To improve staff awareness of the identification and management of dysphagia for all clients in Hamilton Hostel over 12 months.

Patients can expect

• all staff to have a greater understanding of signs, symptoms and management of dysphagia
• a more enjoyable meal time environment
• more guidance from staff at meal time

Staff can expect

• meal times to be pleasant, safe and enjoyable for patients
• more confidence to identify and manage choking risks
• the risk of choking to be reduced
• access to in-services from Speech Pathology students on dysphagia in mental health
• access to consultant Speech Pathologist for patient referral and treatment

Literature review

• Increased incidence of dysphagia within the population with mental health disorders. Regan et. al. 2006
• Dysphagia affects an estimated 32% of people with mental illness compared to 6% of the general population. Regan et. al. 2006
• Swallowing problems, choking, aspiration pneumonia and asphyxia have been known to be a symptom among psychiatric patients for a long time. Dziewas et. al. 2007
• Swallowing problems in psychiatric patients may be a result of behavioral patterns, neuroleptic induced movement disorders, paralytic conditions or medical conditions. Bazemore et.al. 1991
• "Fast eating syndrome is the most prevalent type of dysphagia in psychiatric patients, especially those with schizophrenia and bi-polar disorder …" Applebaum et al 1992
  "These patients typically gorge food, take large bites, consume meals rapidly and pocket food in their cheeks" McMannus, 2001
• A study in Victoria, Australia, reviewed deaths from choking over a 6 year period.  Through this review it was found that people who died from choking were over 20 times more likely to have schizophrenia. Ruschena et al 1998
• The risk of death from non-aspiration choking, also known as café-coronary, was 30 times greater in people with schizophrenia than the general population Warner, 2004

Anecdotal evidence

• Self identified knowledge deficit across all disciplines
• There was a lack of identification measures
• Low confidence in interventions
• There was a high degree of concern about choking risks
• Difficulty in accessing patient assessment from Speech Pathologist
• Choking incidents (including 2 fatalities)

Incident Information Management System (IIMS) Report

Review of reported choking incidences at Macquarie Hospital - Sept 2008 to Sept 2009. 8 incidences, including 2 fatalities.

Speech pathology results

Speech Pathologists identified ‘fast eating syndrome’ and related behaviours as the major reason for swallowing difficulties at Macquarie, with 7 of the 8 choking incidents caused by mealtime behaviours, such as:

• eating too fast
• eating excessively large mouthfuls of food
• not chewing food adequately before swallowing

Meal durations were short – average times:

• breakfast 12 minutes
• dinner 9 minutes - Tarban shortest 6.3 minutes

Project interventions

• Nursing developed and implemented mealtime management strategies in Hamilton Hostel
• Speech Pathology consultancy in 3 high risk units:
  • screened all patients using the DADHC nutrition and swallowing checklist
  • assessed all patients and made recommendations for managing swallowing difficulties
  • assessment and screening identified ‘fast eating syndrome’ and related behaviours as the major reason for swallowing difficulties
• Speech pathology student/s from Macquarie University masters Speech Pathology:
  • undertook scoping study in the 3 high risk units
  • developed and ran training for nurses in application of choking risk
• Dietitian with Food Service:
  • reviewed the menu:
    • to comply to new standard for texture modified food and fluids
    • to include texture modified items at all meals and mid-meals as part of the standard menu
  • implemented recommendations from Speech Pathologist
• Occupational Therapy assessments and implementation of requirements for specialised seating position and eating equipment
• Managing choking competence introduced into BLS annual training

Mealtime interventions

• Music – Play at meal time to commence when dining room opens
• Table cloths - Supply tablecloths to place on the tables at lunchtime
• Menu board - Display the daily menu on a whiteboard outside dining room
• Staff sit with patients – Staff engage with patients during meal
• Water Jugs - Place water jugs on each table and encourage patients to sip water prior, during and after their meal
• Tea and Coffee – Provide tea and coffee for patients and staff in the dining room after patients have finished their lunch
• Review meal serving – Open servery when all patients are seated.  Call tables to be served one at a time.  Space serving courses/food items
• Review dining room seating  - Appropriate upright seating for patients while eating/drinking
• Review eating equipment (cutlery and crockery) – Provide aids the assist patients to feed themselves in a safe manner

