SIPS ProjectStrategy for an IntegratedPreventative pathway for

Swallowing difficulties in Care Homes

Eleanor StoutMary Heritage

Derbyshire Community Health Services NHS Trust

& Pat Betts

Dysphagia: swallowing difficulty

caused by:

• stroke

• progressive neurological conditions

• dementia

Dysphagia in Care Homes – the Quality issues

• Late identification: risks not understood:• Dehydration, weight loss, poor nutrition, chest

infections, pneumonia, increased confusion, choking.

• Distress• Unplanned hospital admission – urgent swallow

assessment.• On discharge – poor transfer of information

Dysphagia in Care Homes – Workforce issues

• SLT - specialist assessment• Dysphagia trained nurses (DTN)• Lack of awareness amongst other staff• Occasionally ‘dysphagia panic’

SIPS project - Aims

• early identification of dysphagia, • prevention of health deterioration, • proactive care planning, • avoidance of hospital admission

Patients with

the most complex

needs access a specialist assessment

Patients with identified symptoms of dysphagia are assessed by a DTN

in their own setting

All residents in care homes are supported by staff that have good nutrition and dysphagia awareness

SIPS project

14 nursing homes and 1 residential home were provided with:– assessment training for DTNs– awareness training for any staff – a named SLT for specialist assessment or

consultation.

Assessment training for DTNs

29

55

18

17

0

10

20

30

40

50

60

70

80

2011 2012

Number of Certificated and Trainee DTNs practising in Derbyshire Care Homes 1st May 2011 / 2012

Trainee DTNs

Certificated DTNs

Awareness training for any staff

• Chart to show increase in scores

0

20

40

60

80

100

120

140

Identifying 5signs of

swallowingdifficulties

Knowing soft isnot blended

Soft is Jacketpotato and fishpaste sandwich

Knowing 8-10recommended

no of drinks

Encouragingperson to holdbeaker/spoon

Bad Strategy touse Spout

Bad Strategy totip head back

Pre Training out of 95

Post Training out of136

SIPS - a named Speech and Language Therapist (SLT) for specialist assessment or consultation

• Direct collaboration DTN and SLT when problem identified

• Support for DTN post training course• Easy access for referral• Identification for urgent assessment

SIPS - Impact on timing of assessment

Number of requests for rapid response SLT assessment

0

1

2

3

4

5

6

7

Baseline Impact

SIPS - Timing of assessment

No residents waiting more than 1 week for assessment

0

2

4

6

8

10

12

14

Baseline Impact

SIPS – impact on admissions

No of hospital SLT episodes for residents with dysphagia from the homes where DTNs were trained

0

10

20

30

40

50

60

01 Jul 2010 - 31 Dec 2010 01 Jul 2011 - 31 Dec 2011

No of hospital SLT episodesrelated to dysphagia inresidents from the Homes withDTNs

SIPS impact of assessments

DTN Assessments

40

1

31

DTN Assessmentsrecommending actions toprevent aspiration

Confirmed avoided admission

DTN assessmentsrecommending actions toimprove quality of life

Patient experience – Mrs S

• Admitted to Care Home from acute hospital

• Progressive physical condition• Fork mashable diet and normal fluids

Patient experience Mrs S

• Grade 3 pressure sores – difficult to position

• Temperature with green sputum (consistent with a chest infection)

• Anxious, with fear of choking

• GP visit - Antibiotics prescribed

• DTN assessment – 24 hr trial before readmission.

Patient Experience Mrs S

DTN: Care Plan:– Syrup thick fluids and soft diet– Family informed ‘Do Not Attempt Resus’.– ‘Right Care’ management plan

Recovery after 3 days of antibiotics

No further chest infections to date

Now enjoying pureed diet and thickened drinks

No referral to SLT.

Impact of DTN roleon Mrs S’ care

Without DTN training:

• Mrs S would have been admitted

• If waited for SLT assessment - ?4 weeks

• Poor quality of life

• Increased distress

• Compromised nutrition, hydration and pressure areas

DTN reflections

• More aware of residents coughing

• More aware of diet, fluids, positioning

• Assessing continually

• Able to sort out problems ‘in house’

• Whole team more aware

• ‘Next day’ assessment

SIPS project – impact summary

• more timely assessment, • positive impacts on well being• up to 50% reduction in hospital admissions

amongst a group of high risk patients

Economic Impact

Cost of training 20 nurses £5,500

If each DTN completes 7 assessments

140 residents will benefit..

If 57% of these have reduced aspiration risk

80 people with reduced risk of aspiration

If 30% of these avoid one admission in Year 1.

Saving 24 hospital admissions is £75,504

2 avoided admissions exceed the cost of

training 20 nurses.

SIPS Next steps

• ‘Partnership with Care Homes’ in CQUIN 12-13 • Business case to extend this project• Learning Beyond Registration funding• Integrated Dysphagia Pathway• a further 180 DTNs to be trained• 2 DTNs per Nursing Home • Build the evidence base re cost benefits

Thank you !

mary.heritage@dchs.nhs.uk