JCPSLP Vol 22 No 2 2020

Table 1. Methodology used for each audit method

Audit method

Methodology used

Bostwick Consistometer (Steele et al., 2014)

The sample was poured into the full height of the end reservoir until the end reservoir was filled, and a flat knife was then used to level the sample ensuring the sample was at the height of the reservoir walls. The measurement distance along the main trough was read after a 30 second period, with the distance the sample travelled recorded to the nearest quarter centimetre. A Plexiglas board marked with a series of concentric circles spaced 0.5 cm apart and divided into four quadrants was used for the LST. A 50ml amount of the thickened fluid sample (measured with a syringe) was placed in a hollow tube (diameter of 5cm) in the centre of the board. The distance the fluid travelled across each of the four quadrants during a one-minute period was recorded. Each sample was tested using the LST three times, with the average mean across the three recordings used to calculate the total line spread reading. Prescribed IDDSI directions for use of the flow test were carefully followed and adhered to (Chichero et al., 2017). The plunger of a 10ml slip tip syringe was removed. The nozzle of the syringe was covered with the auditor’s finger and then 10mls of the sample (measured using another syringe) was placed into the auditing syringe. The auditor’s finger was then released off the syringe nozzle with the amount of liquid that flowed out of the syringe measured after a 10 second period.

Line Spread Test (Mann & Wong, 1996)

IDDSI syringe flow test (Cichero et al., 2017)

norms for each thickness level (Chichero et al., 2017). Audits were completed by one trained staff member using the Bostwick in February 2017, and with four trained staff using the LST and the Flow Test in May 2017 using standardised audit forms and training processes. Individual samples were audited by one rater only; however, a total of five auditors completed audits throughout the study. The training process was conducted by a senior speech pathologist with expertise in food services and thickened fluid auditing, and consisted of the provision of written instructions on how to use each audit method and a visual demonstration by the trainer on how to complete each audit method. Individual auditors then demonstrated competence to the trainer by correctly and accurately auditing several thickened fluid samples with each audit method prior to their commencement of independent auditing. Audits were completed using the Bostwick, LST and the Flow Test using the methodology prescribed in Table 1. Results Total number of audits A total of 77 samples were audited (39 at fridge temperature and 38 at room temperature). Of these samples, 18 audits were conducted with extremely thick fluids, 22 with moderately thick fluids and 37 with mildly thick fluids. As the pre-packaged thickened fluid supplier was phasing out old stock and introducing new stock at the time of auditing with the LST and Flow Test in May 2017, where available, old stock and new stock of each flavour category was subsequently audited with these two audit methods. A total of 62 samples were audited with the LST and Flow Test. Old stock only was available and audited using the Bostwick in February 2017, with a total of 57 samples audited using this method. Mean scores can be found in Table 2. Overall compliance rates Bostwick Of the 57 samples audited using the Bostwick 61% (n = 35) were within acceptable norms for the Bostwick. Of the total number of those that failed (n = 22), 18% (n = 4) were considered too thin with 82% (n = 18) considered too thick. Of the samples that failed because they were too thin, all four samples (18%, n = 4) were mildly thick fluids from three

and moderately thick levels under the Australian Standards (Dietetics Association Australia & Speech Pathology Australia, 2007). The Flow Test has been developed as part of the International Dysphagia Diet Standardisation Initiative (IDDSI) (Cichero et al., 2017) and the IDDSI committee states that the test has been validated using existing laboratory tests and expert judgement (Cichero et al., 2017). The use of low technology devices to audit thickened fluids with pre-approved standards has not been extensively studied in the literature (Hadde, 2017). In the absence of health care site access to instrumental methods such as a rheometer or viscometer, it is assumed that supplied pre-packaged thickened fluids have been previously evaluated by manufacturers using instrumental methods and are compliant with prescribed norms. The primary aim of this study was to provide the results from an audit of all pre-packaged fluids used at a medium- sized hospital using three commonly used low technology audit methods (the Bostwick, the LST and the Flow Test) to determine assumed compliance with prescribed viscosity/flow norms. The secondary aim of this study was to compare testing agreement between these three low technology methods. Method The full range of nine pre-packaged thickened fluid flavours provided to patients at the hospital site were audited at the three levels of thickness prescribed by the Australian Standards (Dietetics Association Australia & Speech Pathology Australia, 2007), resulting in a total number of 77 audit occasions. The 9 flavour categories audited were from a single manufacturer and were from a range of flavours including juices, cordials and creamy based flavours. All fluids were audited at room temperature and fridge temperature (as patients consume thickened fluids at both temperatures) and the temperature on each audit occasion was recorded. The manufacturer does not make any recommendations regarding the specific temperature that the thickened fluids should be served at to ensure appropriate product viscosity levels. Fluids were audited using the Bostwick and the LST against prescribed state health hospital norms for each thickness level (Queensland Health, 2013). Fluids audited using the Flow Test were audited against prescribed IDDSI

Marnie Seabrook (top) and Anne Coccetti

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JCPSLP Volume 22, Number 2 2020

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