Professional Resource Centre

This page provides clinical reference materials for Hong Kong professionals working in dysphagia care:

• Speech-Language Pathologists (SLPs) — IDDSI framework application, assessment tools, referral guidelines
• Occupational Therapists (OTs) — adaptive eating equipment, positioning assessment, environmental modification
• Dietitians — nutritional intervention for dysphagia patients, texture-modified diet planning
• NGO staff and care home management — institutional standard-setting, staff training resources, procurement guidance

Materials on this page are for professional reference only and do not constitute clinical advice. All treatment and dietary decisions should be made by qualified healthcare professionals following individual assessment.

Why Texture Standards Matter: The IDDSI Framework Explained

The Case for Standardisation

Before IDDSI, terms such as “soft diet”, “minced diet” and “fluid diet” lacked consistent definitions across hospitals, care homes, and regions. Foods labelled identically could vary substantially in texture, hardness and safety — increasing patients’ risk of aspiration and aspiration pneumonia.

IDDSI (International Dysphagia Diet Standardisation Initiative) completed global consultation in 2017 and published a framework of 8 levels (0–7), each with defined physical testing methods rather than subjective descriptions.

IDDSI 8-Level Overview

Additional category (EC): Easy to Chew — for patients with mild dysphagia or poor dentition but no aspiration risk.

Standardised Physical Testing

The strength of the IDDSI framework lies in its reproducible physical tests:

Fork Pressure Test — for foods at Levels 4–6:

• Apply approximately 140g of pressure (equivalent to a small apple’s weight) using the back of a standard dining fork
• Level 4: flattens completely, does not spring back, no lumps
• Level 5: compresses noticeably but does not flatten completely, no large particles
• Level 6: offers clear resistance but can be compressed; particle size ≤15mm × 15mm

Syringe Flow Test — for drinks at Levels 0–4:

• Fill a 10ml syringe with the test liquid, depress to 0ml, release and time for 10 seconds
• Level 0 (Thin): ≤1ml remains in syringe
• Level 1 (Slightly Thick): 1–4ml remains
• Level 2 (Mildly Thick): 4–8ml remains
• Level 3 (Moderately Thick): large amount remains but still flows
• Level 4 (Extremely Thick): does not flow

Assessment Tools

EAT-10 (Eating Assessment Tool)

EAT-10 is a widely used dysphagia screening tool consisting of 10 patient-completed questions assessing the impact of swallowing difficulty on quality of life, dietary safety and body weight.

• Score range: 0–40 (each item scored 0–4)
• Threshold: total score ≥3 suggests possible dysphagia; referral to SLP for formal assessment is recommended
• Strengths: brief (approximately 2 minutes to complete), validated Cantonese version available, suitable for initial screening
• Limitations: does not replace clinical assessment; some patients with cognitive impairment may require caregiver assistance to complete
• Download: www.nestlenutrition-institute.org (free)

Try our free digital EAT-10: The SeniorDeli app includes a built-in EAT-10 screening tool with automatic IDDSI recommendations. Download free →

MASA (Mann Assessment of Swallowing Ability)

The Mann Assessment of Swallowing Ability (MASA) is a clinician-administered assessment scale evaluating 24 swallowing-related functional items.

• Items include: alertness, co-operation, respiratory function, dysphasia, auditory comprehension, dysarthria, oral sensation and motor function, cough reflex, voluntary cough, laryngeal movement, and more
• Score range: 24–200; below 178 indicates aspiration risk; below 140 indicates high risk
• Indicated for: early assessment following acute stroke; predicts aspiration and pneumonia risk
• Reference: Mann G. (2002). MASA: The Mann Assessment of Swallowing Ability. Singular Publishing.

Other Commonly Used Assessment Tools

Water Swallow Test (WST)

• Clinician-administered; assesses patient’s ability to safely swallow 5ml, 10ml, and 20ml of water
• Key observations: cough reflex, voice quality change (wet voice), number of swallows
• Limitation: cannot detect silent aspiration; a negative result does not exclude aspiration risk

Videofluoroscopic Swallow Study (VFSS / Modified Barium Swallow Study)

• Dynamic imaging assessment performed in radiology; considered the gold standard for swallowing function evaluation
• Allows direct visualisation of oral, pharyngeal and oesophageal phases; accurately identifies aspiration site and timing
• Hong Kong referral pathway: SLP → attending doctor → radiology

Fibreoptic Endoscopic Evaluation of Swallowing (FEES)

• Performed by an ENT specialist or trained SLP; provides direct endoscopic visualisation of the swallowing process
• Can be conducted at the bedside; suitable for patients unable to be transferred to radiology

Care Planning Guidance

Interdisciplinary Collaboration Framework

Effective dysphagia management requires coordinated interdisciplinary input. The following is a recommended collaboration model:

Acute Phase (Inpatient)

1. SLP: initial assessment; prescribe IDDSI diet and drink levels; issue written Dysphagia Diet Prescription
2. Doctor: confirm diagnosis; coordinate referrals; manage related conditions (e.g. pneumonia, dehydration)
3. OT: assess independent eating ability; recommend adaptive equipment; train safe eating techniques
4. Dietitian: calculate energy and protein requirements; develop texture-modified diet plan; evaluate need for oral nutritional supplements

