The nursing staff and speech pathologists at The Burke Rehabilitation Hospital in White Plains, N.Y., have used evidence-based research to help patients with dysphagia.
The free water protocol, which originated from the Frazier Rehab Institute in Louisville, Ky., gives patients who are diagnosed with dysphagia the opportunity to have free, unthickened water, even though they are on a restricted diet, such as thickened substances only or NPO. Examples of patients who may participate in the free water protocol include those who have had a stroke or those with structural or anatomical abnormalities associated with oral cancer who now have a tracheostomy.
Patients cannot have water with meals or with medications, and they must wait 30 minutes after every meal before they can drink water again. Patients who are NPO can have water throughout the day, after oral hygiene.
Proponents of the protocol believe it is a matter of balancing safety, hydration and quality of life.
Program in ActionNursing Spectrum roundtable attendees are, standing from left, Roseann Cardi, RN, nurse manager; Mairead Carroll, RN, staff nurse; Stephanie Campbell, RN, assistant director of nursing; Laura Cassidy, RN, staff nurse; Rosalee Bowers, RN, staff nurse; Kate Holzel, RN, nurse manager; and Anne Cabello, RN, evening charge nurse. Seated from left, are Marie Spencer, RN, director of nursing; Eileen Williamson, RN, senior vice president, Nursing Communications & Initiatives, Nursing Spectrum; and Eileen Rogan, RN, nurse manager.
Oral hygiene three times a day is critical to the success of the program; it eliminates oral bacteria and prevents aspiration pneumonia. If a patient aspirates small amounts of plain water, it is absorbed in the lungs and is not recognized as foreign matter.
At Burke, patients who participate in the program complete oral care in the morning, afternoon and evening. Oral care includes tooth, gum and tongue brushing with toothpaste; use of mouthwash; and mouth and lip moisturizer, as needed. If patients are wearing dentures, they lightly brush and soak them once a day for 20 minutes in a Perox-A-Mint solution.
Two years ago, nurses and speech pathologists at Burke modified the Frazier protocol and started it on their neurology unit. Once it was approved by the medical director and comprehensive educational inservices were completed, they expanded the protocol to the entire hospital.
It was a matter of educating the staff about the research, and helping everyone to understand that our patients with dysphagia can have water. It was a different way of thinking, said Roseann Cardi, RN, BSN, CRRN, nurse manager of the stroke/neuro rehab unit.
Speech therapists and nurses at Burke monitor patients for any problems by tracking their white blood cell counts and providing meticulous oral hygiene. Assessing the oral mucosa and mouth integrity, an important component of the program, is done by nurses and speech therapists three times a day.
Now we see our patients with strokes enjoying water, staying hydrated and feeling better, all of which helps in their recovery process, said Anne Cabello, RN, BSN, CCRN, evening charge nurse of the stroke/neuro rehab unit.
Spread the Word
Last year, Cardi presented the Burke free water protocol at the Certified Rehabilitation Nurses Association conference in Albuquerque, N.M. Her presentation, Thirst No More, was one of four on the topic of free water; the other presenters came from different areas of the U.S. The topic is gaining momentum as more rehab hospitals are recognizing the benefits of this evidence-based research, which improves the quality of patients lives, Cardi said.
Previously, NPO meant nothing by mouth, said Marie Spencer, RN, CCRN, PhD, director of nursing. Now, we can offer our patients water, one of lifes simple pleasures that we take for granted. It has a positive effect on both our patients and staff.