Approved by: Choking Prevention and Management Sr. Operating Officer, Mental Health & Seniors Care, Edmonton Sr. Operating Officer, Rural Services Corporate Policy & Procedures Manual Number: VII-C-30 Date Approved February 1, 2016 Date Effective August 12, 2016 Next Review (3 years from Effective Date) August 2019 Purpose - To reduce the risk of morbidity and mortality from choking* incidents related to foreign-body airway obstruction. - To increase resident safety by establishing competency/education requirements and processes to manage the risk of choking in a consistent and transparent approach ensuring accurate recording and communication of adverse events. Policy Statement At Covenant Health Continuing Care facilities, unregulated health care providers* who provide assistance with nutrition and hydration and/or medication assistance shall receive training within six months from the date of hire and on an annual basis thereafter in: a) choking prevention; and b) response to a choking event involving a conscious resident with either partial or complete airway obstruction. Unregulated health care providers who care for residents shall have education and demonstrate competency in choking prevention and management prior to providing unsupervised feeding or medication administration. Health care professionals* shall be certified in basic life support (BLS) with cardiopulmonary resuscitation (CPR), inclusive of appropriate responses to a choking event involving an unresponsive resident, as required according to their job description and/or terms of employment. Refer to Covenant Health policy #II-5, Cardiopulmonary Resuscitation (CPR) Certification and Recertification. Applicability This policy and procedure applies to all Covenant Health Continuing Care facilities, their staff, volunteers, students and any other persons acting on behalf of Covenant Health. Responsibility Health care providers who assist residents with feeding or medication administration shall demonstrate compliance with this policy and procedure by: adhering to the education requirements; ensuring they maintain annual competency; acting to minimize risk of choking for all residents; and documenting choking incidents on the resident s health record*. Principles Choking risk identification and risk mitigation are essential components of quality care in all continuing care practice settings. * See 'Definitions'
Choking Prevention and Management Procedure 1. Screening/Assessment Date Effective: August 12, 2016 Policy No. VII-C-30 Page 2 of 7 1.1 A resident must be screened and assessed for choking risk (refer to Appendix A - Choking Prevention in Continuing Care - Care Planning Resources), whenever a RAI assessment is completed and upon significant change in the resident's health status. 1.2 Practice settings (inclusive of site, unit, program, etc.) may choose to implement additional validated screening/assessment tool(s) based on the need of the population served. 2. Care Planning 2.1 When risk of choking has been identified as an issue with regard to a particular patient, an individualized plan to address the risk must be developed and documented in the care plan. As much as possible, include the resident and/or their alternate* decision maker, in the development of the care plan. Document the plan on the resident's health record. Refer to Appendix A - Choking Prevention in Continuing Care - Care Planning Resources for assessment and care planning support. 3. Interventions 2.1.1 Residents and/or alternate decision maker(s) may choose to live at risk despite an identified choking risk. In this case, health care providers will negotiate with residents to minimize the risk as much as possible and document the plan. 3.1 Should a choking event occur, health care providers shall carry out the following choking interventions: 3.1.1 Unregulated health care provider shall, as per level of training: Initiate steps to clear the airway of obstruction on a conscious resident. If the airway is cleared immediately, report to a supervisor and/or a health care professional for further instructions. If the airway does not clear immediately, and the resident becomes unresponsive, notify a health care professional if available at the point of care, and/or active the medical emergency response plan (eg. activate Code Blue or contact Emergency Medical Services [EMS]) appropriate to the site or program. Remain with the resident until EMS or a health care professional arrives and assumes care of the resident.
