Adams School of Dentistry: Procedure for Swallowed Foreign Objects

Introduction

Purpose

To outline the protocol for incidents involving patients swallowing various foreign objects associated with dental treatment including, but not limited to:

1. rubber dam clamps,
2. burs,
3. crowns,
4. implant parts,
5. pieces of broken instruments, and
6. debris.

Scope of Applicability

All Adams School of Dentistry (ASOD) faculty, staff, residents, students, and patients.

Procedure

General Information

1. Provider will stay with the patient, ensure the immediate area is safe and free of hazards, monitor vital signs, observe for acute respiratory distress, and make a preliminary diagnosis from the clinical signs, symptoms, and patient’s response to careful questioning.
   
   IN THE EVENT OF AN EMERGENCY, CALL THE ASoD MEDICAL EMERGENCY TEAM AT (919) 537-3911 AND FOLLOW EMERGENCY PROCEDURES
2. If patient is stable and aware, provider should explain to the patient the purpose and procedure for obtaining radiographs.
3. Provider or appointee will complete an Online Incident Report, which will provide a summary of next steps, paperwork, maps, alert all individuals, of the issue, and automatically document preliminary steps.

Regular Hours & Non-Emergency

1. Regular hours are considered to be Monday – Friday, from 8:30 AM – 4:30 PM.
2. Provider of appointee will escort the patient to ASoD Radiology, located on the 1st floor of Tarrson Hall and at reception, advise that the visit is in relation to a Swallowed Foreign Object incident. Appropriate representative from ASoD Radiology is automatically alerted to the situation, will guide provider through issue, and provide a Radiology Order Form.
3. Patient will require a Medical Record Number (MRN), if they do not already have one. If an MRN is required, provider or appointee will call (984) 974-2041, option 1, and explain the necessity to expedite the call.
4. Write the MRN on the Radiology Order Form and make a note for later.
5. Provider or appointee will escort the patient, with completed Radiology Order Form, to UNC Radiology Department. Map to appropriate area is automatically provided after submission of Online Incident Report.
   • Transportation to hospital radiology (x-ray) is the responsibility of the attending provider or the designated assignee.
   • Transportation for sedated, but not emergent, patients may pose special risks. Obtain a wheelchair from the ground floor of Tarrson Hall, Dental Faculty Practice, Graduate Periodontics or OMFS and transport the patient to the hospital.
6. During transit, monitor the patient for signs of respiratory distress and advise the patient that if they receive a bill to contact the Director of Clinical Compliance. If symptoms of respiratory distress are found during transit, contact EMS and stay with patient until EMS arrives.
7. If more details are needed on the location of UNC Radiology Department, call (984) 974-1884. Map to location is provided automatically when an Online Incident Report is submitted.
8. Upon arrival, explain the situation to the intake staff, provide the Radiology Order Form, explain that the bill should be forwarded to ASoD, and stay with the patient until the procedure is complete.
9. Once the radiology technician calls the patient back to take the film, ask to see the radiograph when it is ready in order to determine the location of the foreign object.
   • If the imaging reveals the patient ingested the object and an emergent situation does not exist, the patient should be informed to contact their medical provider to determine if follow-up radiographs or treatment is needed.
   • If the imaging reveals the patient aspirated the object or an emergent situation does exist, the provider should immediately escort the patient to the emergency department and relay the diagnosis to the emergency department provider, to ensure continuity of care. Once the emergency department provider acknowledges understanding, the ASoD provider may leave the patient. It is strongly advised that the patient follow the treatment guidelines of the hospital medical provider.
10. Within 24 hours of this occurrence, the provider should document the incident in the patient’s record and notate the following:
    • Provider’s recommendation for a medical evaluation, which included radiographs
    • Results of what patient was advised on, specifically if patient was advised to follow up with their primary care provider or required to report directly to the emergency department.
    • Preventative measures taken to avoid the swallowing or aspiration of the object.
11. If a copy of the radiology report is needed, the provider should contact the ordering provider named on the diagnostic radiology and imaging order.
    • Any supplemental information can be uploaded through the Online Incident Documentation Upload by a supervisor.
    • Uploading of documentation is automatically encrypted, logged, and forwarded to the appropriate individuals.
    • Confirmation response of upload will provide with an Upload ID Number, for record keeping purposes
12. Corrections to an Incident Report Form can be completed by a supervisor through the Incident Correction Form.

Outside Regular Hours & Non-Emergency

1. Outside regular hours are considered before 8:30 AM or after 4:30 PM, Monday – Friday, or anytime on Saturday or Sunday.
2. Online Incident Report will provide the Radiology Order Form attached in an email automatically. Provider or appointee will need to print this form and take it with them or have it ready for forwarding to appropriate person at UNC Women and Children’s Hospital.
3. Provider or appointee will escort patient to UNC Women and Children’s Hospital registration desk to obtain an MRN. Map to location is provided automatically when an Online Incident Report is submitted.
4. After securing MRN, add MRN to Radiology Order Form and escort patient to the Emergency Department at UNC Hospital. At the registration desk explain situation to intake, provide Radiology Order Form, explain that the bill should be forwarded to ASoD, and stay with patient until the procedure is complete.
5. Once the radiology technician calls the patient back to take the film, ask to see the radiograph when it is ready in order to determine the location of the foreign object.
   • If the imaging reveals the patient ingested the object and an emergent situation does not exist, the patient should be informed to contact their medical provider to determine if follow-up radiographs or treatment is needed.
   • If the imaging reveals the patient aspirated the object or an emergent situation does exist, the patient should follow the treatment guidelines of the emergency department medical provider.
6. Within 24 hours of this occurrence, the provider should document the incident in the patient’s record and notate the following:
   • Provider’s recommendation for a medical evaluation, which included radiographs
   • Results of what patient was advised on, specifically if patient was advised to follow up with their primary care provider or required to report directly to the emergency department.
   • Preventative measures taken to avoid the swallowing or aspiration of the object.
7. If a copy of the radiology report is needed, the provider should contact the ordering provider named on the diagnostic radiology and imaging order.
   • Any supplemental information can be uploaded through the Online Incident Documentation Upload or by a supervisor.
   • Uploading of documentation is automatically encrypted, logged, and forwarded to the appropriate individuals.
   • Confirmation response of upload will provide with an Upload ID Number, for record keeping purposes
8. Corrections to an Incident Report Form can be completed by a supervisor through the Incident Correction Form.

Emergency Situations

If the patient is demonstrating emergency symptoms, provider will assign another individual to complete one of the following:

1. During regular hours and on campus, appointee will call the ASoD Medical Emergency Team by dialing 7-3911 from any landline in ASoD. Assignee will need to state the location, type of emergency, and stay on the line so information can be appropriately relayed.
2. Outside regular hours and on campus, appointee will call Orange County EMS by dialing 911. Assignee will need to remain on the phone, advise of the situation, and meet with EMS personnel at the appropriate entrance to direct them to the individual requiring assistance.

Refusal of Radiographs

If the patient refuses the radiographs, proper notation should be documented in the patient’s record, with details on the conversation, and complete the Informed Refusal Form. Upload the any related paperwork through the Online Incident Documentation Upload portal.

Related Requirements

Unit Policies, Standards, and Procedures

1. Policy for Management of Medical Emergencies
2. Procedure Following Bloodborne Pathogens Exposure
3. Incident Report Forms