1. First Line Formulary and IDDSI
Presentation to Care Home Managers
Janet Huddleston
Clinical Team Leader, Adult Community Speech and Language Therapy Team
Holly Atkinson, Speech and Language Therapy Assistant

2. First Line Formulary changes for fluid thickeners
What is the First Line Formulary?
This is the Formulary used by Lancashire Care NHS Foundation Trust to recommend the first line choice of thickener to be prescribed by GPs across the trust’s footprint in Greater Preston, Chorley and South Ribble.
Why Change?
Thickeners are used to thicken fluids and foods to help people with dysphagia (swallowing difficulties).
Thickeners are recommended by Speech and Language Therapists following patient assessment. Some thickeners are starch based and some are xanthan gum based. In our area we are now recommending the use of a xanthan gum based thickener.
Thickeners slow the movement of the food through the mouth and throat. This can prevent foods and fluids going into the lungs and causing chest infections and choking.

3. First Line Formulary changes
Which Thickener?
After a lengthy process Thick and Easy Clear has been chosen as the first choice thickener for most patients in Lancashire NHS Trust.
It is the most cost effective and more palatable for patients. It does not thin in the mouth or thicken when standing.
If only one thickener is used throughout the area care homes will find it easier to use and fewer errors will be made.
Training for staff in care homes on how to mix Thick and Easy Clear will be available from the company who makes the product.

4. Thickeners

5. How to mix drinks with Thick and Easy Clear
Practical Session:
Using the Thick and Easy Clear provided get into pairs and mix:
Stage 1 fluids according to the instructions.
Now taste……

6. Fluid Consistency
The amount of thickener needed will vary depending on how much the person drinks in a day and the consistency required e.g:
Stage 1 Coats a spoon and pours like single cream
Stage 2 Can be sipped from a cup but not through a straw
Stage 3 Needs to be taken with a spoon

7. Fluid Consistency
Amount required to thicken 200ml fluid:
Stage 1 = 2 scoops
Stage 2 = 4 scoops
Stage 3 = 6 scoops

8. Fluid Consistency Monthly prescription amounts:
Patient drinking 1500ml a day will need the following number of tubs ordering per month:
Stage 1 = 5 tubs
Stage 2 = 9
Stage 3 = 14
Check stocks before ordering to reduce overstocking and waste. Only use the tub prescribed for the named person.

9. Fluid Consistency
More information about using, monitoring, recording, storage and thickening medications has been sent via the Care Homes Newsletter from the Medicines Optimisation Team
Training for care home staff will be available from Fresenius Kabi who make the product.
They will be able to offer a small supply of thickener to the patient between SLT assessment and GP prescription.

10. IDDSI – new international descriptors
IDDSI- International Dysphagia Diet Standardisation Initiative.
This is an international initiative to standardise all the terminology and descriptors of diet and fluids used in dysphagia (swallowing) assessments. It will be used across several countries throughout the world.
SLT and Dietetic teams in your area are working to adopt the new descriptors over the coming year. The deadline for adoption is April 2019.
We are locally trying to establish our own timeline within the next 12 months to introduce these descriptors.

11. IDDSI – new international descriptors
This is the new ‘triangle’ system for the new descriptors which shows the transition between fluid and food textures.

12. IDDSI – new international descriptors
The new descriptors mean that there is a new fluid descriptor – Stage 1 will be the equivalent of a ‘slightly thick’ drink.
Stage 1 will become Stage 2 and so on.
The food descriptors will have numbers not letters.
Do not introduce these descriptors to staff until everything is in place locally.
Provide large copy of the IDDSI guidelines for the managers. This is just for awareness.
Stage 1 will be thinner than the current Stage 1

13. IDDSI – new international descriptors
Introduction of the new descriptors will involve:
Training for care and nursing home staff.
Changes to SLT and dietetic guidelines and recommendations paperwork.
Instructions on tins of fluid thickener to provide new IDDSI descriptors.
SLT and Dietetic teams will work with Fresenius Kabi to liaise with them about the timing of changing the labels on the tins locally so that it is done in conjunction with staff training in the area.
SLT and Dietetic working party is already meeting to check that all changes are being implemented to prevent risk to patient safety. All the companies who make fluid thickener are aware of the changes and are working with local teams to ensure smooth transition to the new descriptors.

14. IDDSI – new international descriptors
We are also working with the local CCGs and Medicines Management teams to make them aware of the changes as they arise.
Any questions?? Further training can be arranged if felt needed. Would need to include catering staff, chefs etc.
How do you record ‘near misses’ – this may be required in light of IDDSI implementation risks.
Further information:
Royal College of Speech and Language Therapy website: rcslt.org
British Dietetics Association website: