Introduction
The successful introduction of Resource® ThickenUp™ Clear took place across the Leeds Teaching Hospitals NHS Trust (LTHT) in January 2016. This includes:
- Leeds General Infirmary
- St James’s University Hospital
- Chapel Allerton Hospital
- The speech and language therapy LTHT outpatient service
Why switch thickener?
The switch from the previous starch-based thickener was desirable for a number of reasons, based on our experiences:
- Starch-based thickened drinks became thin again when patients with dysphagia held the drink for some time in the mouth
- This is because the amylase in the saliva reacts with the starch
- Some patients with dementia, confusion, delirium, brain injury and learning disability amongst other conditions, can experience this difficulty
- Patients reported that they did not always enjoy the taste and texture of starch-based thickener, especially in hot drinks, such as tea
- This lack of palatability could result in dehydration as patients took fewer drinks
- This was the case when the thickened drink was prepared to the recommended consistency
- Some drinks became over-thick as the starch continued to thicken drinks over time »» A patient is not always able to take their drink immediately
- If it thickens to a greater degree than is recommended by the speech and language therapist (SLT) then it can become more unpalatable or more difficult, even unsafe, to drink
Factors to consider
As a result of this feedback, the SLT department researched an alternative thickener. A number of factors were considered
- Clinical efficacy
- Ease of preparation by staff and patients
- Palatability
- How well it mixed with all drinks
- Aesthetic appeal of the mixed drink
- Likely adherence by patients
- Any medical contraindications
- Cost including implications for the community trust
Pre-launch audits
Patient satisfaction audit
SLTs carried out a snap-shot audit to check patients’ preferences for the gum-based Resource® ThickenUp™ Clear versus the then current starch-based thickener. Patients who were able to provide an opinion overwhelmingly chose Resource® ThickenUp™ Clear for its palatability in terms of taste and texture, and its aesthetic appeal.
Contraindications audit
The SLT service carried out an audit to see if patients had any possible contraindications for Resource® ThickenUp™ Clear. This included looking at sodium issues, milk allergy, lactose/dairy intolerance or renal issues. SLTs work closely with the doctors and dietitians to check if any thickener would be unsuitable for an individual patient. All of the patients audited were suitable for Resource® ThickenUp™ Clear.
SLT qualitative audit
This was carried out to compare Stages 1 and 2 of the starch-based thickener and Resource® ThickenUp™ Clear and how these consistencies matched the National Descriptors for Texture Modification in Adults.1 Palatability from an SLT point of view was also assessed.
The results of the consistency assessment showed that Resource® ThickenUp™ Clear was closer to the National Descriptors for Texture Modification in adults than the starch-based thickener when following the instructions by the manufacturers. SLTs felt that whilst it would take a short time to get used to the difference, it would not adversely affect practice or patient safety.
Comments
The following comments were made by the SLTs on the taste of Resource® ThickenUp™ Clear (RTUC):
“RTUC is smoother; the starch - based thickener is grainy”
“RTUC has better flavour”
“RTUC is more cohesive, not powdery”
Pre-launch audits, cont.
On balance, it was found that Resource® ThickenUp™ Clear solved a number of issues arising from the starch-based thickener and met the needs and preferences of patients and staff alike.
Further consultations took place in task-and-finish and committee groups within the trust to consider clinical and cost issues. It was agreed that pre-thickened oral nutritional supplements would be introduced at the same time as Resource® ThickenUp™ Clear and the much greater adherence to the new thickener over the current starch based thickener resulted in cost benefits.
Staff training
Following consultations with all stakeholders, a date for the launch of Resource® ThickenUp™ Clear across the Trust was agreed. Prior to launch, SLTs worked closely with Nestlé Health Science colleagues to ensure a co-ordinated, smooth, safe, and comprehensive introduction would occur across the hospitals. This was undertaken over a few weeks. Initially, wards where there were fewer patients with dysphagia received training on the use of Resource® ThickenUp™ Clear; this was followed by wards with greater numbers of patients with dysphagia, as this was closer to the launch date.
SLTs worked jointly with Nestlé Health Science colleagues in providing the ward staff training. Not only could Nestlé Health Science colleagues provide excellent in-depth knowledge of the product and how to prepare it, but also SLTs could explain its benefits for specific patient populations
in the Trust and reinforce dysphagia awareness for staff members. SLTs could also answer staff questions specific to the Trust. Three to ten staff members were trained at a time and they cascaded the training to colleagues.
The preparation of Resource® ThickenUp™ Clear was explained and demonstrated using bottled water and cordial. Staff were encouraged to mix it for themselves and to try ‘shots’ of the thickened cordial at different Stages. Nestlé Health Science colleagues and SLTs also provided written resources and materials for staff to use and share.
Staff feedback
Upon completion of the training, staff provided feedback on the training:
“Really useful”
“Mixing it is different to what we’re used to, so it’s good to have it explained face-to-face and not just written down”
“It’s no more difficult to prepare than making a regular cup of coffee, really”
“Good to know how it works from both the people who make it and the SLTs who suggest it”
“That was fun!”
