Caring for Patients who Deliberately Ingest Foreign Bodies

Throughout the past few years, Cleveland Clinic health system has seen an increase in the number and frequency of adult patients presenting with foreign body ingestion (FBI) across all levels of care in its Northeast Ohio hospitals. FBI patients deliberately ingest a foreign substance into their bodies.

Clinical Nurse Specialists (CNSs) Lynne Kokoczka, MSN, APRN-CNS, ACCNS-AG, CCRN, and Catherine Skowronsky, MSN, APRN-CNS, ACNS, CMSRN, who both work at Cleveland Clinic main campus, regularly collaborate and discuss Cleveland Clinic’s FBI patients. Kokoczka primarily works in the medical intensive care unit (ICU) setting and Skowronsky works with medical patients who have behavioral health issues.

“Since much of the medical work of identifying, locating and removing the foreign body occurs in the ICU, Lynne has a wide body of knowledge in this arena,” Skowronsky says. “Between us, we have a robust reserve of knowledge around this phenomenon.”

Kokoczka adds: “Foreign body ingestion is truly a niche diagnosis and between the two of us, we see a lot of it in our patient populations.”

A highly challenging and complex patient population

Patients with deliberate FBI are highly complex. Not only have they ingested something that can potentially cause serious harm to their bodies, they also typically have psychiatric disorders, intellectual disabilities or dementia.

Research published in Gastrointestinal Endoscopy in 2019, noted that patients with recurring FBI often ingest the same object again and again, such as these top ingested objects: plastic bags, batteries, nails/tacks, desk supplies (like paperclips), bags, coins, jewelry, razors, pens/pencils and balloons.

Skowronsky says those with deliberate FBI do not intend to end their lives, but rather the ingestion is an adaptive coping mechanism they’ve developed as a result of poor emotional control or the lack of other coping mechanisms when faced with stress. Specifically, she notes that borderline personality disorder is a common underlying behavioral health diagnosis that accompanies the behavior.

“These patients are challenging for caregivers,” says Skowronsky. “A lot of their feelings come from a fear of abandonment. They have a poor sense of self-identity, intense and rapidly changing moods, chronic feelings of emptiness, and so on.”

Care plans and caregiver communication are crucial

Skowronsky and Kokoczka stress that when caring for this unique patient population, communication between caregivers and across levels of care is crucial, as is establishing an agreed upon care plan.

Skowronsky explains that deliberate FBI patients will often try to manipulate and split caregiver teams. For example, a patient may insist to a nurse that a physician told them they would be getting pain medication, but nothing is noted in the patient’s chart.

“You need to round as a team and everyone needs to know exactly what the plan of care is so there is no opportunity for the patient to split the team,” says Skowronsky.

She says nurses should work with their physician colleagues to determine as many specifics as possible, from medications to when restraints will be used and more. Additionally, cohesive communication with the entire caregiver team will ensure all caregivers are aware of the situation, which will allow for better preparedness in the event of potential patient outbursts or unruly behavior.

Skowronsky also adds that when patient outbursts do occur, nurses should always remember that – no matter the situation – verbal abuse from patients should not be tolerated. She cautions nurses to set firm, compassionate boundaries and confidently tell patients ‘when their behaviors are inappropriate.’ Heightened attention will feed the patient’s behavior and doing this, she says, is a supportive, therapeutic response.

“With deliberate FBI patients, the behavioral and psychological aspect of care is just as important as the physical care,” adds Kokoczka. “As a nurse, you have to make sure you take care of yourself and the other caregivers on your team, including the physicians, social workers, gastroenterologists and others because caring for these patients can be hard on all team members.”

Skowronsky and Kokoczka say that caring for fellow caregivers also includes implementing heightened safety measures. They recommend ongoing safety sweeps of the patient’s room, including checking for screws, small pieces of the bed, eyeglass stems and more, constant patient observation, dressing the patient in a gown without pockets, securing the patient’s personal items, and avoiding taking anything in the room from the nursing unit desk, such as paperclips or staples – anything that could possibly be ingested.

Delivering safe and appropriate medical care

As soon as a deliberate FBI patient is admitted to a medical ICU, Kokoczka and Skowronsky begin collaboratively planning the patient’s care.

Although 90 percent of deliberately ingested foreign bodies pass harmlessly, roughly 1,500 people die from deliberate FBI each year. And, with recurring deliberate FBI, the patient’s risk of complication increases due to previous ingestion and surgeries, etc. For example, another Gastrointestinal Endoscopy article cites that 12-16 percent of deliberate FBI cases require surgical intervention, compared to less than 1 percent with non-deliberate FBI cases. The article also states that approximately 63-76 percent of deliberate FBI cases require endoscopic evaluation.

Kokoczka says it is important to quickly identify the object ingested (typically via X-ray and/or a CT scan) and the urgency of medical intervention needed based on risk of harm. She recommends the following guidelines:

• Emergent Endoscopy: appropriate for esophageal obstruction (patient can’t manage secretions), disk batteries in esophagus and sharp-pointed foreign body substrates in esophagus. Typically requires endotracheal intubation and immediate removal.
  
  
• Urgent Endoscopy: performed for esophageal foreign body substrates that are not sharp-pointed and are significantly impacted, but without complete obstruction, gastric or duodenum foreign body substrates that are sharp-pointed or less than 6 centimeters in length and magnets within endoscopic reach. This classification of items should typically be removed within one to two days.
  
  
• Non-urgent Endoscopy: common for esophageal foreign body substrates such as coins (observe for 12-24 hours before endoscopic removal), gastric foreign body substrates less than 2.5 centimeters in diameter, disk and cylindrical batteries without signs of gastrointestinal (GI) injury (observe up to 48 hours before removal) and batteries in stomach for less than 48 hours. Patients are either monitored in the inpatient setting or may be sent home to pass the object.

In general, Kokoczka says most foreign body substrates do not become impacted in the oropharynx and typically only cause minor lacerations or abrasions. The most common location in which substrates get lodged is the esophagus where potential issues include perforation, mediastinitis, fistula and aspiration. If ingested objects make it into the lower GI system, Kokoczka says they will generally pass without complication as less than 1 percent of objects cause perforation in this area.

She advises that short, blunt objects (less than 2.5 centimeters in diameter) like marbles and buttons can typically be pushed using an endoscope from the esophagus to the stomach, long objects such as toothbrushes and eating utensils should be removed if longer than 6 centimeters and can’t easily pass through the duodenum, and sharp-pointed objects such as straightened paperclips, toothpicks, needles, razors and knives require emergency endoscopy if in the esophagus. She also says if the patient has ingested disk or button batteries and they are lodged in the esophagus, they should be removed immediately as the batteries can cause rapid liquefaction necrosis and perforation, which can be fatal. Similarly, if the patient has ingested magnets, the attractive force of the magnets can lead to necrosis and should also be removed immediately.

The shorter the stay, the better

Skowronsky cautions that deliberate FBI patients do not generally respond well to long hospital stays. She notes that after they have ingested an object, they typically go through a cycle of relief, then shame, which is followed by negative emotion.

In most cases, patients can be discharged directly from the ICU without transitioning to a medical-surgical unit. However, if patients do need further inpatient care, Skowronsky and Kokoczka encourage nurses to proactively update the caregivers on the medical-surgical unit in advance to help prepare for the patient’s arrival and ensure continued care and safety for both the patient and caregivers.