Quality Is No Accident

Massachusetts DDS · Quality & Risk Management Brief · Sept 2013 Issue 9

Ingestion of Foreign Objects (Pica)
The ingestion of foreign objects, sometimes referred to as “Pica,” is a very serious and potentially dangerous behavior.  Denying, ignoring, or minimizing the potential harm that can be caused by this behavior may put a person at risk for injury or death. Regardless of whether someone has a clinical diagnosis of “Pica”, if they ingest non-food items, they should have appropriate safety or behavioral plans in place.

Eating non-food items can result in poisoning, parasitic infection, dental and mouth injuries, choking, bowel blockage, ulceration, and perforation of the esophagus, stomach or bowels. The severity of this behavior varies by person, due to the frequency of the behavior, what is ingested and how hard the behavior is to manage and treat.

This behavior may be managed, but will likely never be completely eliminated. Once someone starts ingesting non-food items, this behavior should be considered a life-long risk factor for the person. 

DID YOU KNOW?

At least 9% of adult DDS service recipients with health care records have Pica mentioned in their record.

27 people supported by DDS were admitted to the ER in the last year for Pica-related incidents.

DDS will host a webinar on September 24th from 12:30 – 1:30pm, presented by Chris Fox, PhD on “Recognizing, preventing and responding to people who ingest non-food items or who have a diagnosis of Pica.” Registration details on page 4 of this Brief.  

**Much of the content in this Brief is taken from previous presentations by Chris Fox, PhD. S/W Area Office DDS**

Quality Is No Accident was developed by the Center for Developmental Disabilities Evaluation and Research (CDDER) of the E.K. Shriver Center/University of Massachusetts Medical School in collaboration with the Massachusetts DDS.

Pica behavior is generally defined using 3 key components:

1)	a pattern, i.e., generally more than one time
2)	of ingesting, i.e., swallowing vs. simply mouthing items
3)	inedible material, i.e., rock or string vs. food from floor or trash

In the Person
When assessing a person’s risk for Pica, consider the following:
•	A person’s past history of behaviors is important when assessing risk.
•	Health conditions that may increase a person’s risk include Obsessive Compulsive Disorders (OCD), Prader Willi Syndrome, sickle cell disease (risk factor mainly present in children), and dementia.
•	People with severe or profound intellectual disabilities may be most at risk for developing Pica.
•	Recent changes for the person, including recent G-tube insertion with “NPO” orders (nothing by mouth), or start of a new, low calorie diet may increase risk.
•	People with greater mobility may be at greater risk than people with limited mobility, due to their access to non-food items. 
•	People who are not able to effectively communicate needs, wants, and desires (i.e., for food) may be at greater risk.
•	People with a greater ability to plan and obtain non-food items may be at greater risk. 

In the Environment
•	Is the environment clear of items or substances that the person could swallow?

•	If the person has a history of eating non-food items, do they eat the same items each time or are the items varied? Will the person ingest any available item?

•	Commonly ingested items include rocks, leaves, string, disposable pads (“chucks”), soap, coins, cigarette butts, paperclips, bolts, screws, & latex gloves.

•	During environmental sweeps, any item or pieces of items that can be ingested should be considered, including light bulbs, needles, and bed springs.

Assessing Risk

Why Pica?
The cause of Pica behavior is usually unknown. The following are important considerations that can help inform appropriate support plans for people with Pica behavior:

1.) Behavioral: Pica may be motivated by automatic positive reinforcement (i.e., swallowing the non-food item produces a good feeling) or automatic negative reinforcement (i.e., swallowing the non-food item relieves bad feelings).
2.) Health: Nutritional deficiencies, i.e., lack of zinc or iron, may be motivating the person. A history of lead poisoning may also be a factor, as are parasites, addiction or mental illness.
3.) Developmental: The person cannot discriminate between food and non-food items due to ID or developmental level.
4.) Other: Hunger or desire to have more food may also be a factor. 

