Effects of a Free Water Protocol for Patients with DysphagiaPresented at the ASHA Convention, Chicago November 21, 2008Christina R. Bronson-Lowe, M.S. CCC-SLP Kate Leising, Ph.D. CCC-SLP Daniel Bronson-Lowe, Ph.D. Shelly Lanham, M.S. CCC-SLP Stefanie M. Hayes, M.S. CCC-SLP Angelene M. Ronquillo, M.S. CCC-SLP Paul A. Blake, M.D.Contact: crlowe gmail.com1Setting John J. Rhodes Rehabilitation Institute at Banner Mesa Medical Center, Mesa AZ Inpatient/acute rehab2Patients Those whose diet consistency was restricted from thin liquids due to dysphagia Any level of PO diet not including thin liquids, up to and including NPO Reduced thirst satiation and fluid intake for patients on thickened liquids (Garon et al., 1997; Finestone et al., 2001) May not meet fluid requirements (Finestone et al., 2001) Reduced quality of life and compliance with restrictions (Purdy, 2006)3Free Water Protocol (FWP) Kathy Panther, MS CCC -SLP Frazier Rehab Institute, 1984 Thin water between meals Oral hygiene Patient-specific precautions Minimize risk of sequelae from episodes of water aspiration which it is assumed will occur Garon et al (1997) Known thin liquid aspirators 10 with, 10 without FWP No aspiration pneumonia or dehydration in either group Panther (2005) FWP review (not study) Mentions chart review: 234 inpatients on thick liquids; 2 developed aspiration pneumonia; both suspected of solid food aspiration4GoalsTo test the hypotheses that we can improve patients fluid intake reduce their risk of dehydration accomplish the above without increasing their rate of pneumonia5Implementation Staff training (SLPs, MDs, RNs, CNAs, PTs, OTs etc) Patient and family training in the protocol, patient- specific aspiration precautions, and oral hygiene Posted protocol and patient-specific aspiration precautions in room 4 cases (9%) in Hx-Ctrl p = 0.097 Dehydration (non-tube-fed patients) 7 cases (41%) for FWP; 11 cases (35%) in Hx-Ctrl p = 0.697 Avg. fluid intake (days with no TF, no IVF) 1104 mL ( 283 mL) FWP; 943 mL ( 239 mL) Hx- Ctrl p = 0.034 (one-tailed)9Results: FWP vs C-Ctrl No significant intergroup differences in any of the demographic, medical history or pneumonia-susceptibility variables reviewed previously Pneumonia 0 cases (0%) for FWP; 4 cases (16%) in C-Ctrl p = 0.023 Dehydration (non-tube-fed patients) 7 cases (41%) for FWP; 5 cases (33%) in C-Ctrl p = 0.647 Avg. fluid intake (days with no TF, no IVF) 1104 mL ( 283 mL) FWP; 802 mL ( 145 mL) C-Ctrl p = 0.0031 (one-tailed)10Summary & Conclusions No pneumonia in the free water protocol (FWP) group. Difference in pneumonia rates (in favor of FWP group) was significant compared to concurrent but not historical control group. If the difference was real, why did it occur? Better oral hygiene in the FWP group? Better oral lubrication in the FWP group? Increased compliance with aspiration precautions in the FWP group? Available data do not permit us to answer this question.11Summary & Conclusions No difference on gross measure of dehydration. Significant improvement in fluid intake for FWP vs. both control groups. Consider implementation in similar settings only with thorough staff, patient and family training and ongoing program evaluation/monitoring of pneumonia rates.12Acknowledgments Patients and families Nurses, CNAs and other staff assisting with protocol implementation Banner Mesa Medical Center medical records staff Barbara Lambeth RN CCRC, Banner Baywood Medical Center Research Director Banner Health Research Institute and IRB members University of Illinois at Urbana-Champaign, Department of Speech and Hearing Science13BibliographyFeinberg MJ, Knebl J, Tully J, Segall L: Aspiration and the elderly. Dysphagia 5:61-71, 1990. Finestone HM, Foley NC, Woodbury MG, Green-Finestone L: Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies. Arch Phys Med Rehab 82:1744-1746, 2001. Garon BR, Engle M, Ormiston C: A randomized control study to determine the effects of unlimited oral intake of water in patients with identified aspiration. Neurorehabil Neural Repair 11:139-148, 1997. Gupta A, Epstein JB, Sroussi H. (2007). Hyposalivation in elderly patients. J Can Dent Assoc 72: 841-846. Holas MA, DePippo KL, Reding MJ: Aspiration and relative risk of medical complications following stroke. Arch Neurol 51:1051-1053, 1994. Langmore SE, Skarupski KA, Parks PS, Fries BE: Predictors of aspiration pneumonia in nursing home residents. Dysphagia 17:298-307, 2002. Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D, Loesche WJ: Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia 13:69-81, 1998.14Bibliography contd.Leibovitz A, Baumoehl Y, Lubart E, Yaina A, Platinovitz N, Segal R: Dehydration among long-term care elderly patien