Free Water Protocols and Its Implementation in Health Care Facilities

Transcription

1 Free Water Protocols and Its Implementation in Health Care Facilities Sarah Petullo, MA, CCC-SLP Speech Language Pathologist Instructor/Clinical Supervisor ID-HCC Conference Des Moines, Iowa March 27, 2017 Fun Fact: A healthy adult can drink 3 gallons (48 cups) of water per day. Retrieved from Salary: Financial Disclosures From the University of Northern Iowa Cedar Falls, IA From place of PRN employment: NewAldaya Lifescapes Cedar Falls, IA Northern Iowa Therapy Waverly, IA Oak Hill Rehabilitation Traer, IA UnityPoint Health - Prairie Parkway Cedar Falls, IA Speaker Honorarium IDHCC There are no nonfinancial disclosures My purpose is to provide evidence basis for clinical decision making. I am not advocating for or against the Free Water Protocol. Objectives 1. Discuss the current state of evidence and limitations for the Free Water Protocol. 2. Identify guidelines for implementing the Frazier Free Water Protocol 3. Identify multi-disciplines involved in implementation of the Free Water Protocol Fun Fact: According to a study over the span of six years, those who drank at least five glasses of water per day were 41 percent less likely to suffer from a heart attack than those who drank two glasses or less each day. Retrieved from

2 Water, Agua, H20 Water is one of the basic of all needs - We cannot live more than a few days without it. Robert Alan Aurthur Thousands have lived without love, but not one without water. W. H. Auden What is thin liquid? Definition: Common liquids people drink on a daily basis (e.g. coffee, juice, water, soda, etc.) Flows very quickly while pouring International Dysphagia Diet Standardisation Initiative (IDDSI) A standardized way of naming and describing texture-modified foods and and thickened liquids for people with dysphagia across the lifespan Established global terminology that will work for all cultures internationally IDDSI Flow Test Use a 10mL syringe when measuring the thickness of liquids Length of 10 ml scale = 61.5 mm Thin Liquids = Level 0 More information available at

3 Aspiration Pneumonia Definition: A bacterial infection resulting from aspiration of bacteria that are pathogenic to lungs (Carlaw & Steele, 2014) Transient Aspiration occurs in healthy adults Aspiration only develops into pneumonia if material aspirated is pathogenic to the lungs (Langmore et al., 1998) 43% - 54% of stroke survivors with dysphagia are likely to aspirate. Only one third of these developed pneumonia (Carlaw et al., 2011) How do the lungs manage aspirated fluids? Reference: Effros, R. M., Jacobs, E. R., Schapira, R. M., Biller, J., (2000). Response of the lungs to aspiration. The American Journal of Medicine, 108(4A), 15S - 18S. Water channels (aquaporins) in the lungs and are associated with endothelium and epithelium of the lungs The exact function of the aquaporins in the lungs remains uncertain Aquaporins may assist in removal of water from airspaces after aspiration while drinking Water Protocol A set of guidelines which enables selected patients with thin liquid dysphagia access to water to improve hydration and provide an alternative to thickened liquids (Carlaw et al., 2011). Use pure water only, no flavoring or additives Level 0 on IDDSI FUN FACT: By the time a person feels thirsty, his or her body has lost over 1 percent of its total water Amount. Retrieved from:

4 Background: What is the Frazier Free Water Protocol? Established in 1984 (Lopez, 2014) The Frazier Free Water Protocol (FWP): Developed by Kathy Panther, MS, CCC-SLP at the Frazier Rehabilitation Institute in Louisville, Kentucky (Panther, 2005) Provides patients diagnosed with dysphagia access to water when prescribed a modified diet of thickened liquids only (Lopez, 2014) Specific guidelines are utilized to reduce risk of developing aspiration pneumonia (Bernard, Loeslie, & Rabatin, 2016). Guidelines for Implementing the FWP Reference: Panther, K.M. (2005). The Frazier free water protocol. Perspectives on Swallowing and Swallowing Disorders, 14, 4-9. All patients are referred to ST to complete initial screen with water Instrumental swallowing exams are completed Water is allowed between meals. Intake is not restricted before a meal and is allowed 30 following a meal NPO patients are allowed water any time Patients given compensatory strategies (e.g. chin tuck) are encouraged to utilize strategies when consuming water Guidelines Continued Patients wear ID bands to indicate thin liquid restrictions Aggressive oral care should be provided to patients not able to clean oral cavity independently Medications should NEVER be given with thin water Education of the rationale for intake of thin water is provided, guidelines are repeated by multi-disciplines, written material is provided

