Dysphagia/ Swallowing

Background

Evidence suggests 30-40% of patients with a neck of femur fracture (NOF#) develop oropharyngeal dysphagia (OPD) during the perioperative period.1-2 Our data, collected over two months, shows our Speech and Language Therapy Team (SLT) identified only 12% of cases. Given the importance of nutrition and medication in the perioperative period, early identification of OPD is critical. We launched a new dysphagia screening tool for all patients admitted to our hospital with a NOF#.

Methods

A retrospective review of patient notes allowed collection of data regarding age, hip injury, frailty score, comorbidities, and staff compliance with tool. Patients with a completed screening tool had outcomes recorded (low, medium, high risk), timeliness of referral to SLT if appropriate, and if OPD was present on assessment. Balancing measures included length of time kept nil by mouth. We completed four PDSA cycles over 5 months.

Results

During this period, 157 patients were admitted with a NOF# and 58 had a completed screening tool. By producing a training pack and expanding into the emergency department, compliance improved by 33% over the 4 cycles. 19 of the 58 patients with a completed screening tool had OPD; 79% had mild, 14% moderate and 7% severe. The screen was adjusted during each cycle improving the suitability of SLT referrals from a 25% identification rate in cycle 1 to 100% in cycle 4. No patients were kept nil by mouth.

Conclusions

The screening tool has increased OPD identification by 21%. However, this requires staff training and high compliance rates to be effective. Next steps include adding the tool to the NOF# proforma, creating a training pack for the wider MDT, and improving the specificity of the tool.

References

1. Love et al. Age and Ageing, 2013. 42(6):782-5. 2. Mateos-Nozal J et al. Age and Ageing, 2021. 28;50(4):1416-1421.

Between 2016 and 2021, HSC Trust reported 1,383 choking-related adverse incidents, highlighting a pressing concern for patient safety. This Quality Improvement (QI) Initiative was developed within a Nursing Home specializing in caring for residents with learning disabilities who faced an elevated risk of eating and drinking difficulties. The primary objective was to enhance safety during meal times by integrating a structured safety pause, aligned with the "7 Rights" framework. The initiative leveraged various QI tools, including process mapping, PDSA (Plan-Do-Study-Act) cycles, structured observations, and interviews.

Results of the initiative demonstrated a notable increase in patient satisfaction, a boost in staff confidence, and a reduction in near-miss incidents. The success of the program prompted its expansion to other nursing homes, involving families in the process. To further support patient safety, each staff member and family member now possesses a small card outlining the "7 Rights," which can be readily utilized before assisting patients with eating and drinking difficulties. This initiative represents a valuable step forward in safeguarding vulnerable individuals and has the potential to positively impact patient care across various healthcare settings.