PATIENT SAFETY

Reducing the risk

Adults with learning disabilities or mental illness are at increased risk of choking. Choking incidents are stressful for the individual involved and for anyone who has to recognise what is happening and assist. Susan Guthrie and Hazel Roddam explore the challenges for speech and language therapists and the wider multidisciplinary team, and the impact of enhanced electronic reporting of incidents and training.
He looked anxious and like he was in a state of panic. He was unable to talk or cough. He was going red at first and his eyes were bulging and watering. He then dropped to his knees and he was going blue around the lips, his eyes were rolling to the back of his head. I felt shaken and anxious that I had to carry out this practice [abdominal thrusts], however I felt a sense of relief when the client resumed normal breathing. (Account of a choking incident by a member of care staff)

READ THIS IF YOU WANT TO SUPPORT OTHER STAFF TO FULFIL THEIR DUTIES CONTRIBUTE TO A CULTURE OF REPORTING AND LEARNING FROM MISTAKES BUILD UP A DETAILED PICTURE OF CLINICAL INCIDENTS

ecent literature has highlighted asphyxiation from choking as an increased risk for people with learning disabilities (Samuels & Chadwick, 2006; NPSA, 2008), and also those who have a mental illness (Corcoran & Walsh, 2003; Bazemore et al., 1991). Studies indicate that dysphagia may be under-diagnosed in this population (NPSA, 2004). The nature of the relationship between dysphagia and choking and the evidence base needs further investigation. A choking incident can, however, act as a trigger. It can alert carers that an individual may be having difficulty at mealtimes, prompting referral to speech and language therapy for dysphagia assessment. While the experience of a choking incident is traumatic for the person concerned, the care staff involved also experience considerable distress. Care staff need clear guidelines for when to be concerned, and for when and how to document their concerns. For staff training, finding a working definition of choking is a priority. The literature tends to offer definitions with medical jargon. Bazemore et al.s definition includes more easily observable characteristics: a choking incident is an acute episode in which the patient coughed incessantly or experienced a colour change (with inability to speak or cough effectively) while ingesting food or drink. The solid or liquid had to be expelled to terminate the event (1991, p.3). Since 2005 Susans specialist trust for adults with learning disabilities has had a policy of reporting patient safety incidents using an electronic system accessed directly by the staff involved. These range from personal accident to a wide variety of clinical incident. This local

Susan risk management procedure then feeds into the national reporting and learning service (NRLS) database coordinated by the National Patient Safety Agency (NPSA) (figure 1). For speech and language therapists the electronic system has provided a new source of information when working with dysphagia referrals. Although fatal incidents are generally known about, in the past it has been more difficult for us to access information on near miss incidents. As part of the multidisciplinary team, we can now access all reports of suspected choking incidents for each service user. The trust includes both small community homes and on-site low and medium secure accommodation. In the last 7 years in the population of adults with mild profound learning disabilities (approximately 400 people) there have been 4 deaths due to choking on food, and 2 sudden deaths related to PICA (ingestion of non food items). The number of reported choking incidents is small; for example, in 2009 there were 40 near miss choking incidents compared to over 9000 total patient safety incidents. A

Hazel

further problem is that these reports often lack information. Such absence of detailed description is of concern, as possible causes or influences for an incident may be lost. Accuracy may also be variable when reports are delayed, rushed or subjective. To address this, and with the help of the IT department, Susan added 10 further prompt questions to the standard open questions already in the electronic system. Supported by speech and language therapy led staff training workshops, these new questions aim to promote greater detail in reporting. Susan derived the prompts from discussion with nursing and care staff, then sought expert speech and language therapy consensus at the ALD Dysphagia UK network forum. The prompts are based on the need to be able to learn from incidents. They are designed to elicit greater detail; for example, describe what you saw prompts staff to include a description of clinical presentation at the time of the incident. Jargon is avoided for nonclinical staff. Susans workshops also raised issues around Basic Life Support (BLS) training. This

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PATIENT SAFETY
Figure 1 National reporting and learning The National Patient Safety Agency (NPSA) National Reporting and Learning Service (RLS) website states: Information from reported incidents helps the NHS understand why things go wrong and how to stop them happening again. Within a local NHS organisation, a serious event may be perceived as a one-off. Reporting to the RLS can reveal similar incidents in other parts of the NHS and can also help identify learning from incidents in different organisations. The RLS helps NHS organisations understand why, what and how patient safety incidents happen, learn from these experiences and take action to prevent future harm to patients. http://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/about-reporting-patient-safetyincidents/ (How reports are used) Accessed: 20 January 2011