5 Which patient is appropriate for the FWP? Patient 1: Has not completed VFSS, but passed the initial swallowing screen Previous history of pneumonia No coughing with PO intake of solids or liquids Diagnosis of Congestive heart failure Patient 2: Excessive coughing with PO intake Failed VFSS Currently diagnosed with low grade fever, altered mental status, dehydration, active pneumonia Mobile Multidisciplinary Team Patient Physician Nurse & Physician PRN Dietitian Speech Language Pathologist Occupational Therapist Other disciplines involved could include: Social worker Dietary staff (kitchen) Certified Nurse Assistant Pharmacist Respiratory Therapist Roles of Patient Actively participate in maintaining oral health Comply with recommendations given by healthcare professionals Receive education and handouts regarding the FWP Ask questions when not understanding Allow family members and/or caregivers to be involved if comfort allows and if possible. Sometimes pt s do not have established relationships or feel comfortable to involve family members in their POC. If elderly, may not have family around to be involved.

6 Physician Roles Refer patients to relevant professionals if dysphagia is suspected Investigate the cause of dysphagia and prescribe treatments if warranted Prescribes medication May order FWP Roles of a Nurse & Physician PRN Implement dysphagia/feeding recommendations Document/Monitor intake of solids and liquids Consult with speech language pathologist, dietitian, & other team members Administer medications as directed Repeat education of guidelines for the FWP to patient Monitor for signs of dehydration (Carlaw & Steele, 2009) Assess patient temperature Monitor for symptoms of aspiration pneumonia including coughing, crackles and rales upon auscultation, and increased temperature (Carlaw & Steele, 2009) Provide, assist and ensure oral cares are completed (Carlaw & Steele, 2009) Monitor patient for signs of dehydration (BUN levels, creatinine; Carlaw & Steele, 2009) Roles of a Dietitian Complete initial screen and comprehensive nutritional assessment Consult closely with speech language pathologist Manage and monitor nutrition and hydration (fluid intake) Monitor for signs of dehydration (Carlaw & Steele, 2009) Assess the need for supplements Manage weight Make oral and tube feeding recommendations Make the prescribed diet as appealing and palpable as possible (Leonard, 2014). Educate patient on fluid requirements (Carlaw & Steele, 2009). Use good clinical judgement with each patient when considering the FWP

7 Roles of the SLP Leads management decisions relating to rehab of swallowing impairment (McFarlane et al., 2014) such as identifying and teaching strategies Assess, diagnose, and treat dysphagia and as well as upgrade diet in collaboration with team members Complete swallow screen, bedside swallow evaluation, VFSS Use good clinical judgement with each patient when considering the FWP Recommend compensatory strategies to improve safety Consult closely with the dietician Initiate oral care (Carlaw & Steele, 2009) Educate patient, family, and team members on guidelines, strategies and oral care procedures, recommendations to promote safe drinking (Carlaw et al., 2011) Roles of an Occupational Therapist Identify and teach strategies to complete oral care (Carlaw & Steele, 2009) Recommend adaptive equipment for oral cares and water swallow (Carlaw & Steele, 2009). Recommend appropriate strategies and positioning for safe feeding Educate Patient on adaptive equipment for feeding Evaluate, recommend, and train patient in positioning for feeding & oral care (Carlaw & Steele, 2009). Assist in staff training to promote safe drinking for patients Use good clinical judgement with each patient when considering the FWP Educate patient and family (Carlaw & Steele, 2009). Evidence in the Literature...Hydration Reference: Murray, J., Doeltgen, S., Miller, S., & Scholten, I. (2016). Does a water protocol improve the hydration and health status of individuals with thin liquid aspiration following stroke? A randomized controlled trial. Dysphagia: Vol. 31(3); p patients with diagnosis of stroke and dysphagia including aspiration of thin liquids Randomly assigned into two groups: thickened liquids only group water protocol group Daily beverage intake recorded using fluid balance charts Hydration measured by using BUN/Cr Satisfaction measured by patients completing a 5 question survey, weekly

