FWP Protocol

The FWP's most important guideline is that individuals drink only thickened liquids with meals. Free water is permitted only between meals, and it can be taken up until the first bite of food. Typically, patients wait approximately 30 minutes after eating before drinking water again.

The 30 minute time frame is arbitrary, Franceschini noted. "We used to wait 30 minutes, but we modified that rule because it didn't always work," she said. "Thirty minutes later you could still find scrambled eggs in somebody's cheek."

Now, nurses perform a quick check of the oral cavity between meals to make sure no food particles are present.

"Hopefully, any residue that's left behind has been swallowed in the subsequent amount of time," Franceschini said.

Medications are not to be taken with water, as pills may be washed into the lungs.

The guidelines also suggest that the patient be offered water throughout the day. A wristband or a picture of a water droplet on a pitcher of water or the patient's door, for instance, indicates to staff members that an individual is on the protocol.

By having patients wear an identifying wristband as they travel throughout the building, "everybody realizes that the person is on the Frazier and they're allowed to offer them water," Franceschini said. "That's one of the key components - not just that they get water, but that they're offered water on a frequent basis."

Staff education is crucial when implementing the protocol. Hancock initially modified its guidelines so all staff could understand protocol, and then developed a letter for families and caregivers to increase their understanding as well.

Patients are encouraged to use swallowing compensatory strategies when drinking water. For example, if someone takes water by teaspoon amount with a chin tuck, that information is written on the wristband by the speech-language pathologist. There also may be a sign over the patient's bed displaying the protocol.

Measuring Success

Healthcare professionals can offer patients water during therapy sessions and monitor progress or decline by measuring the frequency of the cough, if present.

"It's a good gauge to use to advance the patient," Panther said.

The success of the protocol calls into question the use of thickened liquids. Panther said they are unpalatable and patients are unlikely to consume enough to meet hydration needs.

"We were deluding ourselves to think our patients were really following our recommendations about thickened liquids," she continued. "The compliance literature shows that with health related recommendations, if you can't see immediate results, you're less likely to comply. The need for water is very primitive. When it is not permitted, people may not stick to the plan very well."

The most significant aspect of the protocol may be its ability to significantly decrease the incidence of pneumonia to the point that it is rarely seen. After a modified barium swallow (MBS) or bedside exam is performed, the clinician continues to monitor the patient for signs of aspiration, high temperature, positive chest X-rays and elevated white blood cell count.

These events usually don't occur, Franceschini said. "If anything, we see patients who are happier and willing to take their thickened liquids. Once they are well hydrated, there is no problem."