2. What are the stated uses and guidelines of
the Protocol?
Stated Uses:
Increases family and patient compliance with
modified diets and decreases rates of dehydration
by allowing individuals with dysphasia to consume
water within the guidelines of the protocol
Guidelines for the Frazier Water Protocol at the Frazier
Rehabilitation Center
(Panther, 2003; Panther, 2005)
3. To which client/patient population does it apply?
ALL patients who are NPO or on a modified diet due
to Dysphasia
Except those with excessive coughing and those on Strict NPO
Patients with (or who are able to maintain) excellent
oral hygiene
Those who need assistance maintaining oral hygiene are not
excluded as long as assistance is available
(Panther, 2005)
4. Is there documented evidence that it is valid for use
with a specified population?
Extremely limited evidence for use with Adults who
have dysphasia:
(Garon, Engle & Ormiston, 1997)
No studies on using this protocol with the pediatric
population (Weir, McMahon & Chang, 2009)
5. Generalization:
To which other populations does it claim to generalize?
ALL Patients who are either NPO or on a modified
diet due to dysphasia
(Panther, 2005)
6. Outcomes:
Are outcomes clearly stated?
The expected outcomes are clearly stated by the
Frazier Rehabilitation Center’s Official Water Protocol
document written by Panther:
Safe aspiration of water
Maintained hydration
Increased patient and family compliance with modified diets
(Panther, 2003; Panther, 2005)
7. Peer-Reviewed Research
Is there peer-reviewed research that supports or
contradicts the stated outcomes or benefits?
Safe aspiration of water
Lung Damage: Olson, 1970
Aspiration Pneumonia rates: (Garon, et.al., 1997)
Maintained hydration
Two studies that do not support Maintained Hydration: (Garon, et.al.,
1997; Sharpe, Ward, Cichero, Sopade & Halley, 2007)
Other possible factors: (Batchelor, Neilsen, Sexten, 1996)
Increased patient and family compliance with thickened liquid diets
Thirst satiation and relief for dry mouth: (Garon, et.al., 1997)
8. Publications
Are there publications about this procedure?
There are limited publications about the protocol
Is the information published in a peer-reviewed professional journal?
Some information is published in peer-reviewed professional journals;
data in peer-reviewed journals is limited
Is promotional material the only published source of information?
No, there are other published sources of information.
The developer of the FWP appears to have conducted little research
and makes many strong statements about efficacy that do not appear to
be validated based the amount of research that is available. Claims
made in promotional materials (Northern Speech Services & National
Rehabilitation Services , 2010; Panther, 2003) are not cited and do not
refer the reader to peer-reviewed evidence.
9. Developers
What is the professional background of the developers of the
procedure? If a company, how long has it been in existence?
Kathy Panther MS, CCC-SLP
Director of Frazier Rehab Institute
Developed Frazier Water Protocol in 1984
Received State Clinical Achievement Awards in 1996 and 2006
(ASHA member contact directory, 2010)
Frazier Rehab Institute has been in existence since 1954
(Jewish Hospital & St. Mary's HealthCare, 2010)
Have there been complaints to the Better Business Bureau (BBB),
government consumer offices, or licensing boards about the company?
BBB (2010), rates the Frazier Rehab Institute as “A”
No customer complaints in the last 3 years
10. Experience:
Have you talked with others who have experience with this procedure?
Ashleigh Connell, MS CCC-SLP
Feeding Specialist
Providence Center for Medically Fragile Children (CMFC)
Attended conference in February, 2010 to determine if a
Water Protocol is appropriate for children at CMFC
Presented by Caren Carlaw, MA CCC-SLP
A. Connell (personal communication, June 30, 2010)
11. Experience:
What was their experience?
Decided that a Water Protocol is not appropriate for this
population for the following reasons:
Lack of research in the pediatric population
Exclusion criteria: Carlaw (2009) outlines that patients with the
following conditions are not appropriate for the Water Protocol:
• Unstable medical condition
• Excessive coughing during or after intake
• Oral/dental bacteria or infection that cannot be controlled
• Active pneumonia
• Absent swallow reflex
• Respiratory problems
• Medically fragile population
12. Scope of Practice
Is it within my profession’s Scope of Practice?
