysphagia Medical condition Quality of life Options: NBM consider NGT to improve nutrition No fluids; Custard / yoghurt small amounts only at a time

19 Outcome: By this stage, MDT and family felt NGT wasn t in patient s best interests, therefore decided to continue with some oral intake no drinks; yoghurt / mousse / pureed diet Patient died 2 days later. EM continued This was considered a slow death for this lady. Perhaps if her nutritional and swallowing needs had been addressed earlier then the outcome could have been different.

20 Learning from EM Inpatient referrals for adult speech and Language Therapy from March 2017 now on Safehands/ teletracking Referral guidelines and care pathway on intranet Updated food and fluid balance charts Raising awareness of new menus on all wards IDDSI training Safe & Effective Kind & Caring Exceeding Expectation

21 Hopefully No Death Patient Safety Alert 27 June 2018 Resources to support safer modification of food and drink Why? The imprecise term soft diet continues to be used with much confusion to refer to the modified food texture required by patients with dysphagia, and others without dysphagia, for example, with lost dentures, jaw surgery, frailty or impulsive eating. National Reporting and Learning System (NRLS) reported 7 instances of significant harm in a 2 year period including 2 deaths; e.g Patient with documented dysphagia given soft diet including mince and peas at lunch unresponsive episode. Difficulty ventilating patient overnight. Peas [suctioned out via] endotracheal tube. Around 270 similar incidents reported no harm or low harm such as coughing or a brief choking episode.

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23 Benefits of IDDSI Evidence Based Includes levels for fluids as well as foods (fluids not included in current UK descriptors) Worldwide consistency improving patient safety All cultures, ages, care settings Consistency with off the shelf products Greater scope for larger scale dysphagia studies Raises the profile of the care of patients with dysphagia. Commercial implications

24 Changes in Description of food and drink from 3/9/18 for patients with Dysphagia CURRENT DESCRIPTION NEW, IDDSI DESCRIPTION STAGE 1 THICKENED DRINK ADD 200mls FLUID TO 2 SCOOPS OF RESOURCE THICKEN UP CLEAR LEVEL 2 THICKENED DRINK ADD 200mls FLUID TO 2 SCOOPS OF RESOURCE THICKEN UP CLEAR STAGE 2 THICKENED DRINK ADD 200mls FLUID TO 4 SCOOPS OF RESOURCE THICKEN UP CLEAR LEVEL 3 THICKENED DRINK ADD 200mls FLUID TO 4 SCOOPS OF RESOURCE THICKEN UP CLEAR THICK PUREED DIET CATEGORY C PUREED DIET LEVEL 4 SOFT, FORK MASHABLE DIET CATEGORY E SOFT AND BITE SIZED LEVEL 6

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27 Bite-sized pieces of 1.5 x 1.5cm for adults (the size of an adult thumbnail), to avoid choking risk. Chewing is necessary. Tongue strength and control are needed to move food around and to swallow. You should be able to easily cut into this texture with just the side of a fork. Press into a piece of food with your thumb in the bowl of a fork so that your thumbnail turns white. The food should squash easily and NOT return to its original shape.

28 Altered texture diets are all Dysphagic diets! Must use levels at all times, ( IDDSI diagram) No longer acceptable to use generic terms such as soft Level 6, or soft and bite sized thickened Level 2 /mildly thick(syrup of tin of peaches) Level 3/ moderately thick(custard consistency) Level 4/ extremely thick = Puree Reflected in above bed signage/ patient leaflets

29 Questions?

30 For more information RWT Intranet- Departments IDDSI Link to Dietetics and Speech and Language Therapy pages Aiming for intranet page ASAP. Go to for: training materials implementation strategy frequently asked questions Go to for: IDDSI framework, resources, open access articles, frequently asked questions References fdeath df