Free Water Protocol: A Thirst Quencher for Known Aspirators in Inpatient Acute Rehabilitation

Research Objectives: To investigate the feasibility of implementing a free water protocol. This project also investigated improvement in patient satisfaction and the incidence of negative outcomes.

Design: This was a quality improvement project implemented across a 12-month span, with data collected for candidates both prior to and following participation in free water protocol.

Setting: Acute inpatient rehabilitation was the primary setting, with the free water protocol implemented on the brain injury unit at Glen Cove Hospital.

Participants: 113 participants were admitted to the brain injury unit across 12 months with 27 (24%) patients that met criteria for free water protocol. Patients were required to be NPO or on thickened liquids. Exclusionary criteria were active respiratory compromise, medical instability, immunodeficiency, neurodegenerative disorders, low arousal, out of bed tolerance less than 3 hours daily, active oral/dental infection or thrush, fever of unknown origin without complete workup, excessive coughing/discomfort with consumption of water or ice chips, and inability to maintain fluid and/or GI related restrictions.

Interventions: Education was provided to all staff via multiple modalities, with speech pathologists determining candidacy for free water protocol throughout the rehabilitation stay. When candidacy was achieved according to criteria, initial and discharge modified SWAL-QOL was administered. Ongoing education to staff, patients and family was provided regarding procedures to ensure reduction of negative outcomes. Following meticulous oral care and between meals, patients enrolled were given thin water and/or ice chips under direct supervision.

Main Outcome Measures: Outcomes were measured through weekly data collection via medical chart reviews which were completed by skilled speech pathologists from different units. Patient satisfaction was measured via modified SWAL-QOL and aspiration pneumonia incidence was collected.

Results: There was no incidence of aspiration pneumonia. Satisfaction improved an average of 28% from pre and post modified SWAL-QOL data. Patients who met the criteria were placed on free water protocol in 71% of opportunities. Of those patients who were not candidates, thrush was the leading exclusionary criteria (49%).

Conclusions: Initial and adaptation of education was required to implement free water protocol effectively. Patients were generally more satisfied with intake of thin water/ice chips when restricted to thickened liquids or nothing by mouth; however cognitive deficits and duration of participation in free water protocol impacted ability to complete the modified SWAL-QOL. No incidences of pneumonia occurred in patients who participated in the free water protocol. Additional research would be helpful in supporting hospital and system wide use of free water protocol.

Author(s) Disclosures: Receive salary from Glen Cove Hospital