Speech-Language Pathologists are qualified to evaluate and treat
dysphagia. Due to our involvement in swallowing disorders, it is within
the profession’s scope of practice to use the Frazier Water Protocol
once we are fully trained and comfortable with the procedure
Is it within my personal scope of practice to use the Frazier
Water Protocol?
It is within our scope of practice if we meet the listed qualifications:
Full training in the treatment of Dysphagia in the particular population
We need to be comfortable, experienced, and adequately trained in
administering and implementing the Frazier Water Protocol
13. Information/Policies:
Are there any ASHA statements or guidelines on this topic?
There are no ASHA statements or guidelines on this
particular topic due to limited research available.
ASHA (2001) states that Speech-Language
Pathologists have the education, knowledge, and skills
necessary to evaluate and manage swallowing
disorders
Must demonstrate competencies specific to settings, populations
and procedures
Qualified to form treatment plans that address nutrition,
hydration, diet modification and quality of life
14. What is recommended as sufficient training to be
considered a qualified user of the procedure?
Attend a conference or seminar
Seminar brochure (Northern Speech Services & National
Rehabilitation Services, 2010) states that “participants will leave
with the knowledge to effectively implement oral hygiene and free
water protocols at their facilities”
ASHA (2001) states that Speech-Language Pathologists
must demonstrate competencies specific to settings,
populations and procedures
Qualified users of the Frazier Water Protocol need to be
knowledgeable and experienced with dysphagia assessment and
treatment
15. Availability and Cost
Are there similar procedures or programs currently available?
GF Strong Water Protocol
How do they compare in performance and cost?
Performance:
Carlaw (2009), listed the following differences:
Frazier: NPO patients permitted water any time; specific oral care protocols
are not identified; uses term “free water”
GF Strong: NPO patients are not permitted water unless order is made; there is
an algorithm to facilitate consistent decision making; there are specific
exclusion guidelines; oral care protocols are defined; does not use term “free
water” as water is not freely available to all patients
The GF Strong Water Protocol appears to be more specific
Cost: we were unable to locate any information regarding seminars and
materials specific to the GF Strong Water Protocol
16. Cost:
Is the cost reasonable and justifiable?
Asha.org sells the audio CD & manual
Members: $74
Non-members: $99
Seminars
1 person: $215.00
2-4 people: $205.00
5+ people: $185.00
(Northern Speech Services & National Rehabilitation Services, 2010)
The cost is reasonable and justifiable
Even though there is minimal research, this protocol appears to
be an option for specific patient populations
The seminars and available materials are reasonably priced
17. What are potential risks and adverse consequences?
Aspiration Pneumonia
Limited evidence for use with a specific population
Lack of sufficient evidence to indicate that aspiration
pneumonia is not a risk
Confusion regarding guidelines may increase risk
18. What are the potential benefits?
Increased patient compliance to other diet restrictions
Decreased rates of dehydration
Decreased cost to hospitals/patients
Provides a method for continuous evaluation of
changes in swallowing based on bedside observation
19. References
American Speech-Language-Hearing Association. (2001). Roles of speech-
language pathologists in swallowing and feeding Disorders: Technical
report [Technical Report]. Available from www.asha.org/policy.
doi:10.1044/policy.TR2001-00150
American Speech-Language-Hearing Association. (2010). Member
directory: Kathy Panther. Retrieved July 2, 2010, from
http://asha.org/eWeb/mddynamicpage.aspx?
site=ashacms&webcode=memberdetail&key=d1e4f228-6e3b-4450-9a87-
053b298fd565&mbr _cst_key=d1e4f228-6e3b-4450-9a87-053b298fd565
Batchelor, B., Neilsen, S., Sexten, K. (1996). Issues in maintaining hydration
in nursing home patients who aspirate thin liquids. Journal of Medical
Speech-Language Pathology, 4, 217-221.
