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IDDSI- Implementation from a Global Corporation’s Perspective

Gisele Leger, MS RDN LDN CNSC FAND

Holly Brennan, RDN LDN CNSC

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Disclosures

• None

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The Tale of Two Grilled Cheese Sandwiches

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The Tale of Two Grilled Cheese Sandwiches

•Regular, Pureed, Regular

•Regular•Free text: Moist food, chopped meats

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Introduction

• IDDSI officially launched in October 2012

• Goal: Developing a new global standardized terminology and definition to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and all cultures.

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Project Timeline

• Stage 1—Collaboration and Consolidation (Early to Mid 2013)

• Stage 2—Gathering the Evidence (January 2013–September 2013)

• Stage 3—Interlacing Technical and Research Evidence with Clinical and Cultural Needs (October 2013–January 2014)

• Stage 4—Consolidation and Publication (February 2014–January 2015)

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Current international terminology for thickened liquids

Cichero, J.A.Y. et al. 2013

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Current International Terminology for Texture Modified Foods

Cichero, J.A.Y. et al 2013

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Liquids• Findings:

• Thicker liquids reduced 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 related to clinical outcomes.

36 studies:

- 26 related to function in healthy population

- 10 related to individuals with dysphagia:

- Only one related to infants

- Remainder investigated swallowing difficulties associated with cancer

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Foods• Findings:

• The best available evidence regarding the selection of an optimal food consistency comes from the careful exploration of tolerance for different foods during a comprehensive clinical swallowing assessment.

• Thicker and harder items require greater effort in oral processing and swallowing.

36 studies: - 18 related specifically to food

with 1 article covering both healthy adults and children

- 12 related to healthy adults

- 2 related to healthy children

- 5 related to adults with dysphagia

- 2 neurological conditions

- 2 stroke

- 1 dysphagia following head and neck surgery

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Introducing… The IDDSI Framework

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Copyright: The International Dysphagia Diet Standardisation Initiative 2016@https://iddsi.org/framework/

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Food Testing Methods

• Fork Drip Test• Fork Pressure Test and Spoon Pressure Test• Chopstick Test• Finger Test

http://iddsi.org/framework/food-testing-methods/

Level 5 Minced and Moist– Fork Pressure Test

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Liquid Testing Methods

• Gravity Flow Test• Using a 10ml syringe

http://iddsi.org/framework/drink-testing-methods/

Level 3- Moderately Thick Flow Test

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Drinks labeled as a triangle with the level number

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Modified Textures labeled with an inverted triangle with the level number.

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IDDSI FrameworkCopyright: The International Dysphagia Diet Standardisation Initiative 2016@https://iddsi.org/framework/

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IDDSI Framework : Color Scheme

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Supporters

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Who is Compass Group?

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New Zealand• Contract with ~40 hospitals and long term care facilities

• Partnered with IDDSI NZ national working group since 2017

• First country to implement IDDSI, initially January 2018, the launch date was pushed to December 2018

• Issues with lack of collaboration between industry/clinical/food service.

• Analysis and testing of recipe:• Compliant with Level 4 (Pureed) & Level 5 (Minced and Moist)

• Significant gaps with Level 6 (Soft & Bite Size)

• Lack of training support for food service. Developed their own.

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Directives

• Who’s responsible for the education?

• Assessment/Prescribing IDDSI diet in long term care

• How to evaluate compliance to IDDSI?

• How thick should the sauces/gravies be?

• Will SLT be prescribing both a food and fluid texture? (Will pureed, automatically be prescribed extremely thick fluids)

• Do meals have to be cut into 1.5cm particle size when they leave the kitchen? Or is it appropriate that menu items are fork mashable and can flake into pieces? i.e. plain fish

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Directives

• Cereals on a soft & bite sized diet is complicated by the new standard requiring excess milk to be drained. Obviously we cannot guarantee that this will be carried out on the wards.

• Bananas must be given mashed on a soft & bite sized menu. Obviously they cannot be mashed in the kitchen. Does this mean, for patient safety we take bananas off the soft and bite sized menu?

• Many site i.e. senior living use soft mechanical diet e.g. moist sandwiches, soft fruit etc. Is it required to provide them with Level 6?

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United Kingdom

• British Dietetic Association established a special interest group for IDDSI

• BDA developed resources such as a comparison of UK current texture/fluid modified specifications to IDDSI

• Timeline for implementation is April 2019

• In acute care, testing recipes and creating menus

• In long term care settings, no specific recipe can be provided due to inconsistencies in thickener use. Rely on staff education.

• Request specific cuts…

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Directives

• Does food/drink need to be tested via syringe every time it’s prepared?

• Why not have dual labelling on dysphagia products?

• What happens if the manufacturers have changed to IDDSI but the food provider has not?

• Will care settings in all of the UK nations including England, Wales, Scotland and Northern Ireland have to implement IDDSI?

• (Level 7) Easy to chew is still fairly strict, seems same as level 6 without the particle size restriction. Awaiting clarification from IDDSI.

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Canada

• Communication regarding the required changes in nutrition software and hospital information system is imperative.

• Some sites (LTC) are apprehensive of IDDSI due to volume of staff who will be trained and who will train nursing.

• Need to consider dietitian time to update care plans when switching to IDDSI.