Launch of Resource® ThickenUpTM Clear
The launch took place across all of the hospitals in the Trust on the same day. There was sufficient volume of Resource® ThickenUp™ Clear in pharmacy stocks and on the wards, where significant numbers of patients have dysphagia.
On recommending Resource® ThickenUp™ Clear for a patient with a newly diagnosed dysphagia to fluids, SLT:
- Reiterated to staff how to prepare drinks with the new thickener
- Provided further written advice for staff
- Included the name Resource® ThickenUp™ Clear on the over-bed dysphagia recommendations signs
- Ensured that the new thickener name was entered correctly on the drug charts and was written in the medical discharge report drug list
Provided a Resource® ThickenUp™ Clear leaflet and/or Nestlé Health Science literature directly to patients, families/carers and in the SLT Swallow Advice Packs on discharge home
Following the launch of Resource® ThickenUpTM Clear
Questionnaire for ward staff
Four questions were asked of ward staff following the introduction of Resource® ThickenUp™ Clear.
The overall results were:
- Patients’ fluid intake increased orally
- Patients preferred Resource® ThickenUp™ Clear to the starch-based thickener
- Staff felt the same or more confident mixing Resource® ThickenUp™ Clear compared to the previous thickener
- Wastage of thickened fluids had decreased
Staff reflections
Staff provided feedback following a day of trying Resource® ThickenUp™ Clear for themselves at Stages 1 and 2. Patients and family/carers also provided their thoughts.
“I couldn’t tell the difference taste-wise with cranberry drink thickened to Stage 1”
“Stage 1 in hot tea wasn’t too bad, I could get used to it over time”
“Now I have insight into how the patients feel on Stage 2”
“The drinks are quite filling”
“Stage 2 wasn’t as thick as I imagined”
“It worked through a straw”
“Stage 2 was much more enjoyable than I thought it would be”
Patient reflections
“I like that it stays quite clear. It looks like it’s got bubbles in it”
“I’m surprised it mixes with fizzy drinks, even works with lemonade”
“My tea tastes the same, so that’s good”
“It’s better when the nurses make up a whole jug for me and I can help myself to drinks then”
“I hope I’m not on it forever but it’s ok for now and I want to get better”
“It’s better than the other stuff. That was like wallpaper paste”
Family/carer reflections
“Once you get the hang of how to mix it, it’s easy enough”
“It looks a lot nicer than the old one we used to get”
“It’s good that the tub lasts so long”
“[John] can’t tell us what he prefers but he seems to like this”
Videofluoroscopy
Once patients commenced the use of Resource® ThickenUp™ Clear, SLTs realised that the current consistencies mixed in videofluoroscopy required adapting. The starch-based thickener had been slightly thicker and heavier at Stage 1 than Resource® ThickenUp™ Clear and the barium mixed thick drinks had been prepared accordingly.
Experienced SLTs adapted the consistency used in videofluoroscopy by preparing drinks at Stage 1 and 2 with Resource® ThickenUp™ Clear and then mixing drinks with barium and comparing the consistencies and weight. A consensus was achieved on the barium mixed thick drinks and how closely they reflected a regular Resource® ThickenUp™ Clear Stage 1 and 2 drink without contrast material.
Patients found to be safe on Stages 1 or 2 barium mixed thick drinks in videofluoroscopy have remained safe on Resource® ThickenUp™ Clear at Stage 1 or 2 (where there has been no further deterioration in swallow function). In our experience, this indicates that switching to a slightly different barium mixed thick drink is safe and easy to achieve.
Discharge from hospital
Patients are provided with a tub of Resource® ThickenUp™ Clear upon discharge from hospital and it is listed on their prescription. SLTs have also requested that GPs prescribe Resource® ThickenUp™ Clear for LTHT outpatients. There have been no concerns from GP colleagues in providing a new thickener.
Patients, families and carers take a SLT Swallow Advice Pack home including the Resource® ThickenUp™ Clear literature and as part of the post-discharge follow-up, SLTs check that they continue to prepare drinks safely at home.
An effective and successful transition
The introduction of Resource® ThickenUp™ Clear in the largest teaching hospitals trust in Europe involved a large-scale change. With careful and well-coordinated planning, the transition was smooth, safe and well received by patients, family and staff. Nestlé Health Science colleagues were very supportive and friendly, quick to respond to requests and able to make adaptations to plans at short notice. They worked well with SLTs and ward staff and promoted the use of Resource® ThickenUp™ Clear in a patient-centred and pragmatic manner.
Patients continue to benefit from Resource® ThickenUp™ Clear five months following its launch. Patients, families and colleagues agree that the switch to Resource® ThickenUp™ Clear has been clinically effective, improved quality of life for patients, and is also good value.
Reference
1. The National Descriptors for Texture Modification in Adults. BDA & RCSLT, 2012
The successful introduction of Resource® ThickenUp™ Clear took place across the Leeds Teaching Hospitals NHS Trust (LTHT) in January 2016. This includes: Leeds General Infirmary St James’s University Hospital Chapel Allerton Hospital The speech and language therapy LTHT outpatient service Why switch thickener? The switch from the previous starch-based thickener was ...
