Texture and consistency - in practice

A ski bar, Austria, February 2011

I left you in a quandary: we need to supplement the diet of patients on texture-modified diets, but we don't have texture-modified supplements...

So what do we do? Up to now, working on the stroke ward as a newly qualified Dietitian with zero prior experience, I have done what others have shown me and what I can cobble together from resources lying around. For Texture C and Stage 2 fluids we have a 'pudding' consistency supplement and thick yogurts, as well as the puree menu itself and a powder thickener for drinks. For Stage 1 fluids I have been offering a standard concentrated supplement, which may or may not be acceptable but one of the senior Dietitians uses it in the community so that's good enough for me. We also have milkshakes and soups made up from powder that can simply have less liquid added to make them thicker.

The new Dietitian who joined us last week has some previous experience, and has been asking some very interesting questions, mostly along the lines of "...and why do you do it this way?" My somewhat lame answer has been along the lines of "...because that's how I was shown, and I'm only three and a half months old, and I've had your ward and four other wards to cover so limited time to spend thinking about other ways to do it."

So far she has questioned the way that we start new enteral feeds, the way that blood tests are ordered, and now, the range of supplements that we can offer to patients on texture-modified diets. We did a small experiment, mixing two together to try and achieve an intermediate texture, which I promptly poured down my front in a particularly inept tasting session. But that is beside the point - it looks as though some fresh eyes are going to come up with useful tools for the rest of us to adopt. I've already changed the way I start enteral feeds and order blood tests following her suggestions, so I look forward to a Stage 1 thickened fluid supplement option very soon.

Our newest Dietitian is also going to liaise with the SLT team about other aspects of our collaborative working. Exactly how thick should Stage 1 and Stage 2 fluids be? How much fluid should be added to a soup or shake to make it the right consistency? And I'd like her to talk to the SLTs about the 'Texture E' Fork Mashable menu, which is relatively new, and is currently in a different format compared with the other 'special' menu options. The Texture E food is apparently also more expensive to produce, and there are more appetising choices, which means that the kitchen has restricted this menu to patients who have specifically been put on it by a Speech and Language Therapist.

Introducing a new menu within a hospital is no mean feat, mainly because the hospital is a 24/7 full-time operation, but the staff within it obviously don't work 24 hours a day. So you have to roll out any changes multiple times in order to catch those on different shifts or who are on holiday. Done incompletely, there is nothing but confusion, as some ward staff are aware of the change while some are not. And as time goes by, even those who used to know what was going on become unsure of themselves or forget completely what they were shown.

The Texture E menu is an example of this situation. The SLTs who assess patients' swallow have a special sign that they put up over a patient's bed if texture modification is required, and the sign clearly indicates 'Texture E Fork Mashable' among the options. In the medical notes and when talking to nurses, however, they are less consistent, recording for the same patient that 'soft' or 'soft, moist' food is indicated. The nursing staff and Health Care Assistants, who are used to people needing soft options, often offer the same soft meals for these patients as they would for those without good teeth, from the normal menu.

This is the situation I encountered as a new Dietitian on the ward, and to start with, I didn't realise what was going on - I read the notes more often than I look on the wall above the patients, and didn't notice that these 'soft' recommendations actually meant Texture E. Since it became clear (which happened with the help of the more experienced Dietetic Assistant who worked out what was going on) we have been trying to work out how best to make the ward staff aware of the situation and get them to use the correct menu, without having the resources that were available when the new menu was introduced hospital-wide. Our tactic has mostly consisted of keeping an eye out for people being put on the Texture E menu, and providing multiple copies of the menu to the nurses at that point, while making sure that as many people as possible are told about the Texture E menu option, including the patient. Ideally, I'd like to see the SLTs use the same terminology throughout - in the notes, on their notice and when talking to the nursing staff, but it's not up to me.

