All matters IDDSI Dr Elizabeth Boaden Fellow of the Royal College of Speech and Language Therapists Senior Research Fellow University of Central Lancashire

The problem Dysphagia is estimated to affect 8% of the population. 580 million people worldwide / 5.2 million people UK Difficulty with: sucking chewing swallowing food, drinks, medication saliva management airway protection Common management approach texture modified food and drink Confusion and miscommunication regarding diet textures and drink consistencies has resulted in increased risk of poor outcome and death.

The history….. 2013 - IDDSI committee established 2015 - Published 2015 onwards - Implementation

The names, the number of levels of modification characteristics vary within and across countries. Multiple labels increase the risk to patient safety. National standardization of terminology and definitions has been promoted as a means to improve patient safety and inter-professional communication. This article documents the need for international standardized terminology and definitions for texture-modified foods and liquids for individuals with dysphagia. 

systematic review - impact of liquid consistency and food texture on swallowing behavior. search yielded 10,147 non-duplicate articles, which were screened for relevance. full-text reviews for 488 of these articles, which met the study inclusion criteria. 36 articles were found to contain specific information comparing oral processing or swallowing behaviors for at least two liquid consistencies or food textures. Qualitative analysis revealed two key trends with respect to the impact of thickening liquids on swallowing: thicker liquids reduce the risk of penetration–aspiration, but also increase the risk of post-swallow residue in the pharynx. The literature was insufficient to support the delineation of specific viscosity boundaries With respect to food texture, the literature pointed to properties of: hardness, cohesiveness, and slipperiness as being relevant for physiological behaviors and bolus flow patterns.

1. A multi-professional volunteer committee developed 2. Undertook a systematic review 3. Stakeholder consultation. 4. Survey of existing national terminologies and current practice 2050 responses 33 countries Results: Common use of 3–4 levels of food texture (54 different names) ≥3 levels of liquid thickness (27 different names). systematic review regarding the impact of food texture and liquid consistency on swallowing was completed. developed a draft framework. A further international stakeholder survey 3190 responses 57 countries.

Main Outcome Measures Consensual validity criterion validity interrater reliability Results The International Dysphagia Diet Standardisation Initiative Functional Diet Scale showed strong consensual validity, criterion validity, and interrater reliability. The International Dysphagia Diet Standardisation Initiative Functional Diet Scale showed greater sensitivity than the FOIS to specific changes in diet. Most (>70%) respondents indicated enthusiasm for implementing the International Dysphagia Diet Standardisation Initiative Functional Diet Scale. Conclusions IDDSI Functional Diet Scale has strong consensual and criterion validity and can be used reliably by clinicians to capture diet texture restriction and progression in people with dysphagia.

International Dysphagia Diet Standardisation Initiative Published in November 2015. It consists of a continuum of 8 levels (0-7) Global standardised framework Provides terminology and definitions for texture modified foods and thickened liquids Colour-coded model Uses culturally neutral terminology Includes descriptors, testing methods and evidence for both drink thickness and food texture levels The International Dysphagia Diet Standardisation Initiative (IDDSI) was founded with the goal of developing globally standardized terminology and definitions for texture-modified foods and liquids applicable to individuals with dysphagia of all ages, in all care settings, and all cultures. The IDDSI Framework (released in November, 2015) involves a continuum of 8 levels (0–7) identified by numbers, text labels, colour codes, definitions, and measurement methods.

International Adoption Adopted New Zealand - January 2018 Canada - January 2019 UK - April 2019 Australia - May 2019 USA - Voted to adopt IDDSI Translated Brazil, France, Germany, Japan, Netherlands, Norway, Poland, Sweden, South Africa, Thailand. Review Belgium, China, Denmark, Slovenia, Turkey.

BJNN/Stroke Association supplement April/May 2017

UK vs IDDSI There are differences in the textures between the two frameworks that can be obtained at www.iddsi.org

Tests Flow test (levels 0-4) Fork drip test (level 3 drips slowly dollops/strands) Fork drip test (level 4 small amount may form a tail below a fork) Spoon tilt test (level 4 holds shape, not sticky, little left on spoon) Fork particle test (level 5 lump sits between fork prong (4mm adults/2mm paediatrics) Fork pressure test (nail blanches 17kPa) The pressure applied to the thumb mail blanch has been measured to about 17kPa. This pressure is consistent with tongue force used during swallowing (Steele et al., 2014)

