ADULT SERVICES DEPARTMENT PROCEDURE 15/15
Supporting People at Risk of Choking Policy
Effective date / January 2016
Category / Adults
Summary / This policy provides the framework for use within Hampshire County Council as well as for those commissioned to provide services by Hampshire County Councilto supportindividuals at risk of choking.
Keywords / Choking, SALT, dysphagia, pica
Approved by
Date Approved
Procedures cancelled or amended / N/A
Author / Karen Alexander, Governance Manager
Sponsor / Jo Lappin, Head of Safeguarding and Governance
Contact /
Signed
Designation
Date

Version control change record (inside first page)

Date / Version Reviewed / Author / Reason for change / Approved by
07.05.2015

PURPOSE

This policy gives practice guidance for Hampshire County Council staff who directly provide care, or who commission care, for people who may be at increased risk of choking. This guidance has been built on the document,Reducing the risk of choking for people with a learning disability: a multi-agency review in Hampshire produced by Hampshire Safeguarding Adults Board Multi-Agency Partnership (2012). The main purpose of this document is to offer guidelines for staff to follow when a person may be suspected to be or is known to be at risk of choking. For staff working in Hampshire County Council residential or nursing homes this policy should be used in conjunction with the Quality Standard – Care of people at risk of choking.

SCOPE

This policy is relevant to all Hampshire County Council staff providing care to people who are or who may be at risk of choking. This policy applies to staff employed by Hampshire County Council and to those services which have been commissioned by Hampshire County Council.

This policy has considered a number of areas including:

  • Commissioning and monitoring of food provision, mealtime supervision / support and environments
  • Screening for the increased risk of choking
  • Care planning and risk management
  • Training and health promotion
  • Going into hospital
  • Reporting choking episodes/incidents
  • Capacity / best interests issues.

CONTRIBUTIONS

The following organisations and staff made valuable contributions to the content of this policy:

  • Southern Health NHS Foundation Trust Speech and Language Therapists
  • Solent NHS Trust Speech and Language Therapists
  • AS staff in HCC Care units and Day Services

AUTHORITY TO VARY

Graham Allen, Interim Director of Adult Services

Care Governance Board

CONTENTS

page
Duties/Responsibilities/Roles / 4
Introduction / 4
Main content / 5
Requirements for Hampshire County Council staff / 6
  • Training for HCC staff
/ 6
  • Screening the risk of choking
/ 6
  • Managing care
/ 7
  • Hospital stays
/ 10
Requirements for providers of commissioned care / 10
  • Training
/ 10
  • Screening the risk of choking
/ 11
  • Managing care
/ 11
Requirements for those commissioningservices / 11
Implementation considerations / 12
Monitoring compliance / 12
Document review / 12
References / 12
Equality impact assessment / 12
Appendices / 13

DUTIES/RESPONSIBILITIES/ROLES

All Hampshire County Council staff providing care for peopleto adhere to the guidance laid out in this policy to ensure the safety of those people with an increased risk of choking. This policy also applies to services commissioned by Hampshire County Council.

INTRODUCTION

Definition of choking:Choking is the inability to breathe because the trachea is blocked, constricted, or swollen shut.Choking is a medical emergency. When a person is choking, air cannot reach the lungs. If the airways cannot be cleared, death follows rapidly.

The document,Reducing the risk of choking for people with a learning disability: a multi-agency review in Hampshire (2012)was aimed at people who are working with those who have alearning disability, in the role of commissioners or providers of services. A number of recommendations are made at the end of the report as a result of the findings which are all based ona common sense approach and good practice.

The recommendations made in Reducing the risk of choking for people with a learning disability: a multi-agency review in Hampshirecover a wide range of issues including understanding of causes of choking; recognition of choking risk;emergency response to someone who is choking; training for staff commissioning placements and supporting people to keep healthy.This policyhas been written in response to the recommendations made and to ensure that they are implemented across all client groups.

Definition of dysphagia: reduction or loss of oral or pharyngeal skills can impact on risks of choking. The term dysphagia is used to describe swallowing disorders characterised by difficulty in oral preparation for the swallow or in moving the bolus from the mouth to the stomach. Subsumed in this definition are problems in positioning food in the mouth and in the oral movements, including suckling, sucking and mastication.Early identification of the symptoms of dysphagia is essential.

Acute symptoms of dysphagia include:

  • coughing during or immediately after drinking and/or eating
  • choking
  • wet vocalisations after drinking
  • change of skin colour
  • watering eyes
  • refusal of food before or during meal
  • increased anxiety at drink/meal times
  • behavioural difficulties at drink/meal times

Chronic symptoms of dysphagia include:

  • chest infections
  • signs of malnutrition – as identified by MUST assessment, weight loss, skin

breakdown, hair loss

  • signs of dehydration – constipation, strong urine, urinary tract

infections, dry skin

Above information taken from Southern Health Dysphagia (Swallowing Disorder) Policy

MAIN CONTENT

All providers and staff need to beaware of the catastrophic consequences that occur if the person chokes. Recognition of choking (airway obstruction by a foreign body) is the key to a successful outcome, it is important not to confuse this emergency with fainting, heart attack, seizure or other conditions that may cause sudden respiratory distress, cyanosis or loss of consciousness.