The last hurdle is on discharge, if someone is still on puree or Texture E food when they go home, especially if they aren't going to a nursing or residential home. The SLTs have a team providing follow-up in the community, but we don't have any Community Dietitians for this sort of follow-up. We rely on providing written information. a telephone follow-up and/or inviting the patient back for an outpatient appointment. If they aren't able to manage any of these, which is going to be those patients in the most difficult circumstances, then all we can do is let the GP know, and hope for the best.

Texture and consistency - the theory

Norfolk, July 2011

The hospital job that I do involves quite a lot of consideration of texture modification, of both food and drink. This is due to many reasons - poor dentition and dysfunctional swallow being the main ones. Hospital food is obviously not a gourmet delight, and you would be crazy to expect a rare steak (we can't even offer runny egg yolk), but without proper teeth it can be tricky to get through even the softest cut of meat. So there are a lot of soft and wet options on the menu, using minced meat, fish in sauce and stews as well as baked potatoes and sandwiches.

Sometimes the process of swallowing is damaged, either by a stroke or a neurological condition like Parkinsons Disease, Motor Neurone Disease or Multiple Sclerosis, or surgically due to something like head and neck cancer. We learned quite early on in my course that 'Swallowing is the most complex reflex in the body, employs about 25 separate muscles, and once initiated it cannot be stopped.' If any part of the reflex is damaged, whether by a brain injury or surgery to tissue and muscles in the mouth or neck, there is a risk that the swallow will fail, and food will either remain in the mouth, or pass into the lungs (called 'aspiration').

Speech and Language Therapists (SLTs) not only deal with communication in these patients, but are also in charge of the pathway from the mouth to the stomach, which is not reflected in their professional title. Maybe one day they will become Speech, Language and Swallow Therapists. Anyway, they are the ones who investigate and assess the risk of aspiration, using sips of fluid and bites of food, cameras put down the throat (FEES = Fibre-optic Endoscopic Examination of Swallow) and videofluoroscopy using barium drinks, where the internal process of swallowing and route of a liquid can be watched 'live' from various angles.

The treatment they have at their disposal includes both exercise (if the problem is muscular or neurological) and texture modification of food and fluids. Fluid is easier to control in the mouth and to swallow when it is thickened, and presents a lower risk of aspiration. Similarly, removing the lumps from food and reducing it to a puree consistency can reduce the risk of choking. It is not an exact science, and sometimes things 'go down the wrong way.' For many patients, this would provoke a fit of coughing, alerting onlookers that something is wrong. Some do not cough, however, and this 'silent aspiration' manifests itself as a wet voice, 'chestiness', or a drastic drop in blood oxygen saturation as the lungs fill with food or fluid.

Not that long ago, an attempt was made to standardise the classifications of texture modified food and fluids, and the latest reference document is freely available. It contains only the descriptors for food - those for fluids are still under review, although previous standards are still available. The two sets meet in the middle - food is progressively softened and pureed into something approaching a liquid, while drinks are progressively thickened to something approaching a solid.

In the hospital where I work, alongside the normal menu are two 'texture modified' menus, offering Texture C (thick puree) and Texture E (fork mashable) food. Fluids can be thickened to Stage 1 (thin custard) and Stage 2 (thick custard). Each patient is assessed by an SLT, and the most suitable texture is recommended. When any such texture modification of food or fluid is advised, a referral to a Dietitian should ensue (but it doesn't always happen).

The main reason for the Dietitian getting involved is because it is almost impossible for a patient to meet his or her full nutritional requirements on a texture-modified diet or fluids. The thought of thickened fluids - imagine a custard-thick cup of tea or coffee - is enough to put most people off drinking anything, although fruit juice and squash seem much more acceptable in a thickened form. If food is pureed to the right consistency it often has to have water or other liquid added, which dilutes the nutrient content, and many patients who have a compromised swallow will have a small appetite to start with. They simply can't eat enough to provide the protein and energy they need, and again, pureed food on a plate is not the most appetising sight (although I would contend that the taste isn't too bad if you can get past the look of it).