8 Evidence in the Literature...Hydration Reference : Murray, J., Doeltgen, S., Miller, S., & Scholten, I. (2016). Does a water protocol improve the hydration and health status of individuals with thin liquid aspiration following stroke? A randomized controlled trial. Dysphagia: Vol. 31(3); p Outcomes and Findings from the Study No difference in the total amount of liquid consumed between groups Fluid intake did not increase for those in the water protocol group No difference in hydration levels for patients at any point 21% of total sample diagnosed with dehydration Dramatically more UTI s in thickened liquids only group compared to water protocol group No difference in satisfaction scores between the two groups No participants from either group developed aspiration pneumonia No adverse events Evidence in the Literature Satisfaction Reference: Garon, B., Engle, M., & Ormiston, C. (1997). A randomized control study to determine the effects of unlimited oral intake of water in patients with identified aspiration. J Neuro Rehab, 11, stroke patients in rehab unit diagnosed with aspiration of thin liquids Randomly assigned into two groups: Control group (10 participants): thickened liquids only Study group (10 participants): thickened liquids with access to water Follow-up swallowing evaluations completed upon neurologic improvements No direct or indirect swallow therapy completed during study Evidence in the Literature Satisfaction Reference: Garon, B., Engle, M., & Ormiston, C. (1997). A randomized control study to determine the effects of unlimited oral intake of water in patients with identified aspiration. J Neuro Rehab, 11, No patient in either group developed pneumonia, dehydration, or complications Fluid intake increased in study group compared to control group but NOT significantly Control group: mean intake of thickened liquids/day = 1,210 cc Study group: mean intake of thickened liquids/day = 855 cc mean intake of water/day = 462 cc Significant difference between groups with intake of thickened liquids No significant differences in total intake were noted Only 1 participant in control group reported satisfaction with thickened liquids No participants in study group indicated satisfaction with thickened liquids All study group participants reported a high level of satisfaction with water access

9 Evidence in the Literature Safety Reference: Becker, D.L., Tews, L. K., & Lemke, J. H. (2008). An oral water protocol for rehabilitation patients with dysphagia for liquids. ASHA Convention. (Genesis Medical Center, Davenport, Iowa). 26 participants confirmed to aspirate liquids on VFSS Studied effects of water protocols on adverse events; physical, cognitive, and swallowing recovery; duration of hospital stays Randomly assigned into groups: Control group received thickened liquids only Study group received thickened liquids + water (unlimited water allowed between meals) Received oral cares 4 times/day Evidence in the Literature Safety Reference: Becker, D.L., Tews, L. K., & Lemke, J. H. (2008). An oral water protocol for rehabilitation patients with dysphagia for liquids. ASHA Convention. (Genesis Medical Center, Davenport, Iowa). Results: Adverse Events - during hospitalization or 30 days following discharge Pneumonia = 2 participants UTI s = 4 participants Deaths = 2 participants Results: Differences in physical, cognitive, and swallowing recovery Physical and cognitive recovery: No treatment effect for changes in FIMs Swallowing recovery: No treatment effect for changes in FCMs Results Differences in duration of hospitalization Dramatically shorter length of hospital stay for Study group participants (water) Medians: Study group (water) 18 days; Control group (thickened liquids) 41 days Literature Against the WP References: Coyle, J. L. (2011). Water, water, everywhere, but why? Argument against free water protocols. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20(4), Panther, K. (2005). The Frazier free water protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(1), 4-9. Debate 1: Absence of empirical data and lacking scientific evidence supporting use of FWP We cannot disregard the importance of good, solid evidence in our clinical decision-making Inappropriate for health-care professionals to utilize methods that are not scientifically based Debate 2: Because no controlled studies have been published either before or after the inclusion of aggressive oral hygiene, we really do not know whether oral hygiene alone would provide the protective benefits purported by water protocol proponents. Debate 3: A protocol does not take into consideration the numerous individual risk factors within each individual patient.

