Hospitals across Singapore, including SGH, are adopting a global standard of food and drink descriptions to ensure safety for people with feeding, chewing or swallowing problems.

When you hear the word “porridge”, what comes to mind? The Cantonese thick and smooth type, rice-in-clear-soup type, or those with soft yet still distinctive grains? These different ideas of porridge can impact patient safety when our patients and caregivers are told that porridge is one of the recommended foods to be given to them.

Patients who have swallowing impairments may have difficulty chewing and controlling the movement of food and drink in their mouth, and have reduced swallow strength. “This may result in food and drinks entering the airway and cause a chest infection known as aspiration pneumonia,” explained Jaymie Chai, Senior Speech Therapist.

To minimise such infection, speech therapists assess the patient’s swallowing abilities and make recommendations to modify diet and fluid consistencies. The modifications include having softer and smaller food pieces, blending food thoroughly, or adding thickener powder to slow down the flow of fluids. 

One diet texture, many definitions
Although modifications of diet and fluid consistencies have been integral in the management of swallowing difficulties for a long time, there is a lack of standardised understanding of the terms used in describing the consistencies even among healthcare professionals managing patients’ diets across different institutions.

 “Despite everyone’s best efforts to describe our diets within our own settings, there is no standardisation of diet terms and definitions across healthcare sectors in Singapore. For example, what we know in SGH as pureed diet is called minced diet in another institution. Another institution’s “soft diet” could actually be the equivalent of our “chopped diet”,” said Deirdre Tay, Head of Speech Therapy at SGH.

“Even if we agree on the definition, the diet characteristics vary widely, for example one institution’s chopped diet may have larger food pieces than ours. This increases the risk of aspiration pneumonia or choking if patients are given unsuitable consistencies,” she added.

Adopting an international framework to improve safety
To improve patient safety, hospitals across Singapore including SGH are adopting a common standard under the International Dysphagia Diet Standardisation Initiative (IDDSI) Framework.

This is a global standard of food and drink descriptions that have been modified to ensure safety for people with feeding, chewing or swallowing problems. The framework can be used for people of all ages, in all care settings and can be applied to all cultures.

An MOH national workgroup is looking into the implementation of the standard throughout acute hospitals and intermediate and long term care sectors.



Big scale change across all care continuum
Although recommendations of diet and fluid consistencies are made by speech therapists, dietitians, food services staff and nurses each play significant roles in ensuring that the preparation and nutritional value of food and drinks served to patient are suitable. Since 2020, an SGH IDDSI workgroup comprising representatives from the abovementioned departments has been developing educational and publicity materials to create awareness and use of the IDDSI in SGH.

Principal Speech Therapist Lee Yan Shan, one of the leads for the project, said, “Changing our terminologies is not just replacing words. It means that our processes throughout the entire hospital must change.  This is a big scale change as it impacts both internal and external hospital communication processes around diet/fluid terms.”

“We need to change the terms we use in our internal systems such as clinical documentation, diet ordering systems, electronic menu systems, and patient’s bedside food/drink recommendation signs. It will also affect our communication with patients, colleagues in SGH, and colleagues across other healthcare settings when we do discharge planning and transfer of patients.”

Yan Shan and her team actively gather opinions from all relevant stakeholders to ensure that the transition to IDDSI will not compromise patient safety, and the change will be smooth, seamless, and sustainable. These stakeholders include food service staff, nurses, doctors, speech therapists, dietitians, healthcare assistants, and volunteers involved in serving food and feeding patients.

E-learning modules have been created for staff to understand more about IDDSI and posters with the new IDDSI descriptors will be placed in all ward pantries from July. There are also plans for roadshows and quizzes later this year.

The team is working towards standardising the terminology for fluid by July 2021. As more time is needed to work out modifications required for diet characteristics and their preparation methods, the diet terms will only be introduced later.

Making our mark regionally
The standardization has also unexpectedly offered opportunity for SGH to contribute internationally.

Our speech therapists are also actively contributing to discussions with our regional counterparts from Hong Kong, Taiwan, China and Malaysia. Yan Shan explained, “It is very exciting to work together and exchange cultures and ideas with experts in these regions. We recently standardised the Chinese translation of IDDSI terminologies. This means that the same IDDSI terms will be understood across all Chinese-speaking regions and can be easily translated and applied.”

Then whether it’s Cantonese, Teochew or Hokkien style porridge, everyone in healthcare will know exactly the texture we are referring to.

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