Flow Test There is variation in syringes. You should use syringes where the length from the zero line to the 10 mL line on the syringe measures 61.5mm. 1. Remove the plunger from the syringe. 2. Place 10ml in a syringe with your finger covering the end to stop liquids leaving the syringe 3. Time 10 seconds whilst removing your finger from the end of the syringe. 4. Note the amount of fluid remaining in the syringe after 10 seconds. 5. The amount left in the syringe corresponds with the thickness on the IDDSI flow test e.g. if 2ml are in the syringe, the thickness will be 1 – slightly thick. If 7ml are left in the syringe, the thickness will be 3 – moderately thick. Geometry allows for both shear and elongation that closely matches flow conditions within the oral cavity 10ml water will exit the syringe in 7 secs

Flow Test

UK Professional Adoption IDDSI framework was adopted in September 2017 by the

UK External Reference Group Membership IDDSI International Steering Group NHSImprovement RCSLT BDA (England, Scotland, Northern Ireland & Wales) Nursing Hospital Catering Membership Organisation Nursing Home Catering Membership Organisation Manufacturer Membership Organisation Catering Organisations Manufacturers

IDDSI Expert Reference Group: Activity Time line 2015 – now! 2015-6 From November 2015 Nov 2015: NHS England established External Reference Group Feb 2016: RCSLT and BDA Expert Reference group May 2016: RCSLT and BDA External Reference Group Oct 2016: Pilot sites Oct 2016: SWOT analysis 2017 From October 2017 May 2017: RCSLT and BDA membership surveys Sept 2017: RCSLT and BDA support the recommendation to adopt the IDDSI framework Sept 2017: Implementation time frame agreed and communicated to all national stakeholders e.g. charities, manufacturers, professional associations Oct-Dec 2017: An ‘Implementation toolkit’ and resources developed IDDSI compliant labels, foods and products being developed by product manufacturers and caterers 2018 April 2018 – April 2019 Communicate IDDSI adoption to all national stakeholders e.g. charities, manufacturers, professional associations Jan 2018: IDDSI Implementation Checklist and resources available on BDA and RCSLT website April 2018: Healthcare professionals plan and lead local implementation April 2018: IDDSI compliant products, foods and labels start to become available April 2019: All manufacturers and health care settings are fully IDDSI compliant

IDDSI Implementation Plan was disseminated to: RCSLT BDA RCN RCP RCGP Universities Patients Association National Nurses Nutrition Group NHS Supply Chain PRESQuip CQC AHP Leads in Wales, Scotland and N. Ireland PINNT BAPEN BUPA Barchester Malnutrition Task Force Four Seasons Carers UK Suzanne Rastrick (NHS England) Jo Fillingham (NHSI)

IDDSI Issues log: Concerns regarding training materials and resources required Lack of coordinated approach locally to support implementation Concerns about care homes – staff confusion and risk to patients Concerns for patients in their own homes who may not understand the changes and therefore are at risk The inability to map across form UK National Descriptors to IDDSI framework Inability to access correct equipment i.e. forks Inability to access correct syringes i.e. not available in some hospitals The different approaches by manufacturers – introduction of new labels at different times Manufacturers issuing advice to SLTs to reassess all patients Concerns that the levels don’t fit the patients Concerns from the devolved nations  

Resources

Resources to support safer modification of food and drink (27 June 2018) NHS/PSA/RE/2018/004 Local variations have persisted for both food and fluid texture, confusing patients, carers and healthcare staff The imprecise term ‘soft diet’ continues to be used to refer to the modified food texture required by patients with dysphagia, for example, with lost dentures, jaw surgery, frailty or impulsive eating. A review of the National Reporting and Learning System over a 2 year period identified 7 reports of significant harm because of confusion about the meaning of the term ‘soft diet’. These incidents included choking requiring an emergency team response and aspiration pneumonia (2 patients died)

Resources to support safer modification of food and drink (27 June 2018) NHS/PSA/RE/2018/004 270 similar incidents reported no harm or low harm such as coughing or a brief choking episode. For practical reasons and to reduce the risk of errors, IDDSI food texture descriptors also need to be adopted for patients who do not have dysphagia but for other clinical reasons need a modified texture diet equivalent to IDDSI levels 6 to 4 (usually in the short term) This alert serves to assist with transition to the IDDSI framework and eliminate use of imprecise terminology, including ‘soft diet’ for all patients

Mind the gap! IDDSI Survey (Closed in September 2017) Results of the survey state that a recognised foods that are Easy to Chew Unsure how this will be reflected in the framework No extra level

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