Quality Improvement

Department of State Hospitals-Patton

1/29/18

Jonathan Tellier, Dietetic Intern

Introduction.
 Some companies that have become the gold standard for standardization are McDonalds,

Ford, and Volvo. These companies are not health care companies, but every business shares the

common goal of providing a great product and in this case, care to patients. The International

Dysphagia Diet Standardisation Initiative (IDDSI) strives to make diets in every hospital the

same, by placing guidelines for specific diets to cater to all ages, care settings, and cultures.

Implementation as recommended by the authors of the IDDSI framework is best done over the

course of 2-3 years using the MAPA model (Monitor-Aware-Prepare-Adopt). IDDSI is like the

National Dysphagia Diet (NDD), which was brought to fruition in the 1990’s in the attempt to

decrease the amount of confusion in communication between all health care providers and their

patients (Zwiefelhofer). IDDSI is to be fully implemented in the United States at some point, and

other countries Canada and Australia have already fully implemented the IDDSI framework.

Patients being treated for psychiatric conditions tend to refuse medical care and this

applies to diet recommendations as well. The Department of State Hospitals-Patton (DSH-P) is

to fully implement the IDDSI framework by October of 2019. Currently patients refuse

therapeutic diets even when the benefit of diet change is clearly explained. Those patients that

have already agreed to be on a therapeutic diet will have to accept a new therapeutic diet under

the IDDSI guidelines that is not as lenient as the current diet under the NDD guidelines. The

problem is transitioning from NDD to IDDSI a patient may no longer be served food items

outside of their given diet guidelines. The reason why NDD is so lenient with the specifications

for diets is no official measurement technique exists to place food in NDD1, NDD2, or NDD3.

The issue DSH-P and other hospitals face, is if a patient refuses the diet and then chokes this

causes legal problems for the hospital. However, DSH-P must under California Code of

Regulations respect the patient's right to “refuse any treatment” this includes diets.
Background

Patients can refuse any treatment, this puts the patient at risk and staff as well. Belcher et

al. (2017) evaluated if people with mental illness should be awarded the right to refuse treatment.

The argument is the state should have the right to stop mentally ill patients from making bad

choices. However, this is not the case and other approaches such as patient centered treatment is

an option. Patient centered treatment, is the practice of divulging all the risks associated with not

complying to treatment and letting the patient express feelings on the decision. This approach

improves trust between the medical professional and the patient, in turn improving patient

satisfaction and adherence to treatment. Mental Health America (MHA) recognizes that the

patients with mental health problems should be able to make decisions regarding their treatment

and that the best hope for recovery comes from the access to voluntary mental health treatment.

MHA deems involuntary treatment as a last resort, limited to when a person is a danger to self or

others. This makes recommendations for involuntary medication orders difficult regarding diet.

Principles that may be used to place somebody on medication without their consent include

presumption of competency, declaration of incompetence, informed consent, standard serious

risk of physical harm to themselves or others, least restrictive alternative, procedural protections,

qualified right to refuse treatment, opposition to outpatient commitment, voluntary treatment

should be truly voluntary, and advance directives. There is no current policy for refusal of diets

at DSH-P, but involuntary medication orders (probate) is an option.

Method

An assessment of all diet orders in computrition was conducted. To evaluate diet orders

each patient was looked at individually in computrition. Their diet order was then compared to

the IDDSI framework guidelines. If a patient was on a NDDI diet their diet was compared to
IDDSI Puree, if on a NDDII diet or Mechanical Soft (MS) diet their diet was compared to

Minced and Moist, and if on a NDDIII diet their diet was compared to Soft and Bite Sized.