Sub-acute and Rehabilitation Phase

• Regular interdisciplinary meetings (weekly recommended) to review diet level and progress
• Goal-directed: progress toward higher IDDSI levels where safe, or optimise quality of life at current level

Community Follow-up

• Post-discharge connections to confirm: outpatient speech therapy, GP review, community OT (if indicated), social worker referral for SWD services
• Caregiver training: ensure primary caregivers understand IDDSI levels, thickener use, and high-risk foods

Core Elements of an IDDSI Diet Plan

Diet-related sections of care plans should include:

• Food level: explicit IDDSI level (0–7)
• Drink level: IDDSI level for all beverages (0–4)
• Thickener type and dose: brand name, grams per 100ml / 150ml / 200ml of liquid
• Prohibited foods: specific high-risk items listed (not merely “avoid hazardous foods”)
• Eating posture: head position, body angle, assistive equipment
• Monitoring indicators: warning signs requiring reassessment (weight loss, increased coughing, prolonged mealtimes)
• Next review date: newly diagnosed patients — every 4–8 weeks; stable patients — every 3–6 months

Educational Materials (Reference Guide)

Care Home Staff Training

IDDSI Official e-Learning

• Source: iddsi.net/Training
• Free self-paced online course covering IDDSI framework theory and practice; suitable for kitchen staff, care workers and management
• Available in multiple languages; electronic certificate of completion issued on passing

HKCSS Care Food Training

• The Hong Kong Council of Social Service runs care food training programmes for care home staff, including kitchen technique and IDDSI application
• Enquiries: hkcss.org.hk

softmeal.org Downloadable Materials

• IDDSI kitchen operations poster (A3, colour)
• Fork pressure test / syringe flow test instruction guide
• Meal observation record form (7-day version)
• Pre-meal safety checklist

To request these materials, contact [email protected], stating your organisation name and intended use.

Family and Caregiver Education

Discharge Caregiver Education: Recommended SLP Checklist

1. Patient’s current IDDSI food texture and drink thickness level
2. Correct thickener use (demonstrate weighing and dissolving steps)
3. Prohibited foods list (visual format most effective)
4. Correct eating posture and head position during meals
5. Warning signs requiring immediate medical attention (persistent choking, fever, breathing difficulty)
6. Community follow-up appointment details

Referral Pathways: Hospital to Community

Public Healthcare Referral Flow

Emergency admission
    ↓
Inpatient SLP assessment → IDDSI levels + written Dysphagia Diet Prescription
    ↓
Pre-discharge arrangements:
  - Outpatient SLP appointment
  - Geriatric Day Hospital (if appropriate)
  - Medical social worker referral to SWD
    ↓
Community follow-up:
  - GOPC or specialist outpatient clinic
  - Care home / home-based SLP (select clusters)
  - Private SLP (if resources allow)

Professional Referral Contacts

HA Speech Therapy Departments

• Pathway: HA electronic booking system (HA Go App) or attending doctor referral
• Urgent inpatient referral: attending doctor / ward nurse contacts speech therapy department

Private Speech-Language Therapists

• Search: Hong Kong Speech-Language Therapists Association (HKSLTA) register: hkslta.org.hk
• Hong Kong Speech and Hearing Association (HKSHA) register: hksha.org

Community Occupational Therapy

• Public: referral via care home social worker or HA medical social worker
• Private: Hong Kong Occupational Therapy Association (HKOTA) register: hkota.org.hk

Social Welfare Department Services

• Hotline: 2343 2255
• Referral via hospital medical social worker, or patient / family may apply directly

Frequently Asked Questions (Professionals)

Q: Can a nurse or caregiver determine a patient’s IDDSI level without a formal SLP assessment?

A: No. IDDSI level prescription must be made by a trained speech-language pathologist following clinical assessment. Silent aspiration can occur without any cough reflex or visible choking, making observational assessment of mealtime behaviour unreliable. Nurses and caregivers implement the plan prescribed by the SLP and monitor for warning signs — they do not prescribe diet levels.

Q: Can the patient upgrade their own IDDSI level at home?

A: This should not happen without a formal SLP reassessment. Even when a patient subjectively feels they are “swallowing better”, silent aspiration can persist without visible symptoms. Any level upgrade requires a clinical evaluation.

Q: Are Hong Kong care homes legally required to follow IDDSI standards?

A: Current Hong Kong legislation (Code of Practice for Residential Care Homes) does not specifically mandate IDDSI levels. However, the HKCSS Care Food Endorsement Scheme has become the de facto industry benchmark. Using IDDSI documentation and maintaining complete dietary records substantially reduces the legal and reputational risk to care homes in the event of adverse incidents.

Q: How can a care home kitchen implement IDDSI testing on a limited budget?

A: The minimum-cost approach: purchase 10ml syringes from a pharmacy (approximately HKD 5 each) for the flow test; use existing dining forks for the pressure test; download IDDSI’s free testing cards from iddsi.net. Consistent testing discipline matters more than expensive equipment — test every new food batch and record results. The IDDSI Quick Reference Chart, printable for free, should be posted at every kitchen station.

This page is updated periodically to reflect current clinical guidelines. If you identify errors or wish to contribute, please contact [email protected].