The HealthCap QA Reader program has grown tremendously in the past year and many HealthCap members are enjoying the benefit of having flagged incidents reviewed by Risk Management.  The review process includes recommendations to address common types of incidents, documentation best practices and the provision of emergency services. 

Over the past couple of weeks I have reviewed several incident reports involving resident choking incidents.  Each of the events occurred during dining and each of the incident reports indicated the Heimlich maneuver was initiated however the documentation indicated each resident was coughing and one report indicated the resident spoke to the nurse.  Providing the Heimlich maneuver on a person who is able to forcefully cough or speak is a discouraged practice (see guidelines at http://www.nlm.nih.gov/medlineplus/ency/article/000049.htm).

In addition to this guidance there are standards that are universally accepted in long-term care including:

• Assess your community’s current practice for meal service.  Are residents encouraged to dine in congregate style or are residents being served meals in their rooms?  If dining is occurring in resident rooms, this can be a dangerous practice as there is limited assistance on the units during meals.  Residents may experience a choking episode and not receive the necessary, emergency interventions.
• Are there residents in your community who “enjoy” their meals so much that they eat too quickly, failing to chew adequately?  If so, consider having these residents assessed by speech therapy to determine if they would benefit with a mechanically altered diet.
• Have your staff been trained to recognize the signs that would require them to begin emergency interventions?  If not consider providing this training as soon as possible.  If there has been adequate training, consider randomly questioning staff on the process and discuss a “when to wait” scenario (resident coughing, speaking, etc.). 
• Do you provide adequate supervision in dining areas including a licensed nurse?  The standard is that dining areas are never unsupervised even during the times residents are being transported.  Consider reviewing your current process to ensure supervision is maintained until the dining room is empty.
• Are licensed nurses trained to perform a thorough assessment immediately post-incident including auscultation of lung sounds?  If your community does not have licensed staff on duty consider establishing a protocol to have the resident transferred for a post-choking assessment. 

Choking – Adult or child over 1 year

Choking is when someone can't breathe because food, a toy, or other object is blocking the airway (throat or windpipe).

Considerations

A choking person's airway may be completely or partially blocked, so that not enough oxygen reaches the lungs. A complete blockage is a medical emergency. A partial blockage can quickly become life threatening if the person cannot properly breathe in and out.  Without oxygen, permanent brain damage can occur in as little as 4-6 minutes. Rapid first aid for choking can save a life.

Occasionally an object will enter the lung. While the person may appear to improve and breathe normally, in a few days symptoms may develop, such as:

• Persistent cough
• Pneumonia
• Wheezing

Causes

• Eating too fast, failing to chew food well enough, or eating with improperly fitted dentures.  If a resident is observed eating too fast or not chewing well please intervene and provide guidance and assistance as needed.  If dentures do not fit properly a dental consult should be ordered. 
• Drinking alcohol (even a small amount of alcohol affects awareness).  As our communities transition to providing care for community bound residents alcohol use is becoming more common.  Supervision is vitally important if alcohol is being consumed in your community. 
• Being unconscious and breathing in vomited material.  Always remember to turn a victim’s head to the side to assist in preventing aspiration. 
• Breathing in small objects.  This is not usually a problem in our communities however it can occur so be alert to the possibility.
• Injury to the head and face (swelling, blood, or a deformity can cause choking). 
• Aftereffects of a stroke (adult).  Ensure that any resident with a history of stroke (CVA) has been evaluated to the appropriate therapy disciplines. 
• Enlarging tonsils or tumors of the neck and throat.  This is also an unusual condition in the elderly however should be ruled out as a cause if choking is a concern. 

Symptoms

The universal distress signal for choking is grabbing the throat with the hand.

Other danger signs include:

• Bluish skin color
• Difficulty breathing
• Inability to speak
• Loss of consciousness if blockage is not cleared
• Noisy breathing or high-pitched sounds while inhaling
• Weak, ineffective coughing

First Aid

How to perform the Heimlich maneuver:

1. First ask, “Are you choking? Can you speak?” DO NOT perform first aid if the person is coughing forcefully and able to speak — a strong cough can dislodge the object.
2. Stand behind the person and wrap your arms around the person's waist.
3. Make a fist with one hand. Place the thumb side of your fist just above the person's navel, well below the breastbone.
4. Grasp the fist with your other hand.
5. Make quick, upward and inward thrusts with your fist.
6. Continue these thrusts until the object is dislodged or the victim loses consciousness.

If The Person Loses Consciousness

• Lower the person to the floor.
• Call 911 or the local emergency number or tell someone else to do so.
• Begin CPR
• If you see something blocking the airway, try to remove it.

For Pregnant or Obese People

1. Wrap your arms around the person's CHEST.
2. Place your fist on the MIDDLE of the breastbone between the nipples.
3. Make firm, backward thrusts.

After removing the object that caused the choking, keep the person still and get medical help. Anyone who is choking should have a medical examination. Complications can occur not only from the choking, but also from the first aid measures that were taken.

DO NOT

• DO NOT interfere if the person is coughing forcefully, able to speak, or is able to breathe in and out adequately. However, be ready to act immediately if the person's symptoms worsen.
• DO NOT try to grasp and pull out the object if the person is conscious.

When to Contact a Medical Professional

Seek medical help right away if you find someone unconscious.

When the person is choking:

• Tell someone to call 911 or the local emergency number while you begin first aid/CPR.
• If you are alone, shout for help and begin first aid/CPR.

After the object is successfully dislodged, the person should see a doctor because complications can arise.

In the days following a choking episode, contact a doctor immediately if the person develops:

• Persistent cough
• Pneumonia
• Wheezing

These could be signs that the object entered the lung instead of being expelled.

Prevention

• Eat slowly and chew food thoroughly.
• Make sure dentures fit properly.
• Don't drink too much alcohol before or during eating.
• Keep small objects away from young children.

References

Manno M. Pediatric respiratory emergencies: Upper airway obstruction and infections. In: Marx J, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier; 2009: chap 166.

Thomas SH, Brown DFM. Foreign bodies. In: Marx J, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier; 2009: chap 57.

Hauda WE II. Pediatric cardiopulmonary resuscitation. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004:chap 14.

Update Date: 7/20/2013