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Management of Diet for the Treatment of Dysphagia - Adult - Inpatient [53]

Management of Diet for the Treatment of Dysphagia - Adult - Inpatient [53] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols



Delegation Protocol Number: 53

Delegation Protocol Title:
Management of Diet for the Treatment of Dysphagia - Adult - Inpatient

Delegation Protocol Applies To:
UW Health at University Hospital and The American Center (TAC): All hospitalized patients who have provider
written orders for a swallow evaluation.

Target Patient Population:
University Hospital and The American Center (TAC) adult inpatients

Delegation Protocol Champion:
Erick Tarula, MD – Department of Neurology

Delegation Protocol Reviewers:
Cassandra Kight, RDN – Clinical Nutrition
Robin Crist, RDN – Clinical Nutrition
Emily Wallace, RDN – Clinical Nutrition
Molly Knigge – Speech Pathology

Responsible Department:
Clinical Nutrition
UW Health Voice & Swallow Clinics

Purpose Statement:
The purpose of this protocol is to allow Speech Language Pathologists (SLPs) from Swallow Service to proceed
with instrumental swallow evaluations and in collaboration with Registered Dietitian Nutritionists (RDNs) from
Clinical Nutrition Services to initiate, modify and discontinue oral diets based on patient specific conditions and
the results of skilled, objective dysphagia assessments.

Who May Carry Out This Delegation Protocol:
Speech Language Pathologists (SLPs) and Registered Dietitian Nutritionists (RDs).

Guidelines for Implementation:
1. This delegation protocol is initiated when a provider orders “Consult Swallow Therapy” and “Consult
Nutrition (inpatient) along with delegate to dysphagia diet progression intent option. The SLP will
complete a clinical bedside swallow evaluation. Based upon the results of the evaluation, the SLP will
make recommendations for NPO status, initiate an oral diet or proceed with an instrumental swallow
evaluation. The SLP will write orders for the instrumental swallow evaluation as deemed necessary and
appropriate.
2. The SLP will determine the degree of dysphagia and phase of swallowing in which dysphagia occurs. An
individualized program for each patient may include specific diet modification of solids and liquids,
strategies to aid in facilitating a safe swallow, and an appropriate level of supervision. The SLP will also
address if medication modifications are required.
3. The RDN will evaluate and modify dysphagia diet recommendations in accordance with other medical and
nutrition needs. The goal is for diet and nutrient intake to provide adequate calories, protein, vitamins,
minerals, and fluid to prevent or reduce nutritional implications including weight loss, dehydration,
protein- energy malnutrition, and vitamin and mineral deficiencies.
4. The RDN may place orders for vitamins and minerals as warranted by the patient’s condition, laboratory
values, or to correct any deficiencies inherent in the dysphagia diet restrictions. The medication form
listed in Table 1 is tablet. If the patient is unable to take tablet medications, the vitamins will be ordered in
dosage formulation specific to the SLP medication recommendations, or the RND will wait to order until
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


the patient can swallow tablets.
5. The patient's progress is monitored and diet is advanced to the next level of food texture modification
and fluid consistency based on overall progress with swallowing rehabilitation and patient tolerance.
The ordering or covering ordering provider will be contacted by the SLP when:
5.1. The patient has had any surgical intervention during their admission involving the head, neck,
esophagus or gastrointestinal tract
5.2. The patient has had a gastrointestinal bleed or ileus during their admit
5.3. The patient has pancreatitis
6. Patients with dysphagia have the potential for needing specialized dietary restrictions outside of the
modified diet textures SLPs recommend. Therefore, ordering providers and RDNs will be contacted so
they can write for these necessary modifications.

