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QI 152 To Improve Patient Safety for Those at Risk of Choking in an Inpatient Setting
Brown, Karen Ochel, Anna Supported by the Quality Improvement Team, Coventry and Warwickshire Partnership Trust
Brown, Karen
Ochel, Anna
Supported by the Quality Improvement Team, Coventry and Warwickshire Partnership Trust
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Affiliation
Coventry and Warwickshire Partnership NHS Trust
Other Contributors
Publication date
2024
Subject
Research Projects
Organizational Units
Journal Issue
Abstract
Aim: To Increase Awareness and Increase Referrals by 30% for Patients at Risk Of Choking Within Learning Disabilities & Autism & Mental Health Inpatient Services.
This project has been run jointly across MH and LD&A inpatient services. Across the services there were only small numbers of
referrals being received, these were often following very severe choking events. Previous attempts to implement a referral process had been been unsuccessful. The processes, referral information, national guidance etc were reviewed to understand the current situation. Based on this a screening tool and referral process along with awareness training were developed and tested on one ward and gradually rolled out across other wards as the tool and process was adapted. Awareness training has
been rolled out across the mental health wards and as part of staff induction in Learning Disabilities and Autism.
Tools Used:
Driver Diagrams - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf;
SPC Charts - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-statistical-process-control.pdf;
PDSA Cycles - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf.
Project Impact:
Standardised screening tool for assessing risk and making referrals to Dysphagia Service.
Monthly report to Dysphagia Service re: choking incidents.
Increase in referral rate for dysphagia assessment.
Increased staff awareness across inpatient services.
Screening being embedded into MH & LD&A admission pathway.
Screening being completed as standard within Health Action Plan in LD&A.
Facilities awareness and food Modification training.
Citation
Brown, Karen; Ochel, Anna. QI 152 To Improve Patient Safety for Those at Risk of Choking in an Inpatient Setting. Coventry and Warwickshire Partnership NHS Trust, 2024.
Type
Internal Poster