Choking Prevention and Management Date Effective: August 12, 2016 Policy No. VII-C-30 Page 3 of 7 If currently trained in BLS, attempt to clear the airway of the unresponsive resident. 3.1.2 Health care professionals shall: Initiate steps to clear the airway of obstruction. If the airway is cleared immediately, assess the need to transport the resident for further medical treatment, and/or to notify appropriate medical personnel (eg. physician and/or nurse practitioner). If the airway does not clear immediately and the resident becomes unresponsive, active the medical emergency response plan (eg. activate Code Blue or contact EMS) appropriate to the site or program or based on the resident s plan of care. Attempt to clear the airway of the unresponsive resident; and If at anytime the resident is assessed to have no pulse and is not breathing, follow goals of care designation to determine if CPR should be initiated. Refer to Covenant Health Policy #VII- B-350, Advance Care Planning Goals of Care Designation. 4. Notification, Investigation & Reporting Requirements 4.1 In the event of an adverse event, close call or hazard, health care providers shall adhere to the requirements identified in Covenant Health Policy #III-45, Responding to Adverse Events, Close Calls, and Hazards, for notification, investigation and reporting of incidents. 4.2 As appropriate, adverse events shall be disclosed to the resident and their family as per Corporate Policy #III-60, Disclosure of Adverse Events, Close Calls and Hazards. 5. Post Choking Incident 5.1 Following a choking event the health care provider shall; 5.1.1 Investigate and report any new complaints of breathing difficulties, pain, new or unusual cough, discomfort or difficulty swallowing; 5.1.2 Review the resident s care plan to ensure risk mitigation interventions are relevant, appropriate, and based on the individualized need(s) of the resident; and 5.1.3 Identify if any referrals or consults are required for further assessment or to identify risk mitigation strategies (eg. dietician,
Choking Prevention and Management Date Effective: August 12, 2016 Policy No. VII-C-30 Page 4 of 7 6. Documentation occupational therapist, speech language pathologist, respiratory therapist, community paramedic, geriatric consult, etc.) 6.1 In addition to the requirements identified in Section 4 above, the health care provider shall record any choking incidents in the resident s health record; including but not limited to time of day, location of event, description of food/item ejected, level of intervention required, and impact on the resident. 7. Transfer 7.1 Documented choking risk shall be communicated to the receiving site upon transfer of the resident to another care setting. Definitions Alternate decision maker means a person who is authorized to make decisions with or on behalf of the resident. These may include, specific decision-maker, a minor s legal representative, a guardian, a nearest relative in accordance with the Mental Health Act, an agent in accordance with a Personal Directive, or a person designated in accordance with the Human Tissue and Organ Donation Act Choking means, for the purposes of this document, a partial or complete blockage of the airway resulting in obstruction of the flow of air from the environment into the lungs. Goals of care designation means a codified instruction that provides direction regarding general care intentions, specific health interventions, transfer decisions and locations of care, for a patient as established after consultation between the most responsible health practitioner, resident and, when appropriate, alternate decision-maker. Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act [Alberta] or the Health Professions Act [Alberta], and who practices within scope and role. Health care provider means any person who provides goods or services to a resident, inclusive of health care professionals, staff, students, volunteers and other persons acting on behalf of or in conjunction with Covenant Health. Health record means Covenant Health's legal record of the resident s diagnostic, treatment and care information. Related Documents Appendix A Choking Prevention in Continuing Care Care Planning Resources Covenant Health Policies & Procedures: II-5, CPR Certification and Re-certification III-45, Responding to Adverse Events, Close Calls and Hazards III-60, Disclosure of Adverse Events, Close Calls and Hazards VII-B-350, Advance Care Planning Goals of Care Designation
Choking Prevention and Management Date Effective: August 12, 2016 Policy No. VII-C-30 Page 5 of 7 Choking Prevention and Safe Mealtime Management (AHS) resources page @ http://insite.albertahealthservices.ca/13435.asp References Continuing Care Health Service Standards, 2016 Accreditation Canada, Long-Term Care Services Standards for surveys starting after January 1, 2015 Chronological Revision Date(s) February 5, 2016
Choking Prevention and Management Date Effective: August 12, 2016 Policy No. VII-C-30 Page 6 of 7 APPENDIX A Choking Prevention in Continuing Care Care Planning Resources Choking prevention in continuing care involves screening for risk of choking, identifying the level of risk for the individual, and implementing evidence-based risk reduction strategies that promote safe chewing and swallowing. 