Category: Care Management Sub-category: Care Practice Page: 1 of 10 Policy Review Sheet Review Date: 14/10/16 Policy Last Amended: 19/10/17 Next planned review in 12 months, or sooner as required. Note: The full policy change history is available in your online management system. Low Medium High Critical Business Impact: X Changes are important, but urgent implementation is not required, incorporate into your existing workflow. Reason for this review: Were changes made? Summary: New Policy Yes This is a new policy and procedure. It formally defines the steps to take to identify when somebody is at risk of choking whilst eating, and it defines the actions to take, and who should be involved in the management when issues are identified. Relevant Legislation: Equality Act 2010 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Mental Capacity Act 2005 Underpinning Knowledge - What have we used to ensure that the policy is current: National Patient Safety Agency, (2007), Ensuring safer practice for adults with learning disabilities who have dysphagia. [Online] Available from: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59823 [Accessed: 29/07/2016] Department of Health, (2015), Dysphagia (swallowing problems). [Online] Available from: http://www.nhs.uk/conditions/dysphagia/pages/definition.aspx [Accessed: 29/07/2016] Surrey safeguarding Adults Board, (2014), CHOKING PREVENTION POLICY. [Online] Available from: https://www.surreycc.gov.uk/social-care-andhealth/contacting-social-care/surrey-safeguarding-adults-board/surreysafeguarding-adults-board-information-for-professionals/protocols-forms-andguidance/surrey-safeguarding-adults-board-choking-prevention-policy-2014 [Accessed: 19/10/2017] Suggested action: Notify relevant staff of changes to policy Share Key Facts with professionals involved in the service Discuss in team meetings Discuss in supervision sessions
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Page: 3 of 10 1. Purpose 1.1 To enable London Care Responds Limited to deliver services that reduce the risk of choking as part of the safe and appropriate care that people should get that meets their needs and supports their rights. This includes providing a framework for identification and assessment of Service Users with dysphgaia/at risk of choking and associated risks, and ensuring appropriate management that will help to meet the Service User's nutritional and hydration needs. 1.2 To support London Care Responds Limited in meeting the following Key Lines of Enquiry: Key Question EFFECTIVE Key Line of Enquiry (KLOE) E3: How are people supported to eat and drink enough and maintain a balanced diet? 1.3 To meet the legal requirements of the regulated activities that London Care Responds Limited is registered to provide: Equality Act 2010 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Mental Capacity Act 2005 2. Scope 2.1 The following roles may be affected by this policy: All staff 2.2 The following people may be affected by this policy: Service Users 2.3 The following stakeholders may be affected by this policy: Family Advocates External health professionals NHS 3. Objectives 3.1 London Care Responds Limited will provide a safe, effective and responsive service to Service Users presenting with eating, drinking and or swallowing difficulties. This will include the identification, assessment and management of swallowing difficulties 3.2 London Care Responds Limited will ensure that all people using the service with swallowing difficulties or at risk of choking will be assessed so as to accurately determine the level of dysphagia that they have and the associated risks. 3.3 London Care Responds Limited will provide a comprehensive and responsive service for individuals, and their carers, presenting with eating, drinking and/or swallowing difficulties. 3.4 London Care Responds Limited will have an individual management plan that is regularly monitored and updated. This plan may include texture modification, strategies and environmental modifications to effectively minimise weight loss and aspiration while maintaining quality of life. 3.5 London Care Responds Limited will ensure Service User and carer involvement in the planning of dysphagia services, and the care and support they receive allow the best experience of eating/drinking as possible while keeping risks to a minimum.