For greater clarity, this policy has separate sections for those employed directly by Hampshire County Council, and for those who are commissioned by Hampshire County Council to provide a service. There is an additional section for the commissioners of services.

Requirements for Hampshire County Council staff

Training

As a provider of services to adults, Hampshire County Council will ensure that:

  • All Hampshire County Council staff providing care will receive emergency aid choking response trainingas part of the Stepping forward, Stepping Back induction programme
  • Hampshire County Council staff providing care to persons who may be at risk of choking will receive training in managing the risk of choking.

Screening the risk of choking

Whilst it is not possible to prevent all episodes of choking, reducing the risk of choking and improving the safety of individuals who have a risk of choking is essential.

It is important that staff recognise that choking risks can result in fatal choking incidents. Choking can occur as a result of either a single medical problem, e.g. stroke, progressive neurological condition, or as a result of:

  • oropharyngeal structural problems
  • motor processing difficulties
  • central nervous system disorders
  • pharyngo-oesophageal problems
  • poor oral health
  • the psychological effects of institutionalisation
  • mental health problems
  • the effects of medication.

Hampshire County Council staff must use the Solent NHS Trust Choking Screen as part of the assessment process to determine if professional advice is required from a speech and language therapist. Following the completion of the choking screen, if there are concerns relating to questions 1-6, then pre-referral liaison will help staff identify if a referral to SLT is appropriate. Staff will receive local guidance from their head of service / service manager as to which staff will carry out these assessments.

Staff must gain the consent of the person wherever possible, before any screening, assessment or medical investigation is undertaken. Numerous guidelines regarding the assessment of consent are available and it is essential that all decisions are clearly documented. When the person is unable to give informed consent best interest decisions are made using the guidelines in the Mental Capacity Act and best interest guidance.

Some people may exhibit challenging behaviours e.g. putting non-food items into their mouth, swallowing non-food items or deliberately trying to choke themselves through self-harm. If this occurs, staff should immediately seek a multi-disciplinary assessment.

When behaviours and/or choking episodes occur these should be reported through Hampshire County Council internal reporting systems and well documented in care plans in order that frequency and severity can be determined and action (what staff did) reviewed so that assurance can be given that care is delivered safely.

All services should use the ‘swallowing check list’ APPENDIX 2, in conjunction with the Solent NHS Trust Choking Screen or similar to indicate the risk of choking and whether a referral / further discussion with SLT is required. This

This checklist must be completed:

  • every 6 months following the initial assessmentor
  • each time a carer is concerned about a person’s eating and drinking / swallowing ability or
  • if the person is believed to be at risk of choking
  • if there has been a significant change in the person’s condition or social situation which might increase their risk of choking
  • if a person has been identified as being at increased risk of choking then each meal-time should be recognised as an opportunity for reassessing the risk.

Staff must ensure that they follow the recommendations set out by professionals, including speech and language therapists in order to reduce the risk.

Managing care and care planning

Different professionals or care givers will often have their own care plans for the people they are supporting. For example a self-directed support plan, a speech and language therapy care plan, and caregivers may have their own individual care plans. If a person has increased risks around eating and drinking this must be considered and reflected consistently throughout the care planning process by those involved in specialist advice giving, or day to day care provision. A consistent approach across all care givers is very important for keeping the person safe and reducing the risk of choking.

The development of individual care plans must, wherever possible, include the person and those who provide care. The principles and requirements of the Mental Capacity Act 2005 must be considered and implemented when developing an individual care plan.

Each person for whom a service is provided must have an individual first aid treatment plan so that those who are wheelchair users or cared for in bed are treated by first aid appropriate to their needs and staff must be aware of this plan and understand how to execute it if required. In day services, such a plan would only be developed for those people who are both wheel chair users and also identified as at risk of choking.

Where a risk of choking / problems with eating, drinking, medication and pica is identified, the plan must include what the concern is and what needs to be done:

  • to support the person to eat, drink and take medication safely and minimise the risk of choking
  • if the person’s risk of choking increases as a result of their behaviour
  • if an incident of choking or aspiration occurs
  • if there is a change in the risk of choking.

It is important that the risk plan considers the risk of choking presented by both edible and non-edible items.

A person’s care plan and any decisions outlined in it must be checked regularly for any changes. Assessments and decisions must be actively revisited following any change or deterioration in the person’s health or behaviour.