10 Literature Against the WP Reference: Coyle, J. L. (2011). Water, water, everywhere, but why? Argument against free water protocols. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20(4), Debate 4: Based on the study by Becker, Lew, & Lemke, results showed 2 patients from the WP group died. If we cause renal failure/dehydration using thickened liquids believing we are preventing aspiration, what have we gained. Debate 5: the incidence of pneumonia in patients treated with the water protocol was 2/234 patients or less than 1% (Coyle, 2011). Coyle argues it is impossible that pneumonia incidence in patients with dysphagia can be reduced by 90% by drinking unlimited water. Lack of evidence Difficult to measure Limitations for the FWP There are guidelines for the FWP, but there are no specific guidelines on how much water a patient can or should consume in a day. After completing a thorough review of literature, and knowing there is controversy on this topic, people are talking about it, it was difficult to find research against the FWP. Small sample sizes completed in most studies, need larger sample sizes to achieve a better understanding of the efficacy and effectiveness of using the FWP Lack of scientific evidence supporting FWP use (Coyle, 2011). Absence of empirical data regarding FWP safety, efficacy, and effectiveness (Coyle, 2011). No evidence indicating aggressive oral cares prevents aspiration pneumonia Questions? What other limitations could be identified based on the evidence that has been discussed? FUN FACT: Soft drinks, coffee, and tea, while made up almost entirely of water, also contain caffeine. Caffeine can act as a mild diuretic, preventing water from traveling to necessary locations in the body. Retrieved from: FUN FACT: While the daily recommended amount of water is eight cups per day, not all of this water must be consumed in the liquid form. Nearly every food or drink item provides some water to the body. Retrieved from:

11 Closing Statements A collaborative team is vital for the implementation of the FWP. The FWP is NOT appropriate for all patients with a diagnosis of dysphagia. It is important to consider the evidence as well as using good clinical judgement when considering use of the WP with patients (Coyle, 2011). We must think clearly when determining which patients are selected for the WP (Coyle, 2011). More evidence is needed! There is not enough evidence for or against the water protocol. Selected References Becker, D.L., Tews, L. K. & Lemke, J. H. (2008). An oral water protocol for rehabilitation patients with dysphagia for liquids. Chicago, IL: American Speech-Language Hearing Association Convention; Available online at Bernard, S., Loeslie, V., & Rabatin, J. (2016). Brief Report - Use of a modified frazier water protocol in critical illness survivors with pulmonary compromise and dysphagia: A pilot study. American Journal of Occupational Therapy, 70, Burton, S., Laverty, A., Macleod, M., (2012). The dietitian s role in diagnosis and treatment of dysphagia. In Dysphagia (pp ). Springer Berlin Heidelberg. Carlaw, C., Finlayson. H., Beggs, K., Visser, T., Marcoux, C., Coney, D., Steele, C., (2011). Outcomes of a pilot water protocol project in a rehabilitation setting. Dysphagia, 27, Carlaw, C., Steele, C., (2009). Implementation of a water protocol in a rehabilitation setting. New Orleans, LA: American Speech-Language Hearing Association Convention. Cleary, S., Yanke, J., Masuta, B., Wilson., K., (2016). Free water protocols what works, for whom and why? dysphagia and diet texture modifications. Canadian Nursing Home, 27(3), Coyle, J. L. (2011). Water, water, everywhere, but why? Argument against free water protocols. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20(4), Effros, R. M., Jacobs, E. R., Schapira, R. M., Biller, J., (2000). Response of the lungs to aspiration. The American Journal of Medicine, 108(4A), 15S - 18S. Selected References Garon, B. R., Engle, M., & Ormiston, C. (1997). A randomized control study to determine the effects of unlimited oral intake of water in patients with identified aspiration. Journal of Neurologic Rehabilitation, 11(3), Kleiner, S. (1999). Water: An essential but overlooked nutrient. Journal of the American Dietetic Association, 99(2), Langmore, S.E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J., T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13(2), Leonard, R. & Kendall, K. (2014). Dysphagia assessment and treatment planning: A team approach, third edition. Plural Publishing, Inc Lopez, B. (2014). Guest Blog Post: Frazier Water Protocol. Connections Speech & Language Services, LLC. Retrieved from: McFarlane, M., Miles, A., Preetpal, A., & Parmar, P. (2014). Interdisciplinary management of dysphagia following stroke. British Journal of Neuroscience Nursing, 10(1), Murray, J., Doeltgen, S., Miller, S., & Scholten, I. (2016). Does a water protocol improve the hydration and health status of individuals with thin liquid aspiration following stroke? A randomized controlled trial. Dysphagia: 31(3); Panther, K. (2005). The Frazier free water protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(1), 4-9. Sharpe, K., Ward, L., Cichero, J., Sopade, P., & Halley, P. (2007). Thickened fluids and water absorption in rats and humans. Dysphagia, 22(3), ). Steele, C., (2017). Standardization of dysphagia diets: A model of successful international engagement. Case Studies by ASHA Professional Development Available February 1-28, 2017.