Page: 4 of 10 4. Policy 4.1 London Care Responds Limited recognises that reducing the risk of choking and improving the safety of individuals who have swallowing eating and drinking difficulties is an essential part of the safe and appropriate care, that meets individual needs and supports their rights. 4.2 London Care Responds Limited understands that strategies should be in place to identify people at risk of choking. This includes access to dental and medical checks. 4.3 London Care Responds Limited will ensure that staff are adequately trained to address choking risks, have knowledge of dealing with choking incidents, and be able make a first aid response if the person chokes. 4.4 London Care Responds Limited will ensure that all adults who are at risk of choking or with dysphagia are assessed so as to accurately determine the level risk. Appropriate risk assessment forms are attached to the policy. 4.5 There are referral arrangements for both Speech and Language Therapist (SLT) and Dietitian to assess individual residents who have chewing or swallowing difficulties and any special nutritional requirements. 4.6 After a referral a full swallowing assessment should be carried out by specialist practitioners, often Speech and Language Therapists (SLTs) or those trained to recognise the varying symptoms of dysphagia. 4.7 London Care Responds Limited will ensure that all individuals with dysphagia have an individual management/care Plan developed with specialist professionals that is regularly monitored and updated and the risk reassessed as the needs of the person change. 4.8 All Service Users must have their needs met safely and in line with the agreed person centred Care Plan. 4.9 All staff providing care for people should adhere to the choking policy and procedure to support the safety and well-being of those people with an identified increased risk of choking. 4.10 To improve the safety of adults who have dysphagia/at risk of choking accessible information on the assessment and dysphagia management should be made available for Service Users, their carers and families, including advice on the preparation of suitable food and fluids. 4.11 Incident reporting systems must be in place for the accurate recording, reporting and actioning of choking incidents, or potential choking incidents for all people with dysphagia or who are at risk of choking. 4.12 Carers and staff working with Service Users with dysphagia / risk of choking need to be aware that a change in a Service Users medication could produce side effects that may worsen their condition. The implications of any such change should be first clarified with a GP and pharmacist. 4.13 Local liaison and care transfer protocols should be in place between The Agency, hospital and community services. 4.14 London Care Responds Limited will (if possible) identify an appropriately trained, skilled and experienced member of staff with a lead responsibility for dysphagia services.
Page: 5 of 10 5. Procedure 5.1 Risk Assessment To reduce the risk of aspiration and choking, whist meeting the nutrition and hydration needs of the individual, a choking assessment risk should be undertaken and recommended action followed 5.2 A risk assessment must be made on admission and lead to a Care Plan and appropriate course of action. Any appropriate referrals must be made indicating urgency of need. 5.3 As part of the risk assessment procedure, an assessment should be made to indicate risk of choking and whether referral to SLT for swallowing assessment or further discussion with a health professional is required. A risk assessment form is included in the documents attached to this policy. 5.4 Staff must gain consent wherever possible before choking assessment is undertaken. When person is unable to give informed consent best interest decisions are made using the guidelines in the mental capacity act and best interest guidance. 5.5 A Choking risk assessment and reassessment should be undertaken: Every 6 months or every time there is concern about Service Users swallowing ability or eating and drinking If a person is considered to be at risk of choking If there has been significant change in the Service User s level of need which might increase their risk of choking If the persons choking risk increases as a result of their behaviour 5.6 SLT when required will complete a comprehensive assessment (an assessment form is available in the documents attached to this policy) that should investigate potential causes, eating, drinking and swallowing skills and result in recommendations to staff which aim to manage and reduce the risk whenever possible. This should include: Service Users requirements Safe swallowing management Assessment of risk from cognitive factors that could compromise safety of the swallowing process 5.7 Service provider must ensure SLT recommendations are followed to reduce risk. 5.8 Meal times should be recognised as an opportunity for reassessing risk in a person identified as being at increased risk of choking. 5.9 Service Users exhibiting challenging behaviour that increases their risk of choking such as putting non-food items into mouth or swallowing non-food items should have a multidisciplinary team assessment. 5.10 Care Planning Where a risk of choking has been identified the plan must include what the concern is and what needs to be done so that the plan clearly indicates what support should be given to the person to eat and drink safely and minimise the risk of choking 5.11 When required the SLT should provide clear instruction to The Agency to minimise the risk of choking and this advice must be included in the persons Care Plan, and followed by all staff providing care. 5.12 Staff must be fully competent to recognise and assess risk and trained to deliver safe care in line with the agreed Care Plan. 5.13 Care Plan should be reviewed by the care provider and the risk reassessed as the needs of the person change. Assessments and decisions must be actively revisited following any change or deterioration in health or behaviour. 5.14 The development of individual Care Plans should wherever possible include the person and those who provide care. Individual needs and requirements should be accurately documented in the Care Plan.