So we ride to the rescue, the Dietitian on the steed of food fortification and nutritional supplements. But hang on - most of the supplements we use are in liquid form, and by virtue of the complex composition which makes them nutritionally complete (i.e. containing all the essential protein, carbs, fat, vitamins and minerals), they are impossible to thicken successfully. There are pre-thickened supplements on the market, but they are not available in the hospital on our contract with the supplier, due to their high price. And the kitchen in this hospital doesn't provide a fortified menu, let alone a fortified puree menu...

To be continued

Discharge

Pump Room Gardens, May 2012

Today is Friday, the last of my pointless days off, without which I would have felt cheated, but after which there is always twice as much work to do. So yesterday was my last full day in the week, trying at least to see every patient who hadn't been seen the previous week. Yes, I'm struggling to review longstanding patients once a fortnight now.

While I was thus engaged, every colleague in the hospital was conspiring against me. A patient is going home with a tube feed, and both colleagues in the Dietetics office who help out in this situation were on holiday. Another patient may be going home on a puree diet, and will need information and advice on how to achieve this at home. A doctor has specifically requested a Dietitian to see a patient with interesting blood results as soon as possible. A previously tube-fed patient is now able to eat, so the tube feed has to be adjusted or discontinued. A Ward Manager wanted to talk to me in her office about a specific patient, and I had a lecture to attend at lunchtime and my first clinical supervision after lunch.

Patients leaving my wards are almost as much work as patients who stay there. I am still trying to grasp all the different options and processes that need to be followed. If they are eating and drinking well when they go home I can put their Dietetic Record Card in a plastic basket in the office and relax (this is rare). There is a different basket for 'RIP' cards. If a patient is transferred to a different hospital, we have to contact the dietitians there and let them know what the situation is, especially if the patient is being tube-fed, and sometimes send the Record Card over as well (depending on whether the hospital is in our region or not).

If a patient goes home but is not likely to eat and drink enough, there are a number of options. I can write to the GP asking for supplements to be prescribed for a period of time and leave it up to the GP to review the situation, or send the patient an outpatient appointment with a Dietitian (there is a different basket for the Record Card if this is the case). If the patient is going to a nursing home, I can be fairly confident that their nutritional status will be monitored, but I can pass the Record Card to our Community Dietitian if there are any worries. She also looks after every patient who is sent home with a feeding tube, whether it is being used or not. Even if not used, the tube needs to be looked after, and eventually removed.

If a tube is being used for feeding into the stomach, there are many administrative and practical steps that must be taken before discharge. The patient needs to be sent home with enough supplies to ensure they are fed until further supplies are delivered. This means bags of feed (between 7 and 14 kg altogether), a pump, a stand, tubes to connect the feeding tube and the feed, syringes for flushing the tube with water, and sometimes a water container have to be physically taken to the ward in time for the discharge. There is a form that gives the patient and/or their carers instructions on how much feed to give at what rate over a specific period of time and how much additional water is needed. They need to sign a form to consent to their address details being given to the company that will be delivering the feed. The Dietitian has to register the patient with this company and provide all the same details and more, and then print a letter to the GP asking for the feed prescription to be arranged. Then all this is handed over with the Record Card to the Community Dietitian. Sometimes the ward forgets to mention that someone is due to be discharged on a feed imminently, so everything else has to stop until it is all sorted out.

More difficult is if the patient needs a modified texture diet, especially if they are elderly. Constructing a nutritionally adequate diet when everything has to be blended to a smooth lump-free puree is not straightforward, especially if the patient doesn't have a blender or liquidiser. If fluids also need to be thickened, then the choice of supplements is limited too. Chances are that the patient will lose weight, become dehydrated, and/or eat or drink something that goes down the wrong way and they end up with a chest infection or worse. There is a commercial company that will deliver pureed ready meals, a bit like Meals on Wheels, which can help a great deal, as long as the patient can afford it. It is likely that the patient will be on supplements long-term, and even need to be seen occasionally in outpatients.

