Healthcare Choking Protocol

HEALTHCARE CHOKING PROTOCOL ACKNOWLEDGMENT

Patient Information

Insurance Information

Medical History and Risk Factors

Choking Risk Assessment

Facility staff will assess risk for airway obstruction at intake and periodically during care. The following observations are relevant for planning feeding and supervision:

Protocol Summary — Immediate Actions for Suspected Airway Obstruction

This facility follows an evidence-informed emergency response for choking. Staff will follow the steps below according to the victim's age and the severity of obstruction. These steps are authorized now by the undersigned for use in an emergency where the patient is unable to protect their airway.

Mild obstruction (patient able to cough, breathe or speak): staff will encourage effective coughing, monitor closely, position for airway protection, and summon advanced care if obstruction persists or worsens.

Severe obstruction (ineffective or absent cough, inability to speak, cyanosis, loss of consciousness): staff are authorized to perform prompt first aid including back blows, abdominal thrusts (heimlich maneuver) for conscious adults and children, chest thrusts for those where abdominal thrusts are contraindicated, and back slaps and chest compressions for infants as appropriate. If the patient becomes unresponsive, staff will initiate cardiopulmonary resuscitation and activate emergency transport.

Procedures and Clinical Limitations

Interventions will be provided only by personnel trained in basic life support consistent with facility policy. Techniques may include but are not limited to: manual removal of visible foreign body (only when clearly visible and easily accessible), back blows, abdominal thrusts, chest thrusts, airway clearance maneuvers, suctioning, and initiation of basic life support. Advanced airway interventions and invasive procedures will be performed by appropriately credentialed clinicians or emergency responders.

If a feeding tube is present, staff will follow tube-specific protocols for securing, checking patency, and addressing obstruction; these protocols do not preclude immediate actions to clear an airway as clinically indicated.

Communication, Documentation, and Reporting

All choking events require immediate notification of the attending clinician and the named emergency contact when feasible, timely documentation in the medical record, and completion of any internal incident report required by facility policy. Where emergency services are activated, staff will provide a concise handover to first responders.

Consent, Authorization and Acknowledgment

By signing below, the undersigned acknowledges receipt of and understanding of this facility's choking protocol summary and authorizes facility personnel to provide immediate lifesaving and airway-protective interventions as described above in the event of a suspected airway obstruction. Authorization includes basic life support measures and non-invasive airway maneuvers that are standard for the patient's age and clinical status. This authorization does not require prior separate consent at the time of emergency when delay would jeopardize the patient's life.

The undersigned further acknowledges that: (a) staff will act in accordance with applicable standards of care and training; (b) the undersigned has disclosed known conditions that may affect airway management, including DNR/DNI status, swallowing disorders, or feeding devices; (c) refusal of recommended interventions may increase the risk of severe injury or death; and (d) this form does not modify existing advance directives except to clarify emergent airway management consistent with those directives.

To the extent permitted by law, the undersigned releases the facility and its staff from liability for adverse outcomes that result from performance of permitted emergency airway interventions carried out in good faith and within the scope of applicable standards and training. This release does not apply to willful misconduct or gross negligence.

Revocation: The undersigned may revoke this authorization in writing at any time, except to the extent that actions have already been taken in reliance on this authorization during an emergency.

Acknowledgment

I acknowledge that facility staff have explained the choking protocol appropriate for my care setting, answered my questions to the extent possible at the time of this acknowledgment, and provided written information reflecting key steps and contact procedures. I understand the risks and authorize emergency interventions as stated above.

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