Results

There were only two diet orders out of 71 texture modified diets that do not fit within the IDDSI

diet guidelines. One person is located on unit 23 and is receiving (NDDII w/puree vegetable,

regular bread at meals not soaked not cubed) when transitioned to IDDSI Minced and Moist the

dry whole bread will not

be allowed. This person

does have history of

dysphagia and would need

to be on a diet under the

IDDSI framework. The

second patient is on unit

05 their diet order is

(NDDII with oranges as a

snack and hard cooked eggs) oranges and hard cooked egg do not fit within the Minced and

Moist guidelines.

Recommendations

Patient centered treatment should be the first approach when introducing to a patient that

they need a texture modified diet. Going over in detail what the diet entails and telling them

about the risks to not receiving that diet (Belcher et al. 2017). If a patient is to choke on a regular

diet after being educated on diet modification, documentation should be done. Once enough

documentation is done to support the medical teams claim that the patient needs to be on a
texture modified diet because the regular diet is a danger to self, steps can be taken to allocate an

involuntary treatment order otherwise known as a probate. Probate can be used for diet

prescriptions. One example at DSH-P, a patient standing at 77 inches tall and weighing 400 lbs.

has history of falling. The problem was he could not be transported if he were to fall because the

gurney and most people would not be able to lift him. The doctor was able to get a probate to

place the patient on a low-calorie diet and restrict snacking for weight loss. The probate was

applicable because if the patient could not be transported due to weight his weight became a

danger to self.

The diet orders assessed need to be altered to fit within the IDDSI guidelines. If a patient

has a diagnosis of dysphagia or history of choking, placing them on a diet that falls under the

IDDSI framework would be the best option. If a patient is just edentulous there is no obligation

to place this person on a dysphagia diet (IDDSI). Involving the patient in altering their diet order

would be best. For the patient on unit 23 who is on a NDDII w/puree vegetable, regular bread at

meals not soaked not cubed diet, the best option would be to place him on Soft and Bite Sized

diet, puree his vegetables, and request a speech language pathologist to evaluate the patient and

clear the patient to consume dry bread cut into 1.5 cm pieces. The patient on unit 05 who is on a

NDDII diet with fruit as a snack and hard cooked egg can be placed on minced and moist level 5

of the IDDSI framework, however the fruit must be pureed, and the eggs must be scrambled.

Conclusion

This project found implementing IDDSI at DSH-P will be feasible and only two patient

diet orders pose any difficulty. Further investigation into the feasibility is not warranted because

not many issues were found in this initial analysis of diets. Future diet orders until the

implementation of IDDSI should be conservative, not offering patients food items that do not fit
within the IDDSI guidelines for that specific diet. This will reduce the amount of resistance from

patients when IDDSI is implemented.

MS NDD1 NDD2 NDD3 Totals

Diets
compatible with
IDDSI 59 6 1 3 69
Diets not
compatible with
IDDSI 0 0 2 0 2

Totals 59 6 3 3 71

References

Zwiefelhofer, D. Making Dysphagia Easier to Swallow. Retrieved from:

https://www.dysphagia-

diet.com/Images/Making%20Dysphagia%20Easier%20to%20Swallow%2011.pdf

Belcher, J. L., Diblasio, A., Siegfried, L. D., Turnquist, A. G. (2017). Overcoming

medication refusal using a patient-centered approach. Social work in mental health 15(6) 690-

704. doi: 10.1080/15332985.2017.1342115

Mental Health America. Position Statement 22: Involuntary Mental Health treatment.

Retrieved from: http://www.mentalhealthamerica.net/positions/involuntary-treatment

The international dysphagia diet standardisation initiative 2016 @

http://iddsi.org/framework/
 Cichero, J., Steele, C., Duivestein, J., Clave, P., Chen, J., Kayashita, J., Dantas, R.,

Lecho, C., Speyer, R., Lam, P., Murray, J. (2013). The Need for International Terminology and

Definitions for Texture-Modified Foods and Thickened Liquids Used in Dysphagia

Management: Foundations of a Global Initiative. Current Physical Medicine and Rehabilitation

Reports (1) 280-291. doi: 10.1007/s40141-013-0024-z