Corporate Policy & Procedures
Choking Prevention and
Management
Approved by:
Sr. Operating Officer, Mental Health & Seniors Care, Edmonton
Sr. Operating Officer, Rural Services
Purpose
Policy
Statement
Manual
Number: VII-C-30
Date Approved
February 1, 2016
Date Effective
August 12, 2016
Next Review (3 years from Effective
Date)
August 2019
-
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.
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)
b)
choking prevention; and
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
* See 'Definitions'
Choking risk identification and risk mitigation are essential components of quality care in
all continuing care practice settings.
Choking Prevention and Management
Procedure
1.
2.
Policy No.
VII-C-30
Page 2 of 7
Screening/Assessment
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.
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.
2.1.1
3.
Date Effective:
August 12, 2016
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.
Interventions
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
•
3.1.2
4.
5.
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.
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 #VIIB-350, Advance Care Planning Goals of Care Designation.
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.
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
occupational therapist, speech language pathologist, respiratory
therapist, community paramedic, geriatric consult, etc.)
6.
Documentation
6.1
7.
Transfer
7.1
Definitions
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.
Documented choking risk shall be communicated to the receiving site upon
transfer of the resident to another care setting.
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
•
Section K: Oral/Nutritional Status
Supporting assessment information::
Supporting assessment information:
• Section B: Cognitive Patters
• Section B: Cognitive Patterns
• Section G.1(h) Physical Functioning and
Structural Problems – Eating
• Section H.2(g): ADL Self
Performance – Eating
• Section I.1(q-kk) Disease Diagnosis –
• Section J.1(g-l,s,z): Disease
Neurological, Psychiatric/Mood, Pulmonary
Diagnosis – Neurological,
• Section L: Oral/Dental Status
Psychiatric/Mood,
• Section O: Medication List
Emphysema/COPD/Asthma
• Section M: Dental Status (Oral
Health)
• Section Q: Medications
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
• History of: choking; aspiration; swallowing
disorder; chewing problems; mouth pain; dry
• Eats independently
mouth; prolonged swallow; changes in
• No clearly identified risk factors
approach to food: avoidance of eating alone
(fear), avoidance of eating with others
Concerns that may require further
(embarrassment), depression/frustration (r/t
investigation:
restricted food choices);
• Need for repeated swallowing
•
Complaints
of: difficulty initiating a swallow;
• Recurrent chest infections/pyrexia
sensation
of
obstruction in throat or chest;
• Weak voluntary cough
regurgitation
of food or acid; inability to handle
• Food residue in mouth
secretions;
impaired
breathing during meals or
• Inability to maintain optimal eating
immediately
after
eating;
pain on swallowing.
posture
•
Dependent
for
eating/oral
care
• Poor oral/dental health
•
Frail
elderly
• Reduced appetite
• Psychiatric (medication related), neurological
• Poor fitting dentures
(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.
Date Effective:
August 12, 2016
Policy No.
VII-C-30
Page 7 of 7
Risk Reduction Care Planning Interventions
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
Moderate/High Risk
General Interventions:
All general interventions plus consider:
• Ensure dentures (if used) fit
• Evaluate swallowing-specific quality of life using
properly
validated assessment tools (eg. SWAL-QOL; SWAL1
CARE; MD Anderson Dysphagia Inventory; EAT-10)
• Provide oral care before and
after meals
• Medication Review (r/t dry mouth; cause motor
fluctuations; reduce alertness; depress reflexes;
• Ensure the client is seated in
increase reflux; cause nausea; require alteration to
an upright position
administer)
• Sit facing the client while
• Ongoing observation for aspiration pneumonia in highassisting
risk persons
• Adjust rate of feeding and
• Effective mouth care is performed frequently to decrease
size of bites to the person’s
oral bacterial load decreasing chance of aspiration
tolerance
pneumonia
• Avoid rushed or forced
• Consider placement of food in the person’s mouth
feeding
according to the type of deficit (eg. stroke) and
• Ensure enough time to chew
appropriate head positions
between bites
•
Assess
diet modifications to ensure they do not
• Consider using a spoon
contribute
to malnutrition/dehydration (eg. unappealing
instead of a fork when
texture/ presentation (use food molds); decreased food
assisting
choices r/t modification needs (increase choices)
• Alternate solid and liquid
• Re: inappropriate ingestion of non-food items
boluses
o Environmental scan for and removal of high risk
• Observe for and report signs
non-edible / non-food items (eg. paper napkins,
of choking, regurgitating,
condiment packages/lids, pill cups, latex gloves,
drooling, pocketing food, etc.
etc.)
• Provide a pleasant mealtime
o Consider cloth napkins/placemats, bulk condiment
atmosphere
packages (jars), keeping appropriate snacks readily
• Increase concentration by
accessible/ available
reducing distractions (TV off;
•
Involve
a registered dietitian (RD) in care planning and
limit conversation during
assessment
of appropriate diet texture and fluid
swallowing phase)
consistency
and
comprehensive swallowing assessment
• Encourage participation
• 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
Clipart: www.medtrng.com
(clutch neck with both hands)
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 forcefully press
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.