Hospital patients with swallowing issues now have a standardized menu
Nobody ever thinks about swallowing until they have trouble doing it, says Robert Melchionna, MS, CCC-SLP, BCS-S, a speech language pathologist at Cape Cod Hospital. Melchionna spends a lot of his time working with people who have swallowing issues (dysphagia), which he said is more common than people realize.
Dysphagia is a difficult diagnosis for patients, especially since food is central to our socializing and so many customs and holidays revolve around food. But a relatively new system that standardizes the texture and consistency of recommended foods is offering hospitals a way to help dysphagia patients eat the nutritious food they need to get better. Called IDDSI (International Dysphagia Diet Standardisation Initiative), it is now part of the menu offering at Cape Cod Hospital in Hyannis and Falmouth Hospital.
The Cape Cod Healthcare speech language pathologists and dietary department have been meeting monthly since September 2021 to transition to IDDSI, Melchionna said. They have been using dual language (both the old verbiage and IDDSI) to help the staff transition. The transfer was complete as of October 17, 2022.
Cape Cod Healthcare’s food service provider, Morrison Healthcare, is very familiar with IDDSI because a lot of other hospitals use it, so the transition has been much easier than expected, involving mostly just a simple change of recipes.
“IDDSI doesn’t give you a list of things (dysphagia patients) can eat,” Melchionna said. “IDDSI tells you how to prepare the food in a way that it meets IDDSI specifications.”
The IDDSI method to test the food couldn’t be simpler. All you need is a fork, a spoon and a syringe, which makes it easy even for elderly patients and caregivers to master. The fork or spoon is used to test how firm or hard a food is by gently pressing down on it. The fork is also used in a drip test to check for correct thickness and cohesiveness and the spoon can be used in a tilt test for the same qualities. The syringe is used in a gravity test to classify drinks based on their rate of flow.
The causes of dysphagia vary and include stroke, Parkinson’s disease, COPD, head and neck cancers, and many other medical conditions. Sometimes Melchionna’s patients are just elderly people who have become so deconditioned they suddenly have trouble swallowing.
He and the other speech pathologists at the hospital work with both inpatients who are hospitalized and outpatients who are referred to them by their primary care doctor. To test swallowing ability, they may do a Modified Barium Swallow (MBS) test. They take an X-ray video of the head and neck while patients swallow barium, which is a thick and chalky substance. They then watch what happens as they swallow.
“Swallowing is a very complicated maneuver,” Mechionna said. “We’re looking at what’s happening with their tongue, with their larynx, if things are going into their airway or not, if things are getting stuck in their throat, if they are having dysphagia, and the MBS can tell us what’s happening and what to do about it.”
The test is quick and easy and Melchionna can tell patients right away what’s going on with their swallowing. He then makes recommendations to outpatient speech pathology so they can do exercises to improve their swallowing. Melchionna also makes recommendations for their diet because oftentimes people with dysphagia benefit from a texture-modified diet to make it easier and safer for them to eat.
“For example, if somebody has trouble swallowing and whenever they drink liquid it goes into their airway, sometimes we can make the drink a little bit thicker and that slows it down and it gives them time to close their airway before something goes in it,” he said.
In the past, the tricky part then became putting a name to the recommended thickness and texture of food and beverages because there was no consistency between different hospitals and nursing homes about what terms speech pathologists used. This is a problem that Melchionna has witnessed first-hand. When he worked at a hospital in Plymouth, there were three nursing homes within walking distance of the hospital, but they all used different terms for something as common for dysphagia patients as a plate of ground chicken, mashed potatoes and diced carrots.
This caused confusion because without a standard universal language it was possible for patients to eat or drink something that might cause problems. Fortunately, the IDDSI diet has cleared up much of this confusion.
The good news is that for many people, the IDDSI diet can be helpful but does not have to be a permanent lifestyle change.
“I worked in rehab for 20 years before I worked in hospitals,” Melchionna said. “I would have people coming in who had feeding tubes and weren’t able to swallow at all and we could get them to the point where they were eating again, and they could remove the feeding tube. People really do get better with therapy.”
