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Accidental Choking Among Hospitalized Patients in Pennsylvania

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Accidental Choking Among Hospitalized Patients in Pennsylvania Accidental Choking Among Hospitalized Patients in Pennsylvania A 15-Year Retrospective Review By Elizabeth Kukielka, PharmD, MA, RPh DOI: 10.33940/data/2020.9.4 Choking occurs when a foreign body becomes lodged in the airway and obstructs res- piration. In the United States, over 5,000 deaths were attributed to choking in 2015. Among older adults, food is the most common cause of choking, and the death rate for choking events involving food is seven times higher among older adults than young children. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 545 events related to accidental choking on food, beverages, medications, or other foreign bodies reported from 2004 to 2019. Patients who experienced a choking event were more often female (56%; 306 of 545), and they ranged in age from 6 months to 102 years, with a median patient age of 70 years (interquartile range = 54 to 83 years). Among choking events that specified the substance involved, food was the most com- mon (80%; 424 of 528 events). The most common foods that patients choked on were meat or fish (n=77), sandwiches (n=38), and breads or cakes (n=31). Abdominal thrusts were the most common immediate response described in event reports, attempted in more than half of events (56%; 306 of 545). Prevention of accidental choking may in- volve timely assessment of risk factors that predispose a patient to choking, including age older than 60 years, tooth loss and presence of dentures, and underlying psychiat- Patient Safety Authority ric or neurologic illness. Disclosure: The author declares that they have no relevant or material Keywords: choking, foreign body, food bolus, airway obstruction, abdominal thrusts, financial interests. patient safety 42 I PatientSafetyJ.com I September 2020 Patient Safety I September 2020 I 43 hoking occurs when a foreign body be- ● Event described seizure activity without any comes lodged in the airway and obstructs actual choking. respiration. Choking most often affects ● Event described strangulation, including Median 1 young children and older adults. In 2015, self-strangulation (intentional or Patient Age C5,051 individuals in the United States choked to unintentional), strangulation of one patient death, and more than half (57%; 2,858) were over by another patient, or strangulation of a 70 years 74 years old.2 Among older adults, food is the most healthcare provider. common cause of choking.1 From 2007 through ● Event described an unplanned self- 2010, the death rate for choking events involving extubation which resulted from a patient food was seven times higher among patients 65 experiencing the sensation of choking while years and older than among children 1 to 4 years intubated. old.3 Older adults may be predisposed to food-relat- ed choking death due to underlying health condi- ● Event described an adverse drug reaction tions that affect chewing and swallowing of food.3 which resulted in the throat closing and the patient experiencing respiratory distress as Choking deaths, especially those involving food, a result. 6 months 102 years are considered preventable, which makes this an ● Event described coughing and choking in an important patient safety topic.3 We queried the adult that did not result in blockage of the Pennsylvania Patient Safety Reporting System (PA- airway. PSRS)* to identify patient safety events related to ● Event described a choking event reported choking that have occurred in Pennsylvania. The by the patient but not witnessed by any purpose of this analysis was to gain a better un- healthcare provider. derstanding of choking events that occur within ● healthcare facilities and to identify potential risk Event described coughing and/or choking in a newborn patient who had difficulty factors for choking, prevention strategies, and clearing the airway of secretions. treatment options. ● Event included the keyword “chok” in another context. Methods A descriptive analysis was performed to charac- 97% We queried PA-PSRS for events that occurred terize trends in patient age, patient gender, event from May 1, 2004, through December 31, 2019. We harm, facility type, and care area group. A quali- 44% of choking searched free-text fields (i.e., Event detail, Event tative analysis was also conducted to identify the Recommendation, Event Comments, and Event Type specific substance on which the patient choked, events Subtype Other) for the keyword “chok,” which was in- whether there was a deviation from the prescribed tended to capture all conjugations of the verb “choke.” diet, the response and remedies employed by the 56% involved Each event was reviewed by a patient safety analyst to healthcare team, any transfers to a higher level of determine inclusion or exclusion in the