While regular reviews are of course necessary, staff must remain vigilant and responsive to the individual’s needs on a daily basis, during all oral intake, including meals, drinks, snacks and medications.

If a person is unable to make an informed decision about their own care a best interest meeting must be held. This must include the person, if appropriate and a range of people who are able to contribute to the decision making process on behalf of that person and in their best interests. This provides an opportunity to consider all possible options of care and through discussion reach a decision as to what the course of action will be in the “best interest” of the person concerned.

In circumstances where care workers or family members disagree with any decision reached regarding the person’s care, it is up to the decision maker (usually, the commissioning body) to weigh up the views of the different parties and make a best interest decision when developing the care plan.In the event of a significant dispute regarding the best interest’s decision made, every effort should be made to resolve it through discussion, negotiation or mediation. In the event of irresolvable disputes about best interests, an application may need to be made to the Court of Protection for a decision about the person’s welfare best interests.

It may be necessary to restrict access to certain environments, foods or objects for some people due to a risk of choking. In all cases this must be taken as a best interest decision and be documented in the usual way.

Any professionalhas a responsibility to screen for the risk of choking where it is thought that a person may be at risk.

A person’s care plan must:

  • Clearly document all health care that is relevant for the person, such as an annual health or dental check and when and where the care should be sought. It must inform the care givers of what they must do to support the person in their care to visit the GP, dentist etc.
  • Document any medication or treatments prescribed to them. Some medications can have an impact on a person’s swallowing functioning and it is important that any changes are considered before a medication change. Any identified risks following a change in medication must be clearly documented within the person’s care plan.
  • Be reviewed should any changes in medication occur.
  • Clearly document any signs and symptoms of swallowing difficulties or dysphagia that may be relevant to an individual’s health care and condition, and that can assist care givers in identifying an emerging risk of, or change in risk of choking.
  • Document the likely prognosis for the individual deemed to be at increased risk of choking so that care givers will not make false assumptions which might place the individual at risk.
  • Provide detailed contingency plans should emergency intervention be required.
  • Detail first aid care that is appropriate to the person should choking or aspiration occur. This must take into account any wheelchair users or those who are cared for in a bed.
  • Clearly state that the care giver must immediately notify emergency health care services, the GP and Local Authority of any choking incident that may have resulted in harm to the person or if the provision of care is suspected to have resulted in a choking incident.
  • Include information about the person’s mental capacity to be able to understand their risk of choking and their ability to understand and agree to the protective actions which may be put in place to reduce that risk. SaLT have asked for a statement about individual’s capacity and awareness of choking risk.

All staff involved in the person’s care must:

  • be informed of the care plan and any changes to it in relation to eating, drinking and taking medication
  • be involved in the care planning process for people at risk of choking
  • be aware of the consequences of not following an agreed eating and drinking plan (see details on training)
  • complete a swallowing checklist every time concerns are raised or a risk of choking is suspected on current oral intake and be completed every six months after initial completion/initial SLT recommendations are made
  • understand what they are required to do if the swallowing checklist indicates there is a risk of choking or an increased risk of choking for the person
  • be able to recognise and know how to prepare/present food and fluids to the person, in keeping with their eating and drinking recommendations
  • follow instructions in the care plan for giving medications; including correct positioning and making sure medications are in the appropriate format
  • Where a person experiences a choking episode or a near miss choking episode, this must always be recorded on an incident form
  • The incident must also be fully recorded in the daily notes for that person (where relevant) and consideration should be given to whether a referral or re-referral to an appropriate professional is required
  • Consideration should also be made as to whether a safeguarding concern needs to be raised.

The Quality Standard, Care of people at risk of choking, has been developed for Hampshire County Council staff working in HCC Care residential and nursing homes to guide them in the practical steps required to aid them reduce the risks of choking among the people they deliver care to. See Appendix 3

When a service user has a stay in hospital

If a person is going into hospital for any reason, their eating and drinking needs must be communicated verbally or through a document such as their hospital passport.It is of paramount importance that this informationgoes with the person to hospital to detail the person’s most up to date eating and drinking recommendations.

Where the individual is open to speech and language therapy and they are aware of the hospital admission, best practice would be for the community services and acute services for SLT to liaise regarding any changes to the eating and drinking recommendations during the hospital admission and following discharge. When an individual is acutely unwell, their eating and drinking skills often will require assessing within the hospital setting.

This does not negate the importance of clear communication and handover between the hospital, provider, family carers and any Adult Social Care practitioner who may be involved.

Hospitals should also consider whether there are any training needs identified for the provider staff and / or family carers following the discharge of the person back to their care.

Requirements for providers of commissioned care

Training

Provider services regulated by the Care Quality Commission are required to meet a number of essential quality outcomes in order to register to provide services. As part of this arrangement providers must only accept people whose assessed needs can be met safely and in line with the agreed person-centred care plan. This requirement extends to the care of people assessed as at risk of choking.