a measuring scale which can be used and understood by all and crucially - repeated more reliably (figure 2). 2. Frequency The number of incidents appears similar between people in community houses (with a more elderly population, more diagnoses of physical disability) and those in medium / low secure provision (younger population with more diagnoses of mental illness, personality disorder), with 7 per cent of the total service users in this trust experiencing a choking incident. However, a noticeable difference is seen in the medium / low secure accommodation incident reports. They record more examples of service users who have experienced more than three repeat incidents over a 12 month period. 3. Location The majority of incidents take place in usual home settings, and many fewer are reported for eating out. The proportion of meals eaten away from home is much smaller, but this statistic may also be explained by staff comments such as he eats much slower, more politely [sic] when out and about. However feedback and screening would suggest that staff are also less likely to report incidents occurring off-site. 4. Timing Unsurprisingly the majority of incidents (70 per cent) occur at mealtimes, with a strong tendency (42 per cent) at evening meal (tea) (figure 3). The potential influencing factors for incidents at this time of day are complex and multiple. The literature generally refers to factors such as physical and mental health status, behaviours, fatigue and medication. However discussion with nursing staff has suggested many environmental and social factors. There are many stresses for staff around producing and supervising a main meal at the end of a long shift. Self-induced or peer pressure for service users, such as feeling the need to rush to get finished, may also contribute. In this trust immediately after tea is the opportunity for social club, phone calls home, free time or a cigarette. All are highly motivating but also a potential source of anxiety and tension, and incident reports in general show an increase at this time of day. We can attempt to untangle these complex influences via ward round discussions and multidisciplinary team intervention. However, further research is needed to establish an evidence base, as we do not know what influencing factors are significant and what outcomes can be achieved in terms of intervention and risk mitigation. 5. Food types Seventy six per cent of incidents give some description of a solid food item causing choking. The type of bolus described reflects the frequency of evening meal incidents (figure 4).

Figure 2 Measuring scale: Severity of choking incident (degree of first aid) and frequency of occurrence over 12 month period Spontaneous cough 20% Cough after staff prompt 10% Backslaps 44% Abdominal thrusts 5% Paramedic 5% Details unspecified 16%

Figure 3 Timing of choking incidents (Data over period mid 2005- end 2007) 4% 24% 20%

breakfast lunch evening meal (tea)

6% 4%

late snack (supper) unknown not mealtime

42%

Figure 4 Type of bolus

Unspecified Unspecifed food meat

8 8

Bread/ toast
6

Sausage
3

Salad
1

Potato
1

Medication
4

is a mandatory requirement for health care staff (Resuscitation Council UK guidelines) but feedback from agency staff indicates it is not always accessed before they start work with service users. Care staff also highlighted practical problems in attempting the standard recommended BLS procedures with people who are obese, in wheelchairs, or have severe physical disabilities. Susan referred this to the BLS trainer who will now offer individualised guidelines to ensure care staff are able to administer first aid in an emergency. This development made us re-evaluate how far our role and professional responsibility as speech and language therapists extends, and led to a closer working relationship with the BLS trainer.

The database now shows a steady increase in reporting of choking incidents, although it is clear from discussion with care staff that some are still not being reported. We have carried out an informal review of care staff incident reports over a 12 month period and selected 6 themed comments which have implications for practice: 1. Severity The majority of reports now describe the extent of first aid or intervention, which gives a more objective measure of the severity of an incident. Such incidents are emotional and stressful for all concerned and, throughout this work, it has been difficult to achieve objective reporting. It is therefore useful to try to create

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EDITORS CHOICE / PATIENT SAFETY

Editors choice

So many journals, so little time! Editor Avril Nicoll gives a brief flavour of articles on stammering that have got her thinking.

Many clients are so afraid of the reaction if a listener realises they stammer that they go to any lengths not to do it. InListener perceptions of stuttering, prolonged speech, and verbal avoidance behaviors, Von Tiling lays bare the cost, as excessive use of verbal avoidance behaviors like interjections, revisions, incomplete phrases, and pauses make people who stutter look more incompetent than the use of stuttered speech or prolonged speech (p.9). I found the process of this research and the concepts it discussed very thoughtprovoking (core vs associated behaviours, emotional vs communicative competence, entity vs incremental theory). J Commun Dis (2010), in press Plexico, Manning & DiLollo make a convincing case in Client perceptions of effective and ineffective therapeutic alliances during treatment for stuttering for giving more attention to the effectiveness of a clinician rather than focusing solely on the treatment. Citing Brown (2004), they warn that failure to do so limits the potential to improve outcomes and to lower costs (p.350). Their qualitative study investigated the characteristics associated with effective and ineffective clinicians solely from the point of view of the client. Im not sure that the clients were as diverse as the authors believed (8 were speech pathologists!), but the findings ring true. The summary in table 3 could be used for reflection or team discussion. Journal of Fluency Disorders (2010) 35, pp.333-354 In Stuttered and fluent speakers heart rate and skin conductance in response to fluent and stuttered speech, Zhang, Kalinowski, Saltuklaroglu & Hudock replicate previous findings that listening to someone with a moderate-severe stammer induces two significant negative physiological responses in comparison to fluent speech.This study was different in that one group were people who stammer but, interestingly, they showed the same pattern of responses. The authors believe that, The results may provide a unique perspective for helping PWS to understand the negative responses they encounter in their daily interactions with others, and bolster the notion that stuttering therapists should put an emphasis on reducing the aberrance and abnormality of primary and secondary stuttering behaviours in the initial phases of stuttering treatment (p.673). IJLCD (2010) 45(6), pp.670-680