1. Screening/Assessment Utilize the RAI-HC, RAI-2.0 or appropriate Comprehensive Assessment based on client group to help identify dysphagia, chewing problems and potential or actual choking risk. RAI-HC: RAI-2.0: Section L: Nutrition/Hydration Status Supporting assessment information: Section B: Cognitive Patterns Section H.2(g): ADL Self Performance Eating Section J.1(g-l,s,z): Disease Diagnosis Neurological, Psychiatric/Mood, Emphysema/COPD/Asthma Section M: Dental Status (Oral Health) Section Q: Medications Section K: Oral/Nutritional Status Supporting assessment information:: Section B: Cognitive Patters Section G.1(h) Physical Functioning and Structural Problems Eating Section I.1(q-kk) Disease Diagnosis Neurological, Psychiatric/Mood, Pulmonary Section L: Oral/Dental Status Section O: Medication List Also consider any history of choking or ingestion of non-food items. Practice settings may choose to implement an additional screening/assessment tool based on the needs of the population served 2. Risk Determination Past history, current assessment and sound clinical judgment guide effective risk determination. The following may be used as a guideline to classify choking risk potential. Low Risk Moderate/High Risk No history of choking Eats independently No clearly identified risk factors Concerns that may require further investigation: Need for repeated swallowing Recurrent chest infections/pyrexia Weak voluntary cough Food residue in mouth Inability to maintain optimal eating posture Poor oral/dental health Reduced appetite Poor fitting dentures History of: choking; aspiration; swallowing disorder; chewing problems; mouth pain; dry mouth; prolonged swallow; changes in approach to food: avoidance of eating alone (fear), avoidance of eating with others (embarrassment), depression/frustration (r/t restricted food choices); Complaints of: difficulty initiating a swallow; sensation of obstruction in throat or chest; regurgitation of food or acid; inability to handle secretions; impaired breathing during meals or immediately after eating; pain on swallowing. Dependent for eating/oral care Frail elderly Psychiatric (medication related), neurological (paralysis), cognitive (impaired insight), or respiratory disease (micro-coordination of breathing swallowing) Polypharmacy; sedating medications Edentulous/poor dentition History of ingesting non-food items
Choking Prevention and Management 3. Risk Reduction Care Planning Interventions Date Effective: August 12, 2016 Policy No. VII-C-30 Page 7 of 7 The following interventions may be considered based on identified risk and individual assessed needs/preferences. This is not an exhaustive list. Please consider individualized needs and supports available. Low Risk General Interventions: Ensure dentures (if used) fit properly Provide oral care before and after meals Ensure the client is seated in an upright position Sit facing the client while assisting Adjust rate of feeding and size of bites to the person s tolerance Avoid rushed or forced feeding Ensure enough time to chew between bites Consider using a spoon instead of a fork when assisting Alternate solid and liquid boluses Observe for and report signs of choking, regurgitating, drooling, pocketing food, etc. Provide a pleasant mealtime atmosphere Increase concentration by reducing distractions (TV off; limit conversation during swallowing phase) Encourage participation Moderate/High Risk All general interventions plus consider: Evaluate swallowing-specific quality of life using validated assessment tools (eg. SWAL-QOL; SWAL- CARE; MD Anderson Dysphagia Inventory; EAT-10) 1 Medication Review (r/t dry mouth; cause motor fluctuations; reduce alertness; depress reflexes; increase reflux; cause nausea; require alteration to administer) Ongoing observation for aspiration pneumonia in highrisk persons Effective mouth care is performed frequently to decrease oral bacterial load decreasing chance of aspiration pneumonia Consider placement of food in the person s mouth according to the type of deficit (eg. stroke) and appropriate head positions Assess diet modifications to ensure they do not contribute to malnutrition/dehydration (eg. unappealing texture/ presentation (use food molds); decreased food choices r/t modification needs (increase choices) Re: inappropriate ingestion of non-food items o Environmental scan for and removal of high risk non-edible / non-food items (eg. paper napkins, condiment packages/lids, pill cups, latex gloves, etc.) o Consider cloth napkins/placemats, bulk condiment packages (jars), keeping appropriate snacks readily accessible/ available Involve a registered dietitian (RD) in care planning and assessment of appropriate diet texture and fluid consistency and comprehensive swallowing assessment Referral to a speech language pathologist (SLP) for comprehensive swallowing assessment and appropriate interventions Involve Physiotherapy (PT) to improve trunk/head control strength and arm/hand co-ordination Referral to an occupational therapist (OT) to assist with functional challenges and equipment needs and comprehensive swallowing assessment Referral to a respiratory therapist (RT) for comprehensive respiratory assessment and appropriate interventions Referral to a geriatrician for cognitive/medical needs Consult with a dental hygienist for oral care needs 1 Miller, N., & Patterson, J. (2014). Dysphagia: implications for older people. Reviews in Clinical Gerontology, 24(01), 41-57.
Choking: HCA Education Continuing Care Alena Thompson, RN, BScN Reviewed by Professional Practice Dept. Adaptations by Berni Baer RN GNC(c), Education Coordinator St. Joseph s Auxiliary Hospital March 29, 2016
Who do we help? WE HELP ANY ONE WHO IS CHOKING i.e. Resident Client Patient Visitor Co-worker
Signs of poor air exchange and difficulty breathing Mild Airway Obstruction signs: Good air exchange Can cough forcefully May wheeze between coughs
How can you help the Resident who has mild airway obstruction? Rescuer Actions: Encourage the victim to continue spontaneous coughing and breathing efforts Do not interfere with the residents efforts to cough up what they are choking on (ie. Do not slap them on the back, give a drink of water, etc.) Stay with the resident and monitor their condition. If mild airway obstruction persists, call CODE BLUE.
Signs of poor air exchange and difficulty breathing Severe Airway Obstruction signs: Poor or no air exchange High pitched noise while inhaling or no noise at all Increased difficulty breathing Weak ineffective cough or silent cough mouth opening and closing repeatedly as if they are trying to speak but no sound. Think guppy
Signs of poor air exchange and difficulty breathing Severe Airway Obstruction- signs: (continued) Cyanosis (turning blue) Unable to speak May show the universal choking sign (clutch neck with both hands) Clipart: www.medtrng.com Tell a co-worker to call Code Blue.
