BYKIMBERLY JONESOLGA YEGOROV

SLP 6055: OG2DYSPHAGIA

NOVA SOUTHEASTERN UNIVERSITYJULY 15, 2010

Frazier Water Protocol

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)

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)

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)

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)

Outcomes: Are outcomes clearly stated?

The expected outcomes are clearly stated by theFrazier Rehabilitation Center’s Official Water

Protocoldocument written by Panther:

Safe aspiration of water

Maintained hydration

Increased patient and family compliance with modified diets

(Panther, 2003; Panther, 2005)

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)

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.

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

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)

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

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

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

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

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

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

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

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

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.

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.

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/1001176/Prevention_of_Aspiration_Pneumonia_Oral_Care_and_Free_Water/

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.

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.