Aspiration pneumonia

What is aspiration pneumonia? 

• Aspiration pneumonia is a lung infection caused by aspiration, which means inhaling things other than air into the airway, like saliva, food, liquid or stomach contents.
  • Aspiration happens when something you try to swallow accidentally ‘goes down the wrong way’ towards the lungs. It can also happen when something from your stomach goes back up to your throat.
  • Aspiration pneumonia is a bacterial infection, typically in one lung, but sometimes in both.
  • Aspiration pneumonia is usually confirmed with a chest x-ray.
• When aspiration (or an aspiration event) occurs, the body may react by coughing which can help clear the airway. 
• Sometimes, there are no outward signs of aspiration, and the person may not know it has happened. This is called ‘silent aspiration’ and may still result in illness such as pneumonia. If a person is prone to many bouts of pneumonia throughout their lifetime, it could be that they’re silently aspirating. 
• Symptoms of aspiration pneumonia include difficult or laboured breathing (dyspnoea), wheezing, coughing up phlegm that may be dark or contain pus or blood, fever, sweating, fatigue, chest pain and drowsiness.
• If a participant has suspected aspiration pneumonia, it’s important they see a doctor as soon as possible. Call 000 if urgent medical attention is needed.
• Treatment for aspiration pneumonia usually involves antibiotics and may also require hospitalisation, oxygen therapy, and mechanical ventilation. 
• Health complications from aspiration pneumonia can be serious, and in some cases, fatal.
• While there may be signs of aspiration on assessment, the only way to definitively diagnose aspiration is with medical imaging such as a videofluoroscopic swallowing study (VFSS) or fibreoptic endoscopic evaluation of swallowing (FEES).  
   

Who is at risk?

• Research commissioned by the NDIS Commission has shown that aspiration pneumonia is one of the most common causes of death for people with disability in Australia. 
• People who have difficulties swallowing (dysphagia) are at higher risk of aspiration and therefore aspiration pneumonia. This could include those with progressive neurological conditions, stroke, dementia, epilepsy, respiratory diseases, those taking medicines that affect swallowing, and people with physical and/or intellectual disability.
• There are signs and symptoms associated with swallowing difficulties including feeling like something is stuck in the throat, watery eyes when eating or drinking, pain when swallowing, longer mealtimes or food refusal, unintended weight loss, changes to breathing, or having a ‘wet or gurgling’ sounding voice after eating or drinking.
• The risk of developing aspiration pneumonia may be reduced if participants receive support from those who are appropriately trained to support individuals with dysphagia.

This information sheet sets out obligations and recommendations for providers to reduce these risks.

Participant rights 

Practical steps to reduce the risk of aspiration pneumonia

What are some practical steps providers should take to reduce the risk of aspiration pneumonia?

There are several steps you can take to provide safe and skilled supports to participants with dysphagia to try to reduce the risks of choking or aspiration pneumonia.

While every participant will have different support needs for their dysphagia, there are some steps the NDIS Commission recommends, detailed below.

1. Ensure staff know dysphagia symptoms and risks

Your staff should have training to improve their knowledge and develop skills so they can support participants who may have dysphagia.

Staff should understand how to identify and respond to early signs and symptoms of dysphagia and how to support the person to have safe and enjoyable meals. 

For more information, refer to the training resources and information materials listed in Where can I find out more?

2. Support participants with possible swallowing difficulties to be assessed for dysphagia

If a participant shows any sign or symptom of swallowing difficulty, you should support them to consult a GP and a speech pathologist promptly. The GP can assess their swallowing and mealtime assistance needs as well as review their general health.

3. Support participants with dysphagia to have a mealtime management plan

Participants with signs of dysphagia should be supported to develop a mealtime management plan written by a health professional. A speech pathologist can prescribe and recommend specific actions for a person to eat and drink safely and develop a mealtime management plan for their needs. They will also specify when plans need to be reviewed and when the input of other members of the healthcare team is indicated. 

A dietitian may contribute to the mealtime management plan to ensure participants are meeting their nutrition needs, and an occupational therapist may contribute to the mealtime management plan to ensure the participant’s equipment, seating, and sensory needs are met.

The provider is responsible for implementing the mealtime management plan and its associated recommendations.

Mealtime management plans may include recommendations to:

• alter the person’s seating and positioning supports during meals
• modify food or fluid textures 
• provide specific mealtime assistance techniques 
• respond to coughing or choking, and make sure risks are monitored while a person is eating or drinking
• use equipment such as spoons, plates, cups and straws, and tube-feeding equipment for those who require non-oral feeding.

4. Support people with dysphagia to eat and drink safely during mealtimes

You should ensure that:

• staff have the necessary training, knowledge and support to identify swallowing difficulties and to implement mealtime management plans or other mealtime recommendations 
• meals for participants with dysphagia, and medication taken orally, are prepared as directed and that mealtime supports and assistance are provided as recommended by health professionals
• trained staff are available to monitor people with dysphagia during mealtimes
• staff know how to respond if a participant starts to choke during mealtimes, including when they should call an ambulance
• mealtime safety issues for people with dysphagia are regularly considered in staff meetings and addressed in day-to-day procedures, participants’ documentation, and plans for transition to hospital.

5. Ensure mealtime management plans are regularly reviewed

Mealtime management plans need to be reviewed regularly by a speech pathologist and any other member of the healthcare team who has had input into the existing plan. You should support a participant with dysphagia to arrange this.

The speech pathologist who develops a mealtime management plan will specify how often it should be reviewed and the circumstances in which you should request a review. 

6. Ensure medications are regularly reviewed 

You should support a participant with dysphagia to have their medications regularly reviewed by a GP, the prescribing medical practitioner or a pharmacist to assess whether the medications may affect their swallowing. Medications may also at times need to be reviewed to suit the person’s swallowing abilities. 

