Free Water Protocol in Nursing Homes

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There are three major areas you are asking about: (1) free water protocol; (2) use of CNAs and their competence to administer the protocol; and (3) thickened liquids.

First, the free water protocol. Our chief concern is swallowing safety to prevent pneumonia in the nursing facility resident. Literature search engines, such as Pubmed, do not identify any research on a free water regimens or protocols. While talked about and used widely, The Frazier Water Protocol developed by Panther, or some variation of it, while not published as a research protocol, has been discussed in several articles found on the ASHA.org website and are easy to locate. What is not discussed is the absolute necessity for good oral care used in combination with any water protocol (See Ashford and Skelley, 2008, Perspectives in Swallowing and Swallowing Disorders, Div. 13, ASHA). The water protocol was developed for non-acute patients in rehabilitation, i.e. their immune systems were sufficient to defend against most aspirated, bacteria-ladened liquids. As such, it was not developed for, nor is there evidence supporting its use with, acute or critically hospitalized patients, or residents of nursing facilities who remain weakened or ill, or who develop other illnesses. Four studies (Schmidt et al. 1994; Holas et al. 1994; DePippo et al., 1994, & Langmore et al., 1998) suggest that pneumonia is less likely to occur if using thin liquids than if using thicker foods, which stands to reason. Thicker consistencies carry larger bacteria loads than thinner consistencies, such as water. I invite you to read two of the most important studies published in dysphagia treatment and both were published in 2008. They provide us with some real questions to ponder about our ready-use of thickened liquids. The first is by Logemann et al. (A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson's Disease. JSLHR) and the second is by Robbins et al. (Comparison of 2 interventions for liquid aspiration on pneumonia incidence. Annals of Internal Medicine). These two studies should be mandatory reading for any therapist who recommends thickened liquids.

Your idea of using coffee straws is novel and certainly would limit the amount of water taken into the oral cavity at any one time. It is worth experimenting with at your facility. Some residents may have difficulty holding it and sucking it, but it is not "silly, impractical, or dangerous." You must remember who your critics areand why. I have used the Provale cup (5ml) (Google it) for years and still recommend it highly in my practice. It can have one or two handles, is easy to hold by the resident, but only allows 5ml (1 teaspoon) out at one time. That is not too much for most patients. But, the straws are cheaper than the cup, but are also easier to dislodge, drop, or lose in the bed coverings. Use all of your assessment tools to monitor their effectiveness (Clinical Bedside, cervical auscultation, observations) with your residents. Do a trial study with some residents before implementing throughout your facility. If you have contract FEES services at your facility, do another instrumental study for up-to-date assessment information on every resident on the protocol to insure safety, or get new MBS studies. Instrumental studies that are three weeks or older are not valid studies any longer and do not represent your resident's current swallowing status. Do not be afraid to reorder instrumental studies; they are just as important or more important, than any other assessment procedure, such as xrays.

Use of CNAs. The nursing literature is full of references to the shortcomings of CNAs (Coleman & Watson, 2006; Chalmer et al, 1996, & Pelletier, 2005). Basically, CNAs are left to the primary cares of patientsduties once performed by RNs and LPNs. Oral care and feeding are not taught in their training and, if so, not well. Oral care is considered by nursing to be for "comfort" rather than a necessity for good health. CNAs do not understand (and many nurses) that the oral environment is one of the primary sources of infection in patients. This means training is a necessity. It is up to you to be the trainer of your free water program with the CNAs, but if you teach them to give water frequently, then you must also train them as to why, how to administer it, and when to stop it, what signs to watch for indicating the resident should not receive it any longer and to report it, who not to give it to, and the importance of keeping the resident's mouth clean (every 8 to 12 hours).

John R. Ashford, Ph.D., CCC-SP is an Associate Professor at Tennessee State University and an Assistant Clinical Professor at the Vanderbilt University. He recently retired from the VA Tennessee Valley Health Care System after 28 years as a clinical Speech-Language Pathologist. He chaired the VA Best Practices in Dysphagia Treatment Taskforce. He is published and has presented nationally in the areas of dysphagia and voice disorders.