Clinical paperFood choking incidents in the hospital: Incidents, characteristics, effectiveness of interventions, and mortality and morbidity outcomes
Introduction
As the population ages, foreign body airway obstruction (FBAO) due to food has become a major public health concern.1, 2, 3 In the United States in 2020, there were about 5,000 deaths due to choking, the majority were elderly.4 In Japan, where the life expectancy is among the highest in the world, choking from food is a leading cause of accidental death and has killed more people than motor vehicle crashes or violence annually.5
FBAO due to food can occur wherever people eat. Mortality risk factors from food-related choking include increasing age, dementia, and Parkinson disease.6 Acute physiological changes and unfamiliar eating environments in the hospital may increase risk for choking. A single center retrospective study reported 68 in-hospital FBAO cases due to food during the seven-year study period with one-third dying or having residual impairment after choking.7 In-hospital FBAO incidents have received little attention and there are limited reports on the epidemiology and outcomes of in-hospital FBAO incidents.
Patient characteristics and outcomes for in-hospital FBAO incidents due to food might significantly differ from out-of-hospital FBAO incidents. These differences include patients' comorbidity, real time detection of incidents with bed-side monitoring, immediate availability of medical staff, close proximity to necessary devices for foreign body removal. Data on the types of interventions used to treat FBAO in the hospital setting, the success rates of these interventions, and patient outcomes could help reduce FBAO incidents and improve outcomes.
Our primary objective of the study was to characterize in-hospital food-related FBAO incidents focusing on the types of interventions used to treat FBAO, success rates, and patient outcomes. Our primary outcomes were mortality and morbidity from FBAO incidents. The secondary outcome was successful removal of foreign bodies by interventions.
Section snippets
Study design and database description
We analyzed observational data from the Japan Council for Quality Health Care (JCQHC) open database and included all in-hospital FBAO incidents due to food. We excluded non-food FBAO cases. The database is a nationwide in-hospital adverse event data collection system developed in 2004 to prevent medical adverse events and promote patient safety.8, 9 As of 2020, the database included 1,549 medical institutions, representing approximately 20% of all Japanese hospitals. Many of those institutions
Selection of reports
Fig. 1 summarizes the reports. The search strategy initially identified 514 cases. After excluding 203 unrelated incidents (e.g., out-of-hospital FBAO), we reviewed 311 reports in detail. We further excluded five FBAO incidents due to medical treatment (e.g., gauze pads left in the mouth after the procedure) and six FBAO incidents due to swallowing of non-food materials (e.g., urine pad) among patients with pica, leaving 300 reports for our analysis.
Incident characteristics
Most patients were elderly, and the most
Discussion
Using data from a nationwide database of medical adverse events, we found the majority of patients who suffered from FBAO in the hospital did not receive effective first interventions to treat FBAO and had high mortality rate.
Consistent with a previous study including FBAO cases from nursing homes, suction was the most common initial intervention.13 The current International Liaison Committee on Resuscitation (ILCOR) International Consensus on Cardiopulmonary Resuscitation and Emergency
Limitations
Observational studies have a number of limitations including reporting bias. Minor FBAO incidents that spontaneously cleared (e.g., cough) were not likely reported. Thus, the true incidence of all in-hospital FBAO incidents is still unknown. As described above, we did not report the incidence of FBAO in person-time, which would be more appropriate unit to describe the incident rate of FBAO. Future studies should seek to report the true incidence of FBAO in person-time. Since the database
Conclusion
In-hospital FBAO incidents from food choking are uncommon but life-threatening events. The majority of patients who suffered from in-hospital FBAO incidents did not receive effective initially and many of them died. Further efforts are needed to prevent FBAO incidents in the hospital and improve outcomes for victims of in-hospital FBAO.
CRediT authorship contribution statement
Tatsuya Norii: Conceptualization, Methodology, Formal analysis, Investigation, Writing – original draft, Project administration. Yutaka Igarashi: Conceptualization, Methodology, Writing – review & editing, Project administration. Mari Akaiwa: Methodology, Resources, Data curation. Yudai Yoshino: Validation, Investigation. Hiroki Kamimura: Validation, Investigation. Danielle Albright: Methodology, Writing – review & editing. David P Sklar: Writing – review & editing, Supervision. Cameron
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
The authors would like to thank Ms. Hatsumi Nakanishi, Mr. Ichito Shimokawa, and Mr. Yoshiki Sato for their assistance with data entry. We also wish to thank Drs. Hiroya Kida, Masao Tabata, and Kiyomi Suda for their suggestions and support. The authors also thank the JCQHC and all institutions that contributed the data.
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Addresses: University of New Mexico, Department of Emergency Medicine, MSC11 6025, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA. Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan. Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.