The review can also determine if the medications are suitable when managing risks around swallowing. Several medications have impacts on swallowing, particularly medications for epilepsy or mental health conditions. 

7. Seek medical attention promptly where there are signs of respiratory infection

There can be a short window of time between a respiratory infection and severe illness, so it is important that providers support participants to access medical review if they observe any signs of respiratory infection.

What are my obligations as a provider? 

NDIS Code of Conduct

The NDIS Code of Conduct requires all NDIS providers and workers who deliver NDIS supports to, among other things: 

• provide supports and services in a safe and competent manner with care and skill to meet individual needs
  • the NDIS Commission online learning module Supporting safe and enjoyable meals is available to help NDIS workers understand how to best support safe and enjoyable mealtimes 
• where relevant, refer to other qualified professionals to ensure high quality support (such as doctors, speech pathologists). For guidance on when this is appropriate, refer to Policy guidance: Working within your skills knowledge and experience 
• promptly take steps to raise and act on concerns about matters that might have an impact on the quality and safety of supports provided to people with disability. 

Providers have an obligation to ensure supports provided to participants with dysphagia accord with their needs. This includes ensuring support staff have the skills and knowledge to implement prescribed mealtime assistance strategies and stick to mealtime-management plan recommendations. 
There are significant risks associated with dysphagia, including choking or aspiration pneumonia, which could lead to a participant’s death or serious health complications.
Providers should implement policies and procedures according to the NDIS Practice Standards and Quality Indicators to try to avoid this.

NDIS Practice Standards and quality indicators 

If you are a registered NDIS provider, you also have specific obligations under the NDIS Practice Standards for those requiring support with mealtimes and dysphagia. The quality indicators provide further detail on how to meet the standards. 

The NDIS Practice Standards and quality indicators may also be used by unregistered providers to assess the quality of their service delivery.

They are available here:

• National Disability Insurance Scheme (Provider Registration and Practice Standards) Rules 2018 (Practice Standards Rules)
• National Disability Insurance Scheme (Quality Indicators for NDIS Practice Standards) Guidelines 2018 (Quality Indicators Guidelines)
• NDIS Practice Standards and quality indicators (combined)

The NDIS Practice Standard for mealtime management specifies that: 

The quality indicators for mealtime management contain indicators that providers can demonstrate to show they meet the standard. This includes processes for referral to specialists (including speech pathologists) training for workers, ensuring worker competency and how mealtime plans should be developed and reviewed. See:

• section 26A of the quality indicator guidelines
• Mealtime management Practice Standard and quality indicators.

The NDIS Practice Standards also include an additional standard for providers who are registered to support participants with severe dysphagia, delivered as part of high intensity daily personal activities:

The quality indicators for severe dysphagia contain indicators that providers can demonstrate to show they meet the standard. This includes appropriate worker training by qualified health practitioners with relevant skills in severe dysphagia management. See:

• section 30A of the Quality Indicator Guidelines
• severe dysphagia Practice Standard and quality indicators.

When a provider is supporting participants who rely on high intensity daily personal activities, they need to make sure their workers have the skills and knowledge described in the high intensity support skills descriptors.

There are also some general Quality Indicators that apply to participants who are supported with dysphagia and mealtime management including:

Requirements to avoid delays in treatments for participants:

•    protocols are in place for each participant for how to respond to medical emergencies; and 
•    each worker providing support to them is trained to respond to emergencies (including how to distinguish between urgent and non-urgent health situations).

The NDIS Workforce Capability Framework is a useful resource that describes the attitudes, skills and knowledge expected of all workers funded under the NDIS. Further detail can be found on the NDIS Workforce Capability section of our website.

How does the NDIS Commission ensure compliance?

How does the NDIS Commission ensure provider compliance with practice standards on dysphagia and mealtime management?

Providers, including sole providers or workers, that do not comply with their requirements as a NDIS registered provider or do not stick to the NDIS Code of Conduct may be subject to compliance and enforcement action. The NDIS Commission uses a range of compliance tools to prevent and address breaches of the National Disability Insurance Scheme Act 2013 (NDIS Act), including education, banning orders, compliance notices, court-based outcomes and working closely with other complaints and regulatory bodies. 

The NDIS Commission publishes compliance and enforcement action under Part 2 of the NDIS Provider Register including provider specific information on banning orders, compliance notices, and suspensions of registration.

Detail on our approach can be found in our Compliance and Enforcement Policy.

Also, our Regulatory Approach outlines how we use our regulatory capabilities and resources to ensure the quality and safety of services delivered to NDIS participants.

Information on making complaints to the NDIS Commission is available at Report an issue or make a complaint about a provider or worker.

Where can I find out more?

NDIS Commission Practice Alerts 

• Practice Alert – Dysphagia, safe swallowing, and mealtime management
• Easy Read: Practice Alert – Dysphagia, safe swallowing, and mealtime management
• Practice Alert – Prevention of respiratory infections
• Easy Read: Practice Alert – Prevention of respiratory infections
• Practice Alert – Medicines associated with swallowing problems
• Easy Read: Practice Alert – Medicines associated with swallowing problems
• Practice Alert – Oral Health
• Easy Read: Practice Alert – Oral Health

NDIS Commission online learning

Supporting Safe and Enjoyable Meals

NDIS Commission Practice Standards, Quality Indicators and Skills Descriptors

• NDIS Commission Practice Standards and Quality Indicators
• NDIS Practice Standards: High intensity support skills descriptors

Other resources

• Australian Commission on Safety and Quality in Health Care: 
  Hospital-acquired complication 6: Respiratory complications