Order Mode: Protocol/Policy, Without Cosign

References:
1. American Speech-Language-Hearing Association. (2001). Roles of speech-language pathologists in
swallowing and feeding disorders: technical report [Technical Report]. Available from
www.asha.org/policy.
2. National Dysphagia Diet Task Force. National Dysphagia Diet – Standardization for Optimal Care. Chicago,
IL: American Dietetic Association; 2002:10-19.
3. Heiss CJ, Goldberg L, Dzarnoski M. Registered Dietitians and Speech-Language Pathologists: An Important
Partnership in Dysphagia Management. Journal of the American Dietetic Association. 2010;110(9):1290-
1293.
4. Academy of Nutrition and Dietetics. Nutrition Care
Manual: https://uconnect.wisc.edu/depts/uwhc/clinical-nutrition-services/

Collateral Tools: NA

Approved By:
UWHC Nutrition Committee: July 2012, *August 2014; *February 2017
UWHC Medical Board: August 2012, *September 2014; *March 2017

Effective Date: March 2017

Scheduled for Review: March 2020
*Expedited Approval Process















Table 1: Oral Vitamin/Mineral Repletion for Patients on Dysphagia Diet

Vitamin Adult Dose, Route, Frequency Clinical Condition
Ascorbic Acid
500 mg twice daily x 10 days • Non-healing wound or
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


pressure ulcer
Cholecalciferol
Dietary Reference Intake for Vitamin
D: Oral Adults 19 to 70 years:
Recommended Daily Allowance (RDA): 600
units/day (IOM 2011) Female:
Pregnancy/Lactating: RDA: 600 units/day
(IOM 2011). Adults >70 years: RDA: 800
units/day (IOM 2011).
Vitamin D deficiency
prevention: Oral 1,500 to 2,000 units daily
to maintain serum 25(OH)D levels >30
ng/mL (Holick 2011), or other dose as
patient was on at home.
Vitamin D deficiency treatment: Oral
6,000 units daily (or 50,000 units
ergocalciferol once weekly) for 8 weeks to
achieve serum 25(OH)D level >30 ng/mL,
followed by maintenance dose of 1,500 to
2,000 units daily (Holick 2011).
• To meet Recommended
Dietary Allowances with
inadequate intake or
exposure to sunlight
• Documented Vitamin D
deficiency
• Continuation of Vitamin
D supplementation
patient received at home
for underlying medical
condition (e.g.
osteopenia)
Cystic Fibrosis specific
multivitamin ( softgels
and liquids) and Vitamin D
2 capsules of soft-gels
• Cystic Fibrosis (CF)

Folic acid 1 mg once daily
• Low serum folate
• Heavy alcohol use
• Pregnancy
• Pregnancy in CF (in
addition to CF
multivitamins)
• Chronic Kidney Disease
(CKD)
• RRT not on Renal
Multivitamin with higher
amount of folic acid
Multivitamin with
minerals


1 tablet once daily


• Recommended diet fails
to provide 100% of RDI
for one or more vitamins
or minerals
• Increased needs (e.g.
burn, wound healing)
• Prior inadequate
micronutrient intake
• Heavy alcohol intake
• Medications which
interfere with
metabolism of one or
more vitamins
(phenytoin,
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


phenobarbital,
sulfasalazine)
Pyridoxine 25 mg tablet once daily
• CKD
• Acute Kidney Injury (AKI)
with Continuous Renal
Replacement Therapy
(CRRT)
• Documented deficiency
Renal Multivitamin 1 tablet once daily
• CKD, AKI
• Patient on RRT
Thiamine 100 mg tablet once daily
• Risk of refeeding
syndrome
• Heavy alcohol intake
• Documented deficiency
• AKI with CRRT
Vitamin A 15,000 units tablet once daily x 10 days
Continue usual home regimen dose for CF
patients
• Non-healing wound or
pressure ulcer
• Documented deficiency
• Continuation of home
regimen for CF
Vitamin E 400 – 800 units once daily
• Continuation of home
regimen for CF
Zinc 50 mg tablet once daily x 10 days
• Non-healing wound or
pressure ulcer
• Documented deficiency



Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org