Managing Pica

 

Prevention Strategies
Behavior Plans
•	Indicate why the person is at risk (list favored items of pursuit and times/locations where pursuit is most likely, if known).
•	Ensure close supervision of the person in community settings that are not monitored.
•	Provide caregiver training in all locations where the person spends time and evaluate all caregivers for their understanding of the person’s risk of Pica.
•	Advise staff to keep personal belongings secure at all times when supporting a person with this behavior.
Environmental Sweeps
•	Routinely check for ingestible items in all areas where the person spends time. 
•	Check access to office supplies & medical items such as latex gloves, Band Aids or medications. 
•	Disposable underwear and diapers should be stored immediately after use.
•	Remove any small parts (such toothpaste caps) or large parts of objects that can be easily broken off and ingested.
•	Securely fasten buttons/ribbons on clothing and decorative ornaments on hats or purses.
•	Periodically check seats, bedding, and padding for rips and tears that can be ingested. 
Transportation Sweeps
•	Any van/car/staff vehicle should be checked for non-edibles each time a person enters.  
•	Driver should check for Pica behavior when a person is exiting and entering a vehicle.
•	Be extra vigilant in community locations that cannot be “Pica proofed.”

Key Considerations
•	Have an emergency plan in case ingestion happens.
•	Work with qualified clinician(s) to analyze behavior and develop a safety and behavior plan.
•	Treat underlying medical, psychiatric or neurological conditions.
•	Offer easy access to substitutes, including more food (if appropriate). 
•	Be prepared for contacts w/medical professionals & hospitals. Always inform health care professionals about a person’s Pica behaviors especially when seeking medical care for unclear symptoms of illness.
•	Teach individuals alternative behaviors.

What if Ingestion Happens?
The risk of injury is so severe that an appropriate licensed health professional should immediately be contacted.

Remember: The best strategy to address this behavior is prevention!

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Additional Information
MA DDS Pica Fact Sheet
http://www.mass.gov/eohhs/docs/dmr/reports/family-support/fs-pica.pdf

MA DDS Pica Risk Management Protocol
http://www.mass.gov/eohhs/docs/dmr/awp/hpci-risk-pica.pdf

DDS Health Care Records
In July of 2012, about 13,800 adults had a health care record in DDS’s electronic HCSIS system.  This represents almost all adults that receive 24 hour residential supports, and a subset of people receiving individual supports, residential support from other agencies, and those living at home independently or with their family.
About 9% or 1,210 adults were reported to ingest non-food items, often referred to as Pica, in their health care record. These adults may have a clinical diagnosis of Pica, or may have exhibited Pica-like behavior. In addition, some adults may exhibit Pica behaviors but may not have a clinical diagnosis of Pica and may not have this behavior noted in their records. 
Hospital Visits
A recent analysis of unplanned hospital visits over the past year reveals that 27 people visited the Emergency Room due to the ingestion of a non-food item. Six people were hospitalized for ingestion of non-food items over the past year.  

Addition of new HCSIS Question 
In July of 2012, a new field was added to the DDS Incident Report. This field specifically asks about whether the incident being reported is related to the ingestion of a non-food item.  The intent of this field is to help ensure that people who support a person with this behavior are aware of the behavior and can, hopefully, act to prevent it in the future.

PICA Webinar 
Want to learn more about Pica? DDS is pleased to present the following learning opportunity for all staff and support providers:
“Recognizing, preventing and responding to people who ingest non-food items or who have a diagnosis of Pica.”
Tuesday, September 24th, 12:30-1:30pm. Presenter: Chris Fox, PhD.

Registration Now Open for this webinar:
http://onlinetraining.umassmed.edu/pica/event/registration.html

Pica Data for Adults Served by MA DDS

For more information on assessment and treatment options for people with signs of Pica contact: 
Sharon Oxx, RN, CDDN, Director of Health Services, DDS
 Sharon.Oxx@state.ma.us

Analyses conducted by:
Center for Developmental Disabilities 
Evaluation and Research (CDDER), 
E.K. Shriver Center, UMass Medical School