JCPSLP Vol 20 No 3 November 2018

Nutrition, swallowing, mealtimes: Recipes for success

The experience of implementing standardised mouth cares and a free water protocol in a metropolitan hospital rehabilitation unit Maria Schwarz, Inger Kwiecien, Anne Coccetti, and Elizabeth Cardell

Standardised oral cares and free water protocols (FWPs) are an emerging change of practice area in speech-language pathology management of people with dysphagia. The purpose of this article is to provide a narrative description of the implementation process used to commence standardised oral cares and a FWP to improve the hydration of rehabilitation inpatients who present with swallowing difficulties. The standardised oral cares and FWP were implemented using a stepwise framework for instituting a clinical practice change. Purpose and objectives The speech-language pathology (SLP) management of dysphagia in Australia has traditionally relied on the utilisation of thickened fluids as a compensatory strategy to minimise aspiration risk (Atherton, Bellis-Smith, Cichero, & Suter, 2007; Felt, 1999; Ku, Ma, McConnel, & Cerenko, 1990; Lazarus et al., 1993; Robbins et al., 2002). However, poor compliance with thickened fluids results in increased risk of dehydration (Cichero, 2013) as well as patient discomfort and reduced quality of life (Garcia, Chambers, & Molander, 2005; Macqueen, Taubert, Cotter, Stevens, & Frost, 2003). The implementation of a free water protocol (FWP) aims to improve hydration and comfort for patients with dysphagia; however, this will require a significant change to usual clinical care and usual SLP practice in many facilities. While the importance of oral care in reducing the risk of aspiration pneumonia has been well documented in the literature (Langmore, 1999; Langmore et al., 1998; Marik & Kaplan, 2003; Pace & McCullough, 2010; Sarin, Balasubramaniam, Corcoran, Laudenbach, & Stoopler, 2008; Scannapieco, 2006; Scannapieco & Mylotte, 1996; Terpenning et al., 2001), the SLP in clinical practice frequently relies on nursing colleagues to complete tasks related to oral hygiene. To compound this, clinical guidelines state that standardised oral hygiene measures are a key requirement for implementing FWPs (Gillman, Winkler, & Taylor, 2017). Similarly, the Speech Pathology Australia clinical guidelines on dysphagia (2012) support the importance of oral hygiene in dysphagia management. As highlighted by the available evidence, the implementation of a FWP within an inpatient rehabilitation

unit cannot be undertaken without ensuring stringent adherence to regular oral care protocols. The aims of this paper are to provide a narrative outline of implementing these two interrelated clinical practice changes within a large 24-bed rehabilitation unit and to elaborate the barriers and facilitators to change that were encountered. Background While the standard treatment for dysphagia related to thin fluids is to prescribe thickened fluids of different consistencies to slow bolus flow and prolong swallowing