analysis. care that were required, and whether the patient an adult expired as a result of the choking event. An event was included in the analysis if it described accidental or unintentional choking on food, bev- Results erage, or medication. An event was also included if it described choking on an inedible foreign body, The query returned 1,543 events submitted to PA- such as a bone, stem, or denture, if the ingestion PSRS from May 1, 2004, through December 31, Descriptive Analysis About three-quarters of events (73%; 396 of 545) occurred was accidental or unintentional (e.g., a bone pres- 2019. A total of 545 unique events were identified ent in a piece of meat). Patients who experienced a choking event were more of- at an acute care hospital. The remaining events occurred for inclusion in the analysis. The most common at a rehabilitation hospital (12%; 66 of 545), a psychiatric reasons for event exclusion were coughing or chok- ten female (56%; 306 of 545) than male (44%; 239 of 545). Events were excluded for the following reasons: Patients ranged in age from six months to 102 years. The hospital (5%; 28 of 545), a long-term acute care hospital ing in a newborn resulting from excess secretions, (4%; 21 of 545), a critical access hospital (3%; 18 of 545), strangulation events, adverse drug reactions, chok- median patient age was 70 years (interquartile range = 54 ● Event described choking on a bodily fluid, to 83 years). Most events (97%; 526 of 545) involved an adult a children’s hospital (2%; 13 of 545), and an ambulatory such as blood or mucus. ing on a bodily fluid, and a sensation of choking surgery facility (1%; 3 of 545). The most common care area that led to self-extubation. (age 18 years or older). Based on the assessment of the re- porting facility, 90% (491 of 545) of events did not result in groups where a choking event took place were a psychiatric harm to the patient. Of events that resulted in harm to the unit (28%; 153 of 545) and a medical/surgical unit (26%; 139 patient, the harm was usually temporary (6%; 35 of 545). of 545). The care area groups where each choking event *PA-PSRS is a secure, web-based system through which Pennsylvania hospitals, ambulatory surgical facilities, abortion facilities, and occurred are summarized in Figure 1. birthing centers submit reports of patient safety–related incidents and serious events in accordance with mandatory reporting laws The reporting facility specified that 14 events (3%; 14 of outlined in the Medical Care Availability and Reduction of Error (MCARE) Act (Act 13 of 2002).4 All reports submitted through PA-PSRS 545) contributed to or resulted in the death of the patient. are confidential and no information about individual facilities or providers is made public. 44 I PatientSafetyJ.com I September 2020 Patient Safety I September 2020 I 45 Figure 1. Number of Events by Care Area Group Where Event Occurred, Assigned by Figure 2: Foods Identified in Choking Events, N=268 Reporting Facility, N=545 Desserts Psychiatric Unit 153 Candy (3) Medical/Surgical Unit 139 (9) Rehabilitation Unit 83 Specialty Unit 33 Other Emergency Department 20 (3) Intermediate Unit 18 Intensive Care Unit 17 Purees Meat/Fish Pediatric Unit 17 (11) (77) Food & Nutritional Services 16 Other 11 Other Imaging & Diagnostics 9 Foods Surgical Services 9 Sandwiches Outpatient/Clinic 5 (41) Rehabilitation Services 5 Labor and Delivery Combination 3 Foods Pediatric Intensive Care Unit 3 Animal Neonatal Intensive Care Unit 1 Proteins Nursery 1 Obstetrics & Gynecology 1 Pharmacy 1 Pasta/ Rice (6) 0 20 40 60 80 100 120 140 160 Cereal/ Snacks Qualitative Analysis mon foods were eggs (n=19) and mashed potatoes (16) Each event report was reviewed to identify per- (n=7). The most common food groups were meat or fish (n=77), sandwiches (n=38), and breads or Grains tinent trends, including the substance involved Eggs/Dairy cakes (n=31). in the choking event, the response enacted by Produce (21) the healthcare team, and transfers to a higher Patients were reported to have received the wrong level of care. A subgroup analysis of events that diet in 59 events. Among these events, the wrong caused or contributed to the patient’s death was diet was supplied by the food services depart- Breads/Cakes Fruits also performed. (29) ment or a staff member caring for the patient in (27) 48 events and by a family member in 8 events; the Substances Implicated in Choking Events patient obtained food from another source, such Events were classified according to whether the as from another patient’s food tray, in 3 events. Vegetables substance implicated in each choking event was (20) a food, beverage, medication, or another for- Choking events involving medications were the second most common, with medication being eign body. The specific substance was noted if Potatoes that detail was included in the event report. The mentioned in 13% (73 of 528) of events.
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