There are different baskets for Record Cards of clinic outpatients who are going to come back for a further appointment, outpatients who have been discharged, and outpatients who didn't attend their appointments. There is another basket of Record Cards for upcoming outpatient clinics. There are probably more baskets that I'm not even aware of yet, perhaps for newly referred patients, and for IV feeders at home (Home Parenteral Nutrition).The Dietetic admin staff who manage all these baskets (and much more) are universally helpful, patient and good-natured, and don't seem to mind me asking the same questions multiple times. In fact, all the Dietetic staff seem friendly and supportive (have I mentioned that before? Probably). Tonight we have arranged a departmental outing in a local Indian restaurant, and despite my nervousness about large social groups, I think it will be fun.

Nutrition support

All Saint's Church, Leamington Spa, Feb 2012

The vast majority of the patients I have been seeing on the wards are one of two types: a) not eating well and requiring either food- or supplement-based prescribing, or b) needing to be fed through a naso-gastric (NG) tube to the stomach via the nose and throat, or percutaneous endoscopic gastrostomy (PEG) tube to the stomach directly through the stomach wall.

A regimen for tube feeding requires a calculation of the patient's likely nutritional requirements for energy, protein and fluid based on their age, sex, likely level of activity, a stress factor according to their clinical condition, and their weight (or more usually an estimated weight because they haven't been weighed as they're supposed to be). Other considerations may be taken into account, such as a prolonged high sodium level in the blood biochemical results, or impaired kidney function. All of this leads to the dietitian making a choice of a type of feed, the amount that the patient should receive, and the rate at which it should be delivered via a pump, which will start at a low level and then increase over a number of days. I document all this in the notes, and all the nurses have to do is follow the instructions.

Compared with drawing up a feed regimen, oral nutritional supplementation is much more complicated. Where the feed, fluid and pump settings are very much under the control of the nursing staff, when it comes to trying to increase a patient's intake in hospital by getting them to eat and drink, there are a whole lot more variables to deal with. The catering department, the food service staff, support workers and nurses all have to come together at mealtimes to provide appetising food and to help frail and sometimes confused and/or recalcitrant patients to eat it. In theory, snacks and drinks are available between meals, including such wonders as cheese and crackers (8g protein and 130 kcal), but the patients are more likely to get a couple of ordinary biscuits (negligible protein and about 70 kcal).

Worse still is if the patient has an impaired swallow, and cannot be given normal food and fluids because of the risk that it will enter the lungs instead of the stomach. Food with modified texture is usually preferable to tube feeding, but trying to maintain sufficient intake from pureed food and fluids thickened to the consistency of custard or syrup is difficult. The very thought of thickened water or tea is enough to put most of us off drinking as much as we should. If this situation persists and the patient is otherwise medically fit for discharge, it may be necessary to draw up a fluid-only plan for their full nutritional requirement of anything up to and sometimes beyond 2000 kcal. This will rely to a great extent on nutritionally complete supplements in order to ensure that vitamin and mineral requirements are covered, because ordinary everyday fluids rarely contain iron, for example.

Even more difficult are those patients who are eating almost nothing but are deemed unsuitable for artificial feeding through a tube. This may be because of a medical condition that makes the endoscopic placing of an NG or PEG tube inappropriate (e.g. oesophageal varices or abdominal ascites), or a condition where artificial feeding has not been found to improve quality of life or clinical outcomes (e.g. dementia). Or because the patient just doesn't want to eat, which is, after all, their right. A referral is often made to a dietitian, because not to do so might be considered neglectful, but a dietitian can't wave a magic wand and make patients eat if they don't want to.

Towards the end of life it is often the case that a patient will stop eating and drinking, and the evidence suggests that clinical dehydration is actually likely to make the process of dying less traumatic. But the ethical dilemmas that arise are no less intractable because of the evidence - what if a patient with dementia starts to have an impaired swallow? Is tube feeding indicated, contributing little to quality of life and likely to cause distress and confusion and be pulled out, or do we offer food and drink orally that may be aspirated and cause chest infections, or will we allow them to starve? Unfortunately there are no easy answers.