There have been a number of choking-related deaths within the care industry, including a worrying case where a care home resident with Alzheimer’s choked to death on a disposable glove. This led to a coroner calling for more training for care staff dealing with vulnerable people. Martin Hodgson investigates how to deal with choking incidents and how to lessen the risks of choking for residents.
Choking incidents present a potentially serious medical emergency. They are responsible for a number of deaths from asphyxiation each year, particularly among older people.
Choking incidents in older people are usually caused by food getting stuck and blocking the airway. In most cases, the food can be dislodged by coughing. However, sometimes this does not work depending on the severity and placement of the blockage.
Older people face greater choking risks from food because they sometimes find that their mouth dries out naturally as a result of ageing. Without saliva it can be difficult to swallow food properly. In other cases, the mouth can dry out as a side effect of medication, or as a result of simply not drinking enough water.
Risks can be increased if people eat the wrong things or have a medical condition or illness that compromises their ability to swallow. For some people, even drinking or taking medication in the form of tablets can be hazardous.
Food risks
The wrong food includes items that are well-known causes of choking. This includes meat such as steak, chicken with bones, hot dogs, boiled sweets, peanut butter, fruit chunks and popcorn. Medical conditions include people who have had a stroke which makes it difficult to swallow. Conditions such as Parkinson’s disease, muscular dystrophy, and multiple sclerosis may all also influence the ability to swallow, as will
dementia and some forms of cancer, particularly of the throat.
Other people may have dental problems such as bad teeth, loose dentures or painful gums which makes it hard for them to chew.
Trying to rush food will also increase risk.
To reduce the risks, care homes should have clear policies and protocols in place to identify and support people who may be at risk. The policy should be supported by adequate staff training.
Everyone receiving care should have their needs fully assessed when they move into a home. This should include a nutritional assessment which should regularly be reviewed, especially where a person’s needs
change and they start to suffer from swallowing difficulties.
People who seem to be having difficulties with swallowing should be encouraged to chew their food and take smaller bites or mouthfuls. Those who report swallowing difficulties or who have conditions that make it hard for them to swallow should be seen by their GP. The GP may well consider that a referral to a speech and language therapist is appropriate, specialists in assessing and treating swallowing difficulties, or that they should receive advice from a dietician on appropriate diet choices. Any referral should be supported by the home. Any recommendations for special foods or diets should be followed carefully. The home should work closely with the healthcare professionals involved, involving the care home caterers where necessary.
Care plans should be adjusted and all staff made aware of the person’s needs and care options. Many cases of choking in care homes in the past have resulted from people still being given food that goes against what has been recommended by their doctors or specialists.
New framework for people with learning disabilities
Care England has published a new framework and guidance focused on Preventing Choking Deaths Among People with Learning Disabilities. There is a higher prevalence of dysphagia (swallowing difficulties) in
those with learning disabilities. Around 15% of adults reported that they require support with eating and drinking and approximately 8% with a diagnosis of dysphagia. When publishing this new framework, Care England has stated that “choking remains one of the leading preventable causes of death among people with learning disabilities and/or autism, and yet awareness across the sector, and among the wider public, remains far lower than it should be”.
It is vital for the care industry to have a wider and in-depth understanding of the risk of choking in people with learning disabilities and why their risk is higher. Those who have learning disabilities often have other comorbidities which have higher risk of dysphagia, for example Down’s syndrome and Prader Willi Syndrome, or they may have behavioural factors such as eating inedible objects (pica). These other behavioural and physical issues will heighten the risk of choking and show how vital it is that staff have the knowledge, training and confidence around this area.
This new guidance recognises that mealtimes are not just about the food that an individual eats, but it’s a whole experience of choice, dignity, culture and can be something that an individual looks forward to in a day. The new guidance is to support providers to become more proactive and provides care services the
knowledge and tools to be able to be more confident in spotting early warning signs, risks and know how to react appropriately. Although it is essential for staff to monitor those who are at higher risk of choking,
mealtimes should not become a time that becomes clinical and that people receiving care feel like they are being watched. It should be a time when people can enjoy the food they chose, but staff are following their care plans, risk assessments and advice from external professionals.
Specialist feeding requirements
Special considerations apply for service users who require specialist feeding, such as percutaneous endoscopic gastrostomy (PEG) feeding.
PEG feeding is where a tube is inserted for people who cannot swallow. In such cases, homes should follow all best practice guidance on the care and use of PEG feeding tubes. Staff caring for a person using PEG feeding should be fully trained.
While food choices for people with swallowing difficulties should consist of an individualised diet to meet their personal needs, care home menus should be designed generally with choking risks in mind. Without overly restricting choice, high-risk foods should be avoided and safer alternatives used wherever possible.
TTraining is important. Care staff should be trained to be aware of choking hazards and to know how to avoid them. They should be trained in the delivery of special diets, and in the support of nutritional needs in general. Staff who help people to eat should be careful to cut food into small pieces and to take their time and not rush the person. They should be aware of the types of food that might cause difficulties and refer to the person’s care plan and food preferences.
Staff should try not to feed people who are lying down in bed if possible. Where appropriate they should help them into a sitting position first, preferably out of bed. High levels of dental care should also be provided.
Residents should be encouraged to visit the dentist regularly and care staff should provide help to residents where they need it, for instance, in caring for dentures.
What to do if an incident occurs
If a someone does suffer a choking incident then immediate action should be taken by staff.
A qualified first aider should be called who will be trained in dealing with choking. However, it is something that all staff can be trained to cope with.
If someone seems to be in difficulty, the first aider or other staff should ask them if they are choking to check that they are not suffering from something else. If they can still speak it may be possible to support them to clear their own throat by encouraging them to cough.
If the person cannot cough the next stage is for staff to support their upper body with one hand and help them lean forward. Using the heel of the other hand they should give four or five sharp blows between their shoulder blades.
If back blows do not work then abdominal thrusts should be applied. Standing behind the person the member of staff should link their hands between the person’s tummy button and the bottom of their chest with the lower hand clenched in a fist. They should then pull sharply inwards and upwards four or five times.
If choking persists a 999 call should be made for an ambulance immediately. While waiting for the
ambulance back blows and abdominal thrusts should be continued until the blockage is cleared, help arrives or the person becomes unresponsive.
If the person does become unresponsive then cardiopulmonary resuscitation (CPR) should be started.
Following a choking incident which resolves through clearage of the blockage, the person may still need medical attention. They are likely to be shocked and upset and may need help, support and reassurance. After the incident, their needs should be reviewed and any referrals made for additional support as required.
The home should also review relevant procedures and policies following any incident. Each incident should be recorded and reviewed. Lessons should be learnt and changes implemented where required. Particularly relevant are those relating to personal nutritional care, first-aid arrangements, staff training and emergency response.