The higher incidence of tougher, more chewy textures involved in these choking incidents would appear from this small sample to match with the High Risk foods attached to the National descriptors (BDA, 2009). However texture modification leading to changes in food choices and tastes offered must take into account individual circumstances, capacity and quality of life issues around mealtimes. For example, some people are keen to avoid the foods they perceive as difficult to process but others are resistant to change. As a multidisciplinary team we have to consider the impact of changing food and drink choices, balancing this with needs of palliative care, mental illness and challenging behaviours (Langmore, 1999). 6. Clinical presentation of individual incident It has become increasingly clear from care staff comments that the signs of choking are not always obvious or immediately visible. A minority of the reports from care staff have described experiencing a delay in recognising the onset of choking, and there are accounts of service users who become silent and inert when choking. The lack of movement and absence of agitated behaviour in these service users may not attract the attention of the care staff. In addition, familiar staff are more able to identify when an individual is not exhibiting normal behaviour, while agency or unfamiliar staff can miss subtle changes. Full detailed recording of clinical presentation (such as prompting what did you see?) is crucial to ensure quick identification and intervention for further incidents. Given the transitory nature of care staff (NPSA, 2004) it is essential to document fully each suspected incident to allow handover of potentially life saving information. However research is needed to establish what information is relevant, influential and significant and then how this can be used to mitigate risk of future incidents.

Footnote At the time of writing, the NPSA (National Patient Safety Agency) is expected to be abolished as the overall coordinator of learning from healthcare safety incidents. The transfer of the NPSAs different functions is being explored by the Department of Health. References Bazemore, P., Tonkonogy, J. & Ananth, R.(1991) Dysphagia in psychiatric patients: clinical and videofluoroscopic study, Dysphagia 6(1), pp.2-5. BDA (2009) National Descriptors for Texture Modification in Adults. Available at: http:// www.bda.uk.com/publications/statements/ NationalDescriptorsTextureModificationAdults. pdf (Accessed 21 January 2011). Corcoran, E. & Walsh, D. (2003) Obstructive asphyxia: a cause of excess mortality in psychiatric patients, Irish Journal of Psychiatric Medicine 20(3), pp.88-89. Available at: http:// www.ijpm.org/content/pdf/193/Ostruct.pdf (Accessed 21 January 2011). Langmore, S.E. (1999) Issues in the management of dysphagia, Folia Phoniatrica et Logopaedica 51, pp.220-230. NPSA (2004) Understanding the patient safety issues for people with learning disabilities. Available at: http://www.nrls.npsa.nhs.uk/ resources/?EntryId45=92328 (Accessed: 21 January 2011). NPSA (2008) Resuscitation in mental health and learning disability settings: Rapid response report. Available at: http://www.nrls.npsa.nhs. uk/resources/?entryid45=59895 (Accessed: 21 January 2011). Samuels, R. & Chadwick, D. (2006) Predictors of asphyxiation risk in adults with intellectual disabilities and dysphagia, Journal of Intellectual Disability Research 50(5), pp.362-370. Resources ALD Dysphagia UK network forum, email hannah.crawford@tewv.nhs.uk Resuscitation Council UK guidelines - www. resus.org.uk/

Further analysis

The factors influencing choking can be numerous and complex. To explain and then attempt to prevent further incidents as a multidisciplinary team, we need to identify potential risk factors. This may include aspects of a persons diagnosis their physical skills and the presence of dysphagia, mental illness, behaviours, medication history but may also include external influences such as environmental and social factors. We are trying to source funding for further analysis of the nature of choking incidents and the influences present using the wealth of information generated by the incident reports. With a stronger evidence base it will be possible to begin to research strategies to SLTP reduce risk in this area. Susan Guthrie is a Specialist Speech and Language Therapist with East Lancashire Community Health Services and Calderstones Partnership NHS Foundation Trust, email susan.guthrie@ calderstones.nhs.uk. Dr Hazel Roddam is Principal Lecturer in Research, University of Central Lancashire, email HRoddam@uclan.ac.uk.

Clinical questions and challenges 1. Would you recognise if your patient was choking? 2. Could you give standard basic life support or are there complicating factors? 3. Do you know whether choking has happened before? 4. Is there an underlying dysphagia? 5. Can we show that intervention reduces the risk of further incidents?
How has this article changed your thinking? Let us know - see information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

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SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011