20. References
Better Business Bureau. (2010). BBB business review reliability report
for Frazier Rehab Institute. Retrieved from
http://www.bbb.org/louisville/business-reviews/health-and-medical-
general/frazier-rehab-institute-in-louisville-ky-18000500/
Carlaw, C., (2009). Implementation of a water protocol in a
rehabilitation setting [PowerPoint slides]. Seattle, WA: American-
Speech-Language-Hearing-Association.
Garon, B.R., Engle, M. & Ormiston, C. (1997). A randomized controlled
study to determine the effects of unlimited oral intake of water in
patients with identified aspiration. Journal of Neurological
Rehabilitation, 11, 139-148.
21. References
Jewish Hospital & St. Mary's HealthCare. (2010). About Frazier Rehab
Institute. Retrieved from http://www.jhsmh.org/HealthServices/
RehabServicesFrazierRehab/AboutFrazierRehabInstitute.aspx
Northern Speech Services & National Rehabilitation Services. (2010).
Prevention of aspiration pneumonia: Oral care and free water.
Retrieved from http://www.northernspeech.com/seminar_detail/
1000104/Aspiration_Pneumonia__Oral_Hygiene__Free_Water/1001
176/Prevention_of_Aspiration_Pneumonia_Oral_Care_and_Free_W
ater/
Olson, M. (1970). The benign effects on rabbit’s lungs of the aspiration of
water compared with 5% glucose or milk. Pediatrics, 46, 538-547.
22. References
Panther, K. (2003, April 21). New directions in dysphagia. Discussion posted
to http://www.speech-languagepathologist.org, archived at
http://www.speech-languagepathologist.org/archives/
chat/SLP/April212003.html
Panther, K. (2005). The Frazier free water protocol. Perspectives on
Swallowing and Swallowing Disorders (Dysphagia), 14, 4-9.
Sharpe, K., Ward, L., Cichero, J., Sopade, P., & Halley, P. (2007). Thickened
fluids and water absorption in rats and humans. Dysphagia, 22, 193-203.
DOI: 10.1007/s00455-006-9072-1
Wier, K., McMahon, S., & Chang, A.B. (2009). Restriction of oral intake of
water for aspiration lung disease in children (review). Cochrane Database
of Systematic Reviews 2005, 4. DOI: 10.1002/14651858.CD 005303.pub2.
Notes de l'éditeur
Guidelines:
All patients are screened with water
Patients on oral diets are allowed water between meals, NPO patients are often allowed water as well
Patients may ingest water up until the first bite of a meal but must wait for at least thirty minutes after completing a meal before consuming water again
Patients wear a blue bracelet which reads “no thin liquids except water between meals” and staff are trained to check for bracelets before offering liquids
Water is freely offered to patients between meals
Patients are encouraged to use any compensatory strategies that are proven effective when consuming water
Aggressive oral care should be encouraged and provided to those that cannot clean their own teeth and mouths
Medications are NEVER given with water. Instead they are given with applesauce, pudding, yogurt, or thickened liquids
Family education emphasizes the reasons for allowing water intake and is repeated to the family by the Speech-Language Pathologist, the Dietician, and the Nurse
- According to the author of the Frazier Water Protocol, Kathy Panther (2003):
ALL Patients who are NPO or on a modified diet due to dysphasia can benefit from the Frazier Water Protocol (Panther does not indicate age restrictions)
Those demonstrating impulsivity or excessive coughing will require supervision of water intake
Extreme choking may cause too much physical stress and may disqualify a patient for the protocol
OCCASIONALLY a doctor may order a STRICT NPO under which no water or ice chips are allowed
The patients that participate in this procedure must be able to maintain excellent oral hygiene (independently or with assistance)
Oral hygiene is important to reduce chances that pathogenic bacteria from the oral-pharyngeal cavity will be transferred to the lungs and infect the pulmonary system
There is one controlled randomized study for the adult population, and there are no studies for the pediatric population.