• Pre survey of staff knowledge, skills and confidence in managing dysphagia
• Pre and post intervention survey of patients and staffs attitude to meal times
• Meal time diary kept of times spent in dining room for lunch time meal

Staff post intervention surveys indicated that:

• they felt less pressured to fulfil their tasks
• the environment was more pleasant for eating lunch
• there were fewer changes they could implement at lunchtime to make it more enjoyable and easier to manage 

Patient post intervention surveys indicated that:

• They felt less rushed to eat their lunch
• The dining room environment was more pleasant
• Lunch time was enjoyable and there was less nursing staff could do to assist

The time taken for lunch increased from 7 to 30 minutes – a 4 fold increase.

• Jan Plain, Dietitian, Co-Project leader
• Anne Storey, Nurse Educator, Co-Project leader
• Jan Delahunty, Director of Patient Services
• Mehmet Kasif, NUM, Hamilton Hostel
• Denise McGarry, Manager, Nurse Education
• Marco Chan, Occupational Therapist, Hamilton Hostel
• Liz Newton

Acknowledgements

• Elsa Bernardi, Medical Director
• Kate Jeffrey, Community Participation Coordinator
• Hamilton Hostel Staff & Patients
• Josephine Craig and Food Services Staff
• John Glen, Pharmacist

• Applebaum K. L., Bazemore, P., Tonkonogy, J., Ananth, R., & Shull, S. ‘Privilege & discharge decisions for psychiatric inpatients with dysphagia.  Hospital and Community Psychiatry, 1992, 43, 1023-1025
• Bazemore, P.H., Tonkonogy, J., Ananth, R., Dysphagia in psychiatric patients: clinical and videofluroscopic study. Dysphagia 1991, 6:2-5
• Corcoran, E., and Walsh, D. Obstructive Asphyxia: A Cause of Excess Mortality in Psychiatric Patients. Irish Journal of Psychological Medicine, 2003, 20(3) : 88-90
• Dziewas, R., Warnecke, T., Schnabel, M., Ritter, M., Nabavi, D.G., Schilling, M., Ringelstein, E.B., & Reker, T. Neuroleptic-induced dysphagia: case report and literature review. Dysphagia, 2007, 22: 63-67
• McMannus, M. Dysphagia in Psychiatric patients” Journal of Psychosocial Nursing, 2001, 39 (2), 24-30
• Muir, N.J. The role of the speech and language therapist in psychiatry. Psychiatric Bulletin 1996, 20: 524 – 526
• Regan, J., Sowman, R., & Walsh, I. Prevalence of dysphagia in acute and community mental health settings. Dysphagia, 2006, 95 – 101
• Ruschena, D. Mullen, P.E., Burgess, P. et al. Sudden death in psychiatric patients. Br J. Psychiatric, 1998; 172: 331- 336
• Warner, J. Risk of choking in mental illness. The Lancet, 2004, 363: 674.
• Whitty, C. & Fannelli, M. Development of a speech pathology service in a mental health facility, 2000
• Kaatzke-McDonald, M. Assessment of swallowing function in clients with mental health. Report to Macquarie Hospital, 2009
• Jenks, K  Dysphagia. In L. W. Pedretti & M. B. Early (Eds.), Occupational Therapy: Practice Skills for Physical Dysfunction, pp. 730-766. Missouri: Mosby, 2001
• Disabled Living Foundation, 2003, Choosing Eating and Drinking equipment

Nurse Educator, Mental Health Drug and Alcohol
Education & Professional Development Unit
Centre for Training and Development, Macquarie Hospital
Northern Sydney Local Health District
Phone: 02 9887 5612