Does the resident with Severe Airway Obstruction need your help? Rescuer Actions: Ask the resident if she/he is choking: If yes, begin abdominal thrusts. If no, stay close and allow them to try to get it out themselves. If they are showing signs of severe airway obstruction but are unable to confirm or deny that they are choking, begin abdominal thrusts
How to do abdominal thrusts Stand or kneel behind the resident Wrap your arms around their waist Locate their navel (belly button) Make a fist with one hand and place it thumb side inward between the navel and breastbone Grasp fist with other hand and press into abdomen with QUICK, FORCEFUL, UPWARD thrusts Demonstration of Abdominal Thrust: https://www.youtube.com/watch?v=de45ks9miiw
Abdominal thrusts Clipart: www.nursing411.org
How abdominal thrusts work When you choke on something, your body tries to clear your airway by coughing. Abdominal thrusts try to do the same thing with an artificial cough. The illustration on the right shows how an abdominal thrust creates a cough. An abdominal thrust pushes the diaphragm up towards the lungs very quickly - this forces air from the lungs up the airway and, hopefully, blows the object out. For the best effect, your fist has to be in the right place, the forearms off the abdomen and each thrust a strong and sudden movement. Source of quote & associated illustration http://www.familyhealthonline.ca/fho/firstaid/fa_choking_fha06.asp
Chest thrusts If victim is obese or rescuer cannot reach around to victim s abdomen, chest thrusts can be done either standing or with the victim seated(ie. wheelchair): From behind the person wrap your arms around their chest just under the armpits. Make a fist with one hand and place it thumb side inward in the middle of the victims chest Grasp fist with other hand and forcefullypress inward in centre of chest. Alternatively Clipart: www.cc.utah.edu Cross arms over one shoulder and under other arm to reach centre of chest and give chest thrusts
When to stop: Continue abdominal thrusts until: Object is expelled (comes out) Resident collapses/becomes unresponsive
Chest thrusts for person in a wheelchair Push the wheelchair against the wall, lock the brakes and kneel in front of the victim. Place the heel of one hand on the breast bone, at the nipple line, place the other hand on top of it and interlock the fingers. Forcefully press straight back.
Abdominal thrusts for person in a wheelchair Push the wheelchair to a wall, lock the brakes, kneel in front of the victim and give abdominal thrusts from the front by pushing inward between the navel and breastbone. Note: Abdominal thrusts are not as effective for a person in a seated position. Chest Thrusts are the preferred method.
Abdominal thrusts - alternative method Carefully lower the conscious resident to the floor and give abdominal thrusts Straddle the person and put the heel of one hand mid abdomen, just below the ribcage. Place your other hand on top of this hand, interlocking your fingers, then press in and up in a smooth, forceful movement. Do this until object is expelled or the person becomes unconscious. Abdominal Thrust on floor clip art from: http://www.infoplease.com/ipa/a0194633.html
Chest thrusts - alternative method Carefully lower the conscious resident to the floor and give chest thrusts Kneel at person s side, place heel of one hand on chest at the nipple line. Place your other hand over it and interlock your fingers. Press straight down until object is expelled or the person becomes unconscious. Chest Thrust on floor clip art from: http://nursing411.org/courses/md0532_cardiopulmonary_resuscitation/md0532/images/md0532_img_24.jpg
If resident collapses and becomes unresponsive Carefully get them to the floor (if not already there) Make sure a co-worker has called Code Blue & 911 Start CPR (if you ve had the training)
Self-Help Abdominal Thrusts If there are others nearby, get their attention. If you are alone do whatever you must do to get someone's attention. Call 911. Do not allow anyone to slap you on the back. If there is no one else to give you abdominal thrusts, give them to yourself (see illustrations on this slide). Source of information & associated illustration http://www.familyhealthonline.ca/fho/firstaid/fa_choking_fha06.asp
Important note Seek medical attention after abdominal/chest thrusts are performed. There could be injuries from this maneuver i.e. bruised/broken ribs; punctured liver; etc.
References American Heart Association (2011). BLS for Healthcare Providers Student Manual. First Heart and Stroke Foundation of Canada Printing May 2011. Covenant Health Policy VII-C-30: Choking Prevention and Management http://www.familyhealthonline.ca/fho/firstaid/fa_choki ng_fha06.asp
Time to practice With a partner practice correct land marking and hand placement. DO NOT DO ACTUAL PERFORMANCE OF THE MANEUVER as it could injure your partner.