Swallowing and Choking Procedure

Purpose

Mobility is committed to safe and effective service provision to consumers living at home, in accordance with applicable laws and regulations.

By identifying their swallowing needs, goals, and preferences, consumers will be assisted for the best possible outcomes.

Scope

This procedure and work statements applies to Mobility team members (including contractors, staff, consumers and or their substitute decision makers) who have contracted mobility to receive home care and other services.

Where consumers have specific requirements, including modified diets or special support (e.g., enteral feeding or meal preparation for nutrition and hydration), please refer to the relevant procedures.

Definitions

Care Plan

an individual support plan that outlines the measures a support worker must follow to provide support to a consumer

Aspiration

Aspiration means inhaling some kind of foreign object or substance into your airway.
Usually, it’s food, saliva, or stomach contents that make their way into your lungs when you swallow, vomit, or experience heartburn.
Aspiration is more common in older adults.i

Choking

Airway partly or completely blocked

Dysphagia

Difficulty in swallowing.

Positioning

How we position ourselves when we eat and drink.

Procedure

Identifying people at risk of swallowing problems

Swallowing difficulties, known as dysphagia, are most apparent to an older person, their family and home care staff when the person is eating, drinking or taking medication. Swallowing difficulties can have an acute onset during illness and may be short term in nature or they can be a symptom of severe illness and become more severe due to neurological diseases such as Parkinson’s disease or dementia.

Mild swallowing difficulties are common in older people, particularly in those over the age of 80. There are many strategies we can implement to optimise food and fluid intake to avoid the difficulties becoming more severe and avoid a series of cascading risks.ii
The identification and early management of swallowing problems is essential as if a service doesn’t manage swallowing problems, it can lead to at the worse to death from choking.

Signs to look for:

difficulty swallowing or lack of swallowing
coughing before swallowing, during mealtimes, or after eating
heartburn
drooling
taking a long time to eat and drink, wasting food
altered level of alertness or reduced response
speech or voice changes as they may indicate silent aspiration. Look for slurred speech, a weak, hoarse, crackly, gurgling or wet-sounding voice. If in doubt, ask family members if they have noticed any recent vocal changes
a history of recurrent chest infections or suspected aspiration
tongue, facial or lip weakness or altered appearance
pocketing food or tablets in the cheeks
the consumer describing food as sticking to the roof of their mouth or throat, or the sensation of a ‘lump’ or discomfort in the throat or chest, or frequent throat clearing during mealtimes (can indicate GORD)
unexplained weight loss
reluctance to swallow food, water or medication.

In addition to the above ALL consumers with the following diagnoses must be referred for a speech pathology assessment:

Parkinson’s disease and other neurological problems
head strike due to a fall
depression
dementia (mild, moderate or severe)
delirium
previous surgery to the mouth, throat, nose, spine or brain
cancer of the mouth, throat, head or neck
GORD
multiple comorbidities
frailty which is associated with a high risk of swallowing problems and malnutrition2.

Oral health should be screened at the same time as swallowing. Poor oral health and dental issues can seriously impact on swallowing and enjoyment of foods and liquids.

Personal Care Workers (PCW) or Registered Nurses (RN) should raise any observations and concerns with mobility.

Once assessed by a Speech Pathologist they will recommend the appropriate consistency of food and fluids the consumer can manage (refer to the Supporting Clients with Modified Diet Procedure). This may include eating and drinking postures and strategies, such as a double swallow, to assist the consumer to safely eat and drink.

Risks associated with the services and supports of each consumer will be managed in line with the consumer’s care plan, for example, meal preparation may need to avoid particular foods for some consumers (due to allergies, diabetes, or cultural needs). Or the texture of food might need to be changed for consumers who have difficulty swallowing

Refer to the Supporting Clients with Modified Diet Procedure.

Choking

People over 65 years of age have seven times higher risk for choking on food than children aged 1–4 years of age. Food texture modification is often used in the treatment of dysphagia to encourage sufficient intake where chewing strength is reduced and also to reduce choking risk.

Choking risk

Mobility team members will consider and respond to consumers choking risks. Choking risk can be viewed as it relates to food features, person features and environment features.

Food features that increase choking risk include for example the physical textural, size and shape of foods. For example, foods that are fibrous, hard, firm, stringy, chewy, sticky, dry, crumbly, crunchy, or shaped in such a way that they can occlude the airway (round or long) pose a choking risk

Person features that increase choking risk relate to inadequate dentition, difficulty maintaining posture and positioning, fatigue during meals and impaired function as a result of medication and poor decision-making capacity. There is a high correlation between absent teeth, ill-fitting dentures, dental disease and sudden choking deaths.

The need for medication with sedative qualities, such as anti-psychotics, opioid analgesics, hypnotics and anti-anxiety medications impact the central nervous system and can also impair the integrity of the swallow and cough reflexes.

The need for supervision is an environmental risk factor for choking. For example, a requirement for sedating medication may increase choking risks that could be mitigated with supervision or assistance at mealtimes. In pathologic aging, cognitive impairment such as that which accompanies dementia, increase choking risk with behaviours such as: eating too fast, not chewing very much, over-filling the mouth, or swallowing large mouthfuls. Inadequate mealtime supervision of individuals at risk of choking can have fatal consequences.

Signs and Symptoms

Mobility team members will observe and respond to signs of consumers choking, including but not limited to:

Frantic coughing
Gagging
Turning blue in face and lips
Suddenly not able to talk in complete sentences or at full volume
Passing out
Clutching at or point to the throat
Panicked and distressed behaviour
Unusual breathing sounds, such as wheezing or whistling
Watery eyes
Red Face

Aspiration

Aspiration may result from a choking episode. Personal Care Workers and RN’s will observe and respond to symptoms of aspiration and aspiration pneumonia.

Symptoms of Aspiration include:

Sudden appearance of respiratory symptoms (such as severe coughing and cyanosis) associated with eating, drinking, or regurgitation of gastric contents.
A voice change (such as hoarseness or a gurgling noise) after swallowing.
Pocketing of food on one side of the mouth.
Small-volume aspirations that produce no overt symptoms are common and are often not discovered until the condition progresses to aspiration pneumonia.

Aspiration Pneumonia:

Older persons with pneumonia often complain of significantly fewer symptoms than their younger counterparts; for this reason, aspiration pneumonia is under-diagnosed in this group.
Delirium may be the only manifestation of pneumonia in elderly persons.
An elevated respiratory rate is often an early clue to pneumonia in older adults.
Other symptoms to observe for include fever, chills, pleuritic chest pain and crackles.
Observation for aspiration pneumonia should be ongoing in high-risk persons

First Aid and emergency care with choking episodes

All PCW and RN’s will utilise their mandatory first aid and CPR training when responding to a choking episode. For example, to begin with, reassure the person. Encourage them to breathe and cough. If coughing does not remove the blockage:

Call triple zero (000).
Bend the person well forward and give five back blows with the heel of your hand between their shoulder blades – checking if the blockage has been removed after each blow.
If unsuccessful, give five chest thrusts by placing one hand in the middle of their back for support and the heel of the other hand on the lower part of their breastbone – checking if the blockage has been removed after each thrust.

Dignity of Risk choices

When consumers choose to take risks against advice, please follow the Dignity of Risk Duty of Care Policy and Procedure.

Reporting

Incidents, concerns, or questions should be reported in accordance with Mobility’s Incident Management Policy and Procedure.