Faerella Boczko

The IDDSI (International Dysphagia Diet Standardization Initiative) was recently founded with the goal of developing globally standardized terminology and definitions for texture-modified foods and liquids applicable to individuals with swallowing disorders (dysphagia) of all ages, settings and cultures. 

Dysphagia is a secondary condition and has many possible causes. It most frequently affects older adults, but ultimately any condition that leads to the weakening of or damage to the muscles used for swallowing may cause dysphagia. If the incorrect diet is prescribed including food pieces that are potentially too large for swallowing, there is an increased risk and could result in aspiration and pneumonia. 

This blog will discuss the importance of IDDSI implementation in a long-term care setting, and the process required for successful implementation at a 514-bed long-term care facility in an urban setting.

First, a multidisciplinary IDDSI workgroup was formed to develop a plan for IDDSI implementation. The team consisted of representatives from various departments, including food and nutrition, nursing, medicine, speech pathology, information technology and quality improvement. 

The aim was to review existing standards and meet the challenge of changing to globally standardized categories. The team discussed that ambiguous terms without standardized definitions lead to dangerous trays being given to patients. The new IDDSI framework consists of 8 levels; drinks are measured 0-4, and foods are measured 4-7. Each level has specific standards with clear specifications. Levels can be identified through text labels, numbers and color codes to improve safety and identification. 

IDDSI provides greater clarity and compliance, ultimately delivering improved nutrition and safety for patients with swallowing disorders. The framework aims at being person-focused, rather than profession-focused.  IDDSI provides valid measurement techniques that can be used by long-term care facilities with patients with dysphagia, and by their caregivers, clinicians and food service professionals.

The implementation included half-hour weekly meetings that were held over an eight-month period. The group identified what was needed and continually assessed where they were and what was needed to move forward. 

The first item identified was education, and the dissemination of information to key departments. Education included an overview and familiarity with IDDSI and standardized terminology in-services to key departments and a general in-service open to all departments. IDDSI framework was introduced, and labels on food items were reviewed. 

This was followed by trial recipes with food production, and measurement methods with audit tools for the description and characteristics of each food item and drink on the facility’s menus.  Menu items were tested and audited with feedback from the IDDSI workgroup expanded to include additional invited participants, such as geriatric fellows, dietary interns, IT staff, nursing assistants and speech pathology interns. IDDSI tools and criteria for inclusion in an IDDSI food and drink level were used. 

Testing and tasting began with breakfast items: fortified oatmeal, eggs, muffins, french toast, waffles, pancakes, scrambled eggs, and slurry bread. Records were kept in regard to what to eliminate and what items needed changes. The next items tested and tasted included soups. Entrees followed during the next few weeks and included items such as shepherd’s pie, breaded fish, mac and cheese, meatloaf, pasta, hamburger, chicken tenders and turkey. 

All levels were tested including pureed, minced and moist, soft and regular. Various vegetables and sides were then tasted and tested. The finale included desserts including pureed honeydew, carrot cake, rice pudding and a fruit cocktail. 

In addition to testing and tasting, IDDSI flyers and laminated posters were placed in each patient dining room with the new terminology and the old terminology in parenthesis. Initial discussion involved order sets and order entry in the electronic record and identifying those responsible in order to achieve our target date and time frame for implementation. 

Next, policy was developed. Announcements and handouts for patients included placing information on patient trays. At the conclusion of the eight months, a “switch over” date and time was agreed upon and a general email was sent to all staff alerting them to the change in effect.

Monthly IDDSI workgroup meetings continued for an additional four months following implementation. These were needed in order to review issues and compliance and troubleshoot for any additional problems. Due to staff turnover, additional short in-services to review IDDSI were provided to nursing and dietary departments for any new employees.  

The implementation had been a joint effort among the facility’s speech-language pathologists, dietitians, food service staff, nursing team, medical team and IT.  As other facilities implement this standard, patients should be able to move from one care setting to another and their medical teams will know exactly what foods and liquids are safe. 

IDDSI implementation will lead to improved safety for our dysphagic patients. 

Faerella Boczko, MS,CCC-SLP,BCS-S, is Director of Speech-Language and Swallowing Disorders for The New Jewish Home in New York. She is a Board Certified Specialist in Swallowing and Swallowing Disorders, and has served as principal investigator to two research grants, authored book chapters, published research articles, and presented at professional society meetings. She has over 35 years of experience working with the geriatric population.  

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.