Adults:
Garon, et.al. (1997):
The results of this study may not be applicable to the following types of patients due to their exclusion from the study:
Patients with multiple CVA’s
Patients with degenerative neurological function
Patients with pneumonia
Patients with multiple medical diagnoses
Patients with reflux or esophageal disorders
Patients with poor cognition
Patients with severe cough reflex reaction upon consumption of thin liquids
Patients who are unable to rinse and expectorate
Patients who are unable to hold a cup or self-feed
Patients with impulsivity
Patients with a pre-existing concern regarding hydration status
Pediatric:
A systematic review by Wier, et.al (2009) yielded no studies of the Frazier water protocol with the pediatric population as of December 2008.
The authors of this presentation were unable to locate studies for use of the FWP with the pediatric population as of June 2009.
The author of this protocol, Kathy Panther, indicates that all patients who are either NPO or on a modified diet due to dysphasia are candidates for the protocol. She does not specify a particular population outside of this stated criteria.
There is only one randomized controlled study, by Garon, et.al. (1997), directly evaluating the effects of allowing water to patients who aspirate thin liquids and the participants were extremely limited in range of characteristics.
The authors of this poster were unable to locate any studies on the use of this protocol in the pediatric population.
As of December 2008, there were no studies available examining the efficacy of this protocol for use in the pediatric population (Wier, et.al 2009).
Safe Aspiration of Water:
Small amounts of water taken into the lungs are safe and easily absorbed by the body
Compared to other liquids water is free from bacteria, other contaminants and chemicals and has a neutral PH
Maintained Hydration:
The encouragement of free water consumption can create a significant improvement in hydration status for many
Use of the protocol should reduce the risks and costs of hydration via IV fluids
Post discharge surveys of patients from the Frazier center who have dysphasia indicate that water is the main source of hydration for most patients
Family and Patient Compliance
Patients and Families often object to thickened liquids
Patients frequently complain of thirst and state that thickened liquids do not quench their thirst
At home preparation, availability and cost of thickened liquids can make it difficult for the patient and family to maintain compliance.
Safe Aspiration of Water:
An extensive search for evidence that small amounts of water can be safely absorbed by the lungs yielded only one study by Olson (1970) which evaluated amounts of damage to the lungs of rabbits when small amounts of water were aspirated compared to a 5% glucose liquid and milk. Results indicated that significantly less damage was found in the lungs of those who aspirated water compared to the other two liquids.
Garon, et.al. (1997): The only Randomized Controlled study which directly evaluates whether or not the allowance of water for patients who aspirate on thin liquids increases aspiration pneumonia rates, decreases dehydration rates, and increases patient thirst satiation.
Randomized controlled study with 20 recent stroke patients(within 3 weeks of CVA) who were shown to aspirate on thin liquids via MBS and were not disqualified due to one of the above criteria.
Control group had 10 participants who consumed thickened liquids only.
Study group had 10 participants who consumed thickened liquids but were allowed free access to water.
Water was placed out of reach in the patient’s room and patients were instructed to notify a nurse or family member when they wanted water.
No water was allowed for an hour after meals and pre-rinse was required before any water intake.
There were no compensatory strategies or cues given to patients in either group. (Author does not indicate if certain specific guidelines of the FWP were followed: water offered frequently throughout the day, medication not given with water)
Results:
No patient in either group developed aspiration pneumonia, dehydration or other complications during the study or within 30 days after the study.
The end point of the study was different for each individual: Individuals continued to participate in the study until they recovered to a point of no thin liquid aspiration detected by follow-up videofluoroscopic imaging
There was no statistically significant difference in the mean length of study participation between groups: Control group averaged 27.2 days while the study group averaged 19.1 days
There was also no significant difference in the mean amount of liquid consumed between groups: Control group averaged 1,210 cc/day while the study group averaged 1,318 cc/day
Regarding satiation: one patient in the control group reported satisfaction with the thickened liquids and no patients in the study group reported satisfaction with thickened liquids. All of the patients in the study group reported high satisfaction with access to water.
Results of the Garon, et.al. (1997) study do support the safe aspiration of water because neither the control group nor the study group developed aspiration pneumonia or other complications during the study or within 30 days after the study. (Clinical implications remain limited due to the limitations of the study: length of study, characteristics of participants)
Hydration:
Results of the Garon, et.al. (1997) study do not support use of Frazier Water Protocol as compared to typical dysphasia protocol in an effort to maintain hydration because neither the control group nor the study group became dehydrated however the study occurred over a relatively short period of time and with few participants that were relatively healthy aside from one CVA causing dysphasia.
