THE FRAZIER REHAB INSTITUTE WATER PROTOCOL

KATHY PANTHER, M.S., CCC

LOUISVILLE, KENTUCKY
After several years of a conventional dysphagia program, Fraziers 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 !"#.
$reviously prohibited, oral inta%e of water became a ma&or feature in both treatment and day to
day hydration. Features of Fraziers program include the points listed below'
Safety of Water
(he human body is about )*+ water. ,mall amounts of water ta%en into the lungs are
quic%ly absorbed into the body pool. -.iscussion initiated by programs pulmonologist./
0nli%e other liquids, water has a neutral p1.
2ater provides a safe means of assessing patients with thin liquids. All patients -of any
diagnosis/ referred to ,peech $athology are screened for dysphagia with water sips.
2ater is safely utilized in daily treatment of thin liquid restricted patients. 0nli%e in a
conventional program, swallow compensations can be practiced with thin liquid.
.rin%ing 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.
Hyrat!o"
Free water consumption is encouraged for all patients and ma%es a significant
contribution in hydration for many.
(he ris% and cost of 34 fluids should be decreased.
$ost-discharge surveys of Frazier dysphagic patients indicate water often is the primary
means of hydration.
Co#$%!a"&e
Complaints of thirst were frequently voiced prior to !"#. $atients reported thic%ened
liquids did not quench thirst. 2ater eliminates thirst and patient complaints are now
much less frequent.
5any patients and families ob&ect to thic%ened liquids. ,ince water is an option, patients
appear more li%ely to comply with the thin liquids restriction.
6nce home, preparation of thic%ened liquids often becomes burdensome. After days or
wee%s at home the family may tire of patient complaints and abandon thic%ened liquids.
Availability and cost of thic%ening agents and7or prepac%aged thic% liquids may preclude
patient compliance.
(hic% liquid preparation, in addition to other time and energy consuming patient care
tas%s, can overwhelm many families.
THE FRAZIER REHAB INSTITUTE WATER PROTOCOL
WATER BETWEEN MEALS
BY POLICY, ANY ENTERALLY FE' PATIENT OR PATIENT ON A 'YSPHA(IC
'IET MAY HAVE WATER.
All patients are screened with water. $atients e8hibiting impulsivity or e8cessive
coughing and discomfort will be restricted to water ta%en under supervision. $atients
with e8treme cho%ing may not be permitted oral inta%e of water due to the physical stress
of coughing.
For patients on oral diets, water is permitted between meals. 2ater inta%e is unrestricted
prior to a meal and allowed 9* minutes after a meal. (he period of time following the
meal allows spontaneous swallows to clear pooled residues.
After the screening described above, enterally fed patients are often permitted water.
$atients who are thin liquid restricted wear pin% wristbands to communicate the liquid
restrictions to all staff. (ypically, the band reads, :;o thin liquids e8cept water between
meals.< (he wording on the band is individualized as appropriate when specific
compensations are recommended. For e8ample, a band may read :;o thin liquids e8cept
water by teaspoon between meals.< All rehab staff are oriented to the pin% bands and
chec% for bands before offering liquids to patients.
2ater is freely offered to patients according to the guidelines documented on the pin%
bands throughout the day.
$atients for whom compensations, i.e. chin tuc%, head turn, etc., have proven to be
successful are encouraged to use compensations while drin%ing water. (his information
is also included on the pin% 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 li%ely to contaminate
secretions.
5edications are never given with water. $ills are given in a spoonful of applesauce,
pudding, yogurt, or thic%ened liquid.
Family education includes emphasis on the rationale for allowing water inta%e. (he
,peech-=anguage $athologist, .ietician, and ;urse repeat the guidelines for water inta%e
during the education process. 2ritten material is provided as well. >ducation is
documented in the medical record.
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