5.15 In addition to regular reviews staff should remain vigilant and responsive to individual needs on a daily basis. 5.16 Any choking episode/incident must be reported and well documented in Care Plans in order that frequency and severity can be determined and action reviewed so that assurance is given that care is delivered safely. 5.17 Care Plans must: Give clear information to caregivers on how to manage the choking risk and make meals safe and enjoyable Include recommendations on fluid and food consistencies recommended position equipment and level of assistance required for the person Include information on the Service Users food and drink preference where applicable but it's important to remember that foods need to be given in accordance with food modification and texture advice Follow the principles of the Mental Capacity Act, and where decisions are made on behalf of the person then they need to be in the Service Users best interests Be reviewed every 6 months (minimum) using an appropriate assessment tool 5.18 When there is an identified choking risk a review of oral medication should be undertaken, and for all medicines that need to be continued an alternative dietary route should be considered. Alternative dose forms may be required advice from GP/pharmacist should be sought on changes in medication that may be necessary. 5.19 If person is admitted to another health/social care provide for any reason (e.g. hospital admission), eating and drinking needs should be communicated. 5.20 Staff Requirements Staff must know who is at high risk of choking, understand the individualised support needed to reduce their risk of choking when eating or drinking and provide the required support to promote people's safety. Daily records should indicate that the appropriate foods have been given according to advice from an SLT 5.21 It is the responsibility of the service provider to ensure all staff (including catering staff if applicable) are trained to meet the needs of the person they care for who may present with a risk of choking. 5.22 Staff must be familiar with choking policy. 5.23 Relevant staff must be able to identify and manage Service Users at choking risk / with dysphagia and ensure appropriate management. 5.24 Staff must understand and follow the referral process to SLT. 5.25 Staff must ensure they follow the recommendations set out by professionals including SLTs in order to reduce risk. 5.26 Staff supporting people identified at risk of choking must have the first aid training to be able to provide emergency aid response to choking. 5.27 Staff should recognise early the signs and symptoms that may indicate risk of choking: Coughing during or immediately after eating or drinking Wet vocalisation after drinking Change of skin colour Watering eyes Refusal of food before or during meal Increased anxiety when eating or drinking Behavioural difficulties when eating or drinking times 5.28 Staff should be aware that chronic symptoms of dysphagia include chest infections, malnutrition and dehydration. 5.29 Staff should have the skills to support individuals at risk of choking with their eating and drinking including: Being involved in the Care Planning process for people at risk of choking Being aware of the consequences of not following an agreed eating and drinking plan Page: 6 of 10
Completing a choking risk assessment any time a new or increased risk of choking is identified Having adequate skills in making mealtimes as safe and pleasurable as possible, including communication at mealtimes Ensuring Service Users are positioned correctly and safely when eating or drinking Being able to prepare and present food and drink to the person in a way that follows with their documented recommendations Ensuring that any foods brought in match the appropriate consistency Being aware of foods with high choking risk Identifying support services and referral process 5.30 Robust procedures should be in place to ensure that all staff are aware where Service Users require a modified diet or fluid consistency and this must be communicated to all staff involved in the care of the Service User. Service Users on a recognised modified texture must only be given the correct diet consistency. This includes snacks and foods given out of mealtimes and across all settings. 5.31 Presence of staff at mealtimes is critical for observation and to reduce the risk of any unobserved incident of choking. Mealtimes are also a good time to build relations with Service Users, and to more fully understand their behaviour, motivations and specific dietary requirements. 5.32 Any choking incident (whether there are serious consequences or not) must be reported. 6. Definitions Page: 7 of 10 6.1 Choking The inability to breathe because the trachea is blocked, constricted or swollen shut 6.2 Dysphagia Medical term used to refer to difficulty/discomfort in swallowing It is a serious problem can lead to malnutrition, dehydration, choking and aspiration pneumonia 6.3 Aspiration The inhalation of food/drink particle into lungs 6.4 Speech and Language Therapist (SLT) Health professional that provides life-improving treatment, support and care for children and adults who have difficulties with communication, eating, drinking or swallowing 6.5 Nutritional Requirement The amount of nutrients needed to maintain health and reduce the risk of diet-related diseases 6.6 The Mental Capacity Act 2005 Primary legislation designed to support and enhance the lives of people that are assessed as not having capacity to make decisions themselves