Water absorption rates: (Sharpe, et.al., 2007):
Study examining the absorption rates of thickened liquids versus water in rats and humans. (only 6 human participants) Researchers found no significant differences in the absorption rates of thickened liquids (regardless of type of thickener) and water in either rats or humans.
Other Possible Factors in hydration: (Batchelor, et.al., 1996)
Dehydration may be a result of many factors including:
decreased thirst
decreased ability to recognize and/or satiate ones own thirst due to age and/or medical conditions
decreased overall liquid consumption due to distaste for thickened liquids
The FWP may maintain hydration better than typical dysphasia treatments because patients are offered water frequently which may encourage consumption beyond what would otherwise be ingested. However, there are currently no studies which compare a study group on the FWP with a control group offered thickened liquids just as frequently as water would be offered to the study group.
Increased patient and family compliance:
There is weak evidence that the FWP may increase patient compliance from the study by Garon, et.al. (1997):
Patients filled out a satisfaction survey after the study.
All study group participants reported great satisfaction with the allowance of water with most of the comments relating to thirst satiation and reduction in dry mouth.
All study participants also reported that thickened liquids were not thirst quenching and did not taste good.
ninety percent of control group participants reported they were displeased with thickened liquids and desired ice chips or water for thirst.
Results indicate increased patient satisfaction when they are allowed water which MAY increase patient compliance to other diet restrictions.
No information about complaints are available about Kathy Panther or the Frazier Rehab Institute from the government consumer offices or licensing boards.
The conference presented both the Frazier Water Protocol and the GF Strong Water Protocol. Ashleigh Connell considered implementing a general water protocol that would use the combination of both protocols as researched and presented by Caren Carlaw (2009).
Have you considered posting a query on ASHA’s interactive member forum on its website?
We did consider posting a query on ASHA’s member forum, but decided that Ashleigh Connell’s experience answered the question very well.
Please note that the items listed in this slide include only several areas that an SLP is qualified to treat, as related to our subject. ASHA (2001), lists other areas that an SLP is qualified to address in the treatment of swallowing disorders.
The GF Strong Water Protocol is based in British Columbia, Canada. There is little information available on the protocol, its cost, and performance. Based on the presentation by Carlow (2009), the GF Strong Water Protocol appears to be more specific in terms of the best candidates for the protocol, and the way it should be implemented.
Aspiration Pneumonia:
Insufficient evidence to support safe use of this protocol with many populations of patients:
Only limited evidence for use with a select group of recent stroke survivors and little if any other medical conditions (Garon, et.al., 1997)
Limited studies showing that small amounts of water in the lungs is safe
Only one study was located evaluating the damage of small amounts of water on the lungs of rabbits (Olson, 1970)
Confusion regarding the guidelines may increase risk:
Caregivers/nursing staff may assume that patients can take medicine with water or can drink other thin liquids
Some patients may not be cognitively able to follow guidelines without direct assistance
Increased patient compliance to other diet restrictions
Anecdotal evidence indicates patients are more compliant with other diet modification strategies when they are allowed to drink water
Patients report increased thirst satiation and relief of dry mouth when allowed water which may contribute to their willingness to follow other diet modification guidelines
Decreased Rate of Dehydration
Additional research is needed but the nature of the Frazier water Protocol results in water being offered to the patient frequently throughout the day which may overcome many factors that contribute to dehydration in patients with dysphagia.
Decrease cost to hospitals/ patients
If the FWP results in decreased dehydration rates then there should be a decrease in the frequency of IV fluid administration which reduces cost for the hospital and the patient. Additionally, thickeners and pre-thickened liquids are expensive and time consuming.
Continuous Evaluation
Patients who are consuming water can be observed frequently for changes in coughing behavior and posturing which may indicate the need for additional imaging to further evaluate changes in swallowing ability.
