152
JCPSLP
Volume 16, Number 3 2014
Journal of Clinical Practice in Speech-Language Pathology
Clinical insight
Charissa Zaga
(top) and Joanne
Sweeney
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
KEYWORDS
ADVERSE EVENT
AUDIT
MEAL PROVISION
PATIENT SAFETY
TEXTURE
MODIFIED DIET
Reducing error in a
complex system
Texture modified diet and fluid provision
Charissa Zaga and Joanne Sweeney
of dysphagia can lead to significant poor health outcomes
including aspiration, pneumonia, malnutrition, asphyxiation
and death (Langmore et al, 1998; Cichero, 2006). A
common method of management for dysphagia by speech
pathologists is the provision of texture modified diet and
fluids (Garcia, Chambers & Molander, 2005). Cichero (2006)
reports that thickened fluids or altered texture provide
additional cohesion to the bolus, slow oral and pharyngeal
transit and provide greater oropharyngeal control of the
bolus.
Austin Health is a major provider of tertiary health
services and health professional education and research in
the northeast of Melbourne comprising 980 beds across
three sites. At Austin Health, the meal provision system
is complex. Meals are transported across the three sites,
multiple disciplines are involved from the prescription of
diet and fluids to delivery at the patient’s bedside. All meals
are prepared at the Heidelberg Repatriation Hospital (HRH)
in a large food production kitchen. Meals for the Austin
Hospital and HRH are transported to the Austin Hospital
for plating and heating in re-therm trolleys. Meals for Royal
Talbot Rehabilitation Centre (RTRC) are transported directly
to RTRC for heating and serving. Meals for patients at the
Austin Hospital are taken to the ward in the re-therm trolley
and delivered. Meals for HRH are placed in the re-therm
trolley at the Austin Hospital, then loaded onto a truck and
transported back to HRH where the re-therm trolley is
unloaded, taken to the ward and the meals are delivered.
There are two electronic meal-ordering systems: TrakCare
and ChefMax. All ward staff including nurses, dietitians and
speech pathologists order meals via TrakCare. Following
this, menu monitors enter the TrakCare diet code into
ChefMax with the patient’s relevant menu preferences.
ChefMax generates a meal tray slip that is printed for each
patient and placed on the tray where the meal is plated.
There are set meal ordering cut-off times on TrakCare
whereby any diet/fluid changes entered after the cut-off
time will not come into effect. This reflects the timeframe of
the process from when the meal reports and meal tray slips
are printed, plating begins and all plated meals are placed
in the re-therm trolley. At the Austin Hospital, this timeframe
is approximately two hours; however, at HRH this timeframe
is between 5 and 11 hours. Speech pathologists must
communicate all diet/fluid changes verbally to the menu
monitors in cases where delivery of the new diet/fluid would
result in risk to the patient (e.g., patient with worsened
dysphagia requires a more modified diet). This process
aims to ensure the meal that is plated and delivered is safe
as the meal report for plating has already been printed. In
This paper describes how a complex meal
provision system in an acute hospital setting
supports clinical decision-making in
dysphagia management at the ward level.
The aim was to reduce the number of
incorrect texture modified diet and/or fluids
delivered to patients with dysphagia. A
process map of the meal provision system at
The Austin Hospital was revised and an
auditing tool created for the purposes of this
study. This auditing tool comprised nine key
parameters in the meal provision process for
texture modified diet/fluids. An audit was
conducted across eleven acute wards over
three breakfast, lunch and dinner meals over
four non-consecutive days. Following
analysis of the audit, focus groups were held
with seven speech pathologists, four nurse
unit managers and the food services
coordinators. Audit results, barriers to
achieving higher accuracy across auditing
parameters and areas for intervention were
discussed in these groups. Intervention was
three-fold: targeting safe swallowing bed-
signs, and supervision of the plating line and
in the re-therm trolley room. Three and a half
months after the first audit and
implementation of the interventions, a
subsequent audit was conducted on six acute
wards over two breakfast and lunch meals on
two consecutive days. Overall reductions in
the number of delivered meals of incorrect
texture were noted between the initial audit
and the subsequent audit results.
D
ysphagia is associated with many different etiologies
across the lifespan, including but not limited
to neurological conditions, trauma, respiratory
disorders, psychiatric conditions and effects from
polypharmacy (Cichero, 2006). The estimated prevalence
of dysphagia varies depending on the classification of the
medical condition. Consequences of unmanaged cases
