KATHY PANTHER, M.S., CCC
LOUISVILLE, KENTUCKY

After several years of a conventional dysphagia program, Frazier’s swallowing management protocol changed dramatically.  Concern over patient and family non-compliance with thin liquid restrictions both within the facility and after discharge led us to alter our protocol in 1984.  Previously prohibited, oral intake of water became a major feature in both treatment and day to day hydration.  Features of Frazier’s program include the points listed below:

Safety of Water

• The human body is about 60% water.  Small amounts of water taken into the lungs are quickly absorbed into the body pool.  (Discussion initiated by program’s pulmonologist.)
• Unlike other liquids, water has a neutral pH. 
• Water provides a safe means of assessing patients with thin liquids.  All patients (of any diagnosis) referred to Speech Pathology are screened for dysphagia with water sips.
• Water is safely utilized in daily treatment of thin liquid restricted patients.  Unlike in a conventional program, swallow compensations can be practiced with thin liquid.
• Drinking water during swallowing therapy allows ongoing assessment of swallow improvement and permits better recognition of patient readiness for repeated videofluoroscopy or endoscopy and diet advancement.

Hydration

• Free water consumption is encouraged for all patients and makes a significant contribution in hydration for many.
• The risk and cost of IV fluids should be decreased.
• Post-discharge surveys of Frazier dysphagic patients indicate water often is the primary means of hydration.

Compliance

• Complaints of thirst were frequently voiced prior to 1984.  Patients reported thickened liquids did not quench thirst.  Water eliminates thirst and patient complaints are now much less frequent.
• Many patients and families object to thickened liquids.  Since water is an option, patients appear more likely to comply with the thin liquids restriction.
• Once home, preparation of thickened liquids often becomes burdensome.  After days or weeks at home the family may tire of patient complaints and abandon thickened liquids.
• Availability and cost of thickening agents and/or prepackaged thick liquids may preclude patient compliance.
• Thick liquid preparation, in addition to other time and energy consuming patient care tasks, can overwhelm many families.

THE FRAZIER REHAB INSTITUTE WATER PROTOCOL

WATER BETWEEN MEALS

BY POLICY, ANY PATIENT NPO OR ON A DYSPHAGIC DIET MAY HAVE WATER.

• All patients are screened with water.  Patients exhibiting impulsivity or excessive coughing and discomfort will be restricted to water taken under supervision.  Patients with extreme choking may not be permitted oral intake of water due to the physical stress of coughing.
• For patients on oral diets, water is permitted between meals.  Water intake is unrestricted prior to a meal and allowed 30 minutes after a meal.  The period of time following the meal allows spontaneous swallows to clear pooled residues.
• After the screening described above, NPO patients are often permitted water.
• Patients who are thin liquid restricted wear yellow wristbands to communicate the liquid restrictions to all staff.  Typically, the band reads, “No thin liquids except water between meals.”  The wording on the band is individualized as appropriate when specific compensations are recommended.  For example, a band may read “No thin liquids except water by teaspoon between meals.”  All rehab staff are oriented to the yellow bands and check for bands before offering liquids to patients.
• Water is freely offered to patients according to the guidelines documented on the yellow bands throughout the day.
• Patients for whom compensations, i.e. chin tuck, head turn, etc., have proven to be successful are encouraged to use compensations while drinking water.  This information is also included on the yellow bands.
• Aggressive oral care should be provided to those patients who are unable to clean their own teeth and mouths so that pathogenic bacteria are less likely to contaminate secretions.
• Medications are never given with water.  Pills are given in a spoonful of applesauce, pudding, yogurt, or thickened liquid.
• Family education includes emphasis on the rationale for allowing water intake.  The Speech-Language Pathologist, Dietician, and Nurse repeat the guidelines for water intake during the education process.  Written material is provided as well.  Education is documented in the medical record.

FRAZIER WATER PROTOCOL
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Service Locations:

• Frazier Rehab Institute

• Frazier Rehab Institute - Downtown