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US: IDDSI Task Force• Creation of a toolkit:

• Adapted implementation timeline • Training materials for several key positions

• Chef• Food service staff• Clinical• Other

• Testing and creating recipes• Metric standards: ruler on cutting board/wound tape +fork• Standardized chart for fluid• Competence assessment

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Grassroots ApproachesWhere do I begin to Implement IDDSI?

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Grassroots Approach: Practical Steps for IDDSI Implementation

• Is this the right time?

• Support

• Prepare yourself:

• Check (and clear the calendar)• Get Informed

• Commit to the project• Be realistic

• Keep an open mind

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IDDSI Implementation Timeline• 12 months to launch

• Six key tasks• Become familiar with IDDSI• Form a team• Develop timeline• Educate everyone• Recipe and menu development• Clinical communication

• Tasks will run at the same time

• Guideline only

• Expect the unexpected

• May take 24 months to implement

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IDDSI Timeline Tool

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Get to know IDDSI.orgTASK ONE

IDDSI Framework Implementation Resources:

E-Bites (newsletters) Timelines

Webinar Events and Recordings Posters

YouTube links Training guides/cards

Global resources/progression Audit Sheets

FAQ Foodservice tools

Initial &Ongoing

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Team IDDSI: Create a TaskforceTASK TWO

AdministrationMD ChampionRegistered Dietitian/Nutritionists (RDNs)Speech Language Pathologists (SLPs)NursingCulinary / FoodserviceInformation Technology (IT)Quality

Initial: 12 months out

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Team IDDSI: Master Task List

• Educate team on IDDSI

• Develop account task list and timeline

• IDDSI Calendar of Events

• Sub Committees• Responsibilities and Focus

• Regular meetings

• Policy and Procedures

Initial & Ongoing

Task Three

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Facility ConsiderationsTask Three

11, 10, 9 months out

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IDDSI is Coming! Spread the Word!• Start with posters: departments, café,

offices, doctors dining room

• Schedule short “learning bursts”

• Education Stations: hands on testing

• Orientation

• Make sure to explain the Why!!• Consistency: Internally and Externally

• Patient safety

• Standardization

Task Four

11 months out & ongoing

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Let’s Get Cooking!

• Recipe testing: current dysphagia menu

• Recipe development and testing

• Map current recipes to IDDSI

• Trial thickeners

• Equipment needs• Robot Coupe• Food Mill• Blixir

Task Five

11 months out & Ongoing

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Additional Considerations

Determine approach to testing foods

Ensure recipe compliance

Recipe Development RDN style!

How will IDDSI roll out?Full forcePilot unitLiquids first

Task Five

10 months out & ongoing

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Notes from the Kitchen

• Practice testing techniques

• Gather plenty of tools:

syringes, rulers, forks, spoons

• Take robust notes

• Take numerous pictures

• Remember temperature

• Experiment with equipment

Task Five

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Focused Education: How to Test

Speech Language Pathologists (SLPs)

Registered Dietitian Nutritionists(RDNs)

Nursing

Food Service Staff

Culinary

Task Five

6 months out & ongoing

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Clinical Communication

• EMR changes

• Nomenclature crosswalk/dual label

• Documentation/Education changes

• Process changes• Where are liquids thickened• IDDSI tray delivery

• Medications/Testing: contrast, elixirs

Task Six

3-6 months out

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Mapping to IDDSI: NDD IDDSI

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Patient Education

• Determine who will educate patients• Facility menus

• Testing at home

• Modified diet restrictions• Supplies (syringes)

Task Six

2-3 months out

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Competency ValidationWho:

Culinary

Food service associatesNursing

SLPs

RDNs

What format?

How oftenInitial

No less than annual

Task Five

1 month and ongoing

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Ready to Launch!

• IT has been tested

• Staff has been educated

• Recipes and menus have been developed

• Auditing processes are in place

• Anticipate questions

• Expect errors

• Anticipate unforeseen situations

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Tips from the Field

Dual Labeling

Alternative languages for training materials

Peer Expert: RDN, SLP, Nursing, Chef

Community Collaboration

Continue Recipe Development

Stay up to date: IDDSI.org, IDDSI app

Administration: keep up dated and engaged

Communication: What’s working, What’s not

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Let’s Talk Syringes…..

• Get the correct one:• 10 ml

• Slip Tip or Luer Lok

• 303134 (Slip Tip)

• Note:• 301604 = 303134 (different pack size)

• Re-sellers (ie Sysco) may still have the 301604 in stock

• Can reuse until the markings rub off

• Wash in warm, soapy water

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The “New” Will Become Routine

• Continue to educate• Orientation

• Learning Blasts• Department meetings

• Continue to monitor• Kitchen

• At bedside• Recipe compliance

• Audit sheets

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Copyrights

• All materials posted on the IDDSI can be used

• The IDDSI logo cannot be downloaded or added for use on any materials

• The images can be used as long as you cite the CreativeCommons BY-SA 4.0 license:Copyright: The International Dysphagia Diet Standardisation Initiative 2016@https://iddsi.org/framework/

• Modification of any of the IDDSI materials and images is discouraged and not recommended

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Looking into the Future

• RDN Opportunities• IDDSI education• IDDSI auditing• Recipe and menu development• Nutrient analysis

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