Page: 8 of 10 Key Facts - Professionals Professionals providing this service should be aware of the following: Reducing the risk of choking and improving the safety of individuals who have swallowing eating and drinking difficulties is an essential part of safe and appropriate care, that meets individual needs and supports their rights To reduce the risk of aspiration and choking, whist meeting the nutrition and hydration needs of Service Users, a choking assessment risk will be undertaken and recommended action followed Where Service Users are identified at risk of choking, a Care Plan will clearly indicate what support should be given to the person to eat and drink safely and minimise the risk of choking Staff will be aware of Service Users at high risk of choking, and understand the individualised support needed to reduce their risk of choking when eating or drinking, including keeping records indicating the appropriate foods and drinks according to advice from health professionals Any choking incident (whether there are serious consequences or not) will be reported The involvement of external professionals such as Speech and Language Teams (SLT) is paramount in the support of individuals identified as at risk of choking Key Facts - People Affected by The Service People affected by this service should be aware of the following: Service Users will have their choking risks assessed to ensure that risks for choking when eating and drinking are reduced, and individual nutrition and hydration needs are met To reduce the risk of choking, whist meeting the nutrition and hydration needs of Service Users, a choking assessment risk will be undertaken and recommended action followed Where Service Users are identified at risk of choking, a Care Plan will clearly indicate what support should be given to the Service User to eat and drink safely and minimise the risk of choking Care and support surrounding Service Users with risk of choking is an essential part of safe and appropriate care that meets individual needs and supports their rights Any choking incident (whether there are serious consequences or not) will be reported Further Reading As well as the information in the 'Underpinning Knowledge' section of the review sheet we recommend that you add to your understanding in this policy area by considering the following materials: A Series of fact sheets sets out the 10 key characteristics of good nutritional care in healthcare environments, which recognises that care providers should: Deliver food service and nutritional care safely. Fact sheet 1 Food service and nutritional care is delivered safely is available from: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59865
Page: 9 of 10 Outstanding Practice To be outstanding in this policy area you could provide evidence that: There are no incidents of choking reported even though Service Users have been identified as being at risk The local SLT team report excellent relationships with the service and that the service clearly follows their advice The local SLT team reports that referrals are always appropriately made, and there is excellent and detailed evidence to support any referral Staff in all departments are clear on the issues surrounding choking, have received training and are confident in their own knowledge to manage situations when they arise People using services report that staff are extremely knowledgeable and act in a clear, decisive and effective way when dealing with a choking incident The service recognises how stressful being involved in a choking incident can be and provides debriefing sessions, and emotional support for staff, people subject to the incident and if appropriate their relatives Documentation surrounding choking is very clear, and the service is highly transparent in the management of choking incidents Creative, attractive and person centred menu options are provided for people at risk of choking Forms The following forms are included as part of this policy: Title of form When would the form be used? Created by Dysphagia Risk Management Plan Identification of Risk of Choking (IRC Tool) To assess the risk of dysphagia for a service user. To identify risk of swallowing difficulties or dysphagia NHS British Nutrition Foundation (BNF)
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Client s Name:......Date:... Dysphagia risk management plan What could go wrong (risk area) Impact of problem Likelihood of harm occurring low med high low med high Severity (impact x likelihood) What needs to be done Agreed actions Named person responsible for actions Timescale (date by which action is to be completed) Date of next review (must be included) : Clinician s Name:... Date:... Tick this box if review will be conducted by the assessment group
Client s Name:......Date:... Dysphagia risk management plan review What could go wrong (risk area) Impact of problem Likelihood of harm Agreed actions Named person Agreed timescale Progress to date Revised problem impact Revised harm likelihood Revised agreed actions High med low high med low high med low high med low Date of next review: Clinician s Name:... Date:... Tick this box if review will be conducted by the assessment group
Identification of Risk of Choking (IRC Tool) Name of Individual: Date identification form completed: Identification form completed by: The table below lists signs and symptoms of swallowing difficulties or dysphagia. Service users with these symptoms may be at higher risk of choking and may need to be referred to a speech and language therapist Choking Risk History of choking episodes Coughing during or after eating/drinking Choking before / during or after eating/drinking Frequent chest infection and/or pneumonia Painful or difficult chewing/swallowing food Gurgly or wet voice Difficulty controlling food, liquid or saliva in the mouth Drooling Difficulty initialling a swallow Complaint of swallowing difficulty Regurgitation (bringing food back up) of undigested food Nasal regurgitation Feeling of obstruction Feeling like food or drink is going down the wrong way Sounds of respiratory difficulty e.g. increased shortness of breath, shallow breathing/wheezing during or immediately after eating and drinking Unsafe posture / poor head and neck control when eating or drinking Change of colour in face when eating/drinking Severe sleepiness or drowsiness whilst eating or drinking Symptom present Y/N Lack of awareness of risks associated with eating or drinking e.g. temperature, speed, amount Lack of ability to recognise foods Difficulty placing food in mouth Holding food/drink in mouth Prolonged chewing time Unexplained weight loss Frequent throat clearing Change in eating like eating slowly/ avoiding food Limited or no capacity to make decisions
Limited concentration whilst eating or drinking The individual s behaviour does not promote safe eating or drinking Unmanaged pain distracts the person whilst eating or drinking Oral health problems e.g. ulcers, poorly fitting dentures The environment, or others in the vicinity overly distract the person whilst eating or drinking If any of the above symptoms are present, then a full risk assessment should be completed. If any of the issues in bold are identified a referral to Speech and Language Therapy (SLT) must be made, and they should be part of any review and involved in the development of the person s care plan. Action Taken Referral to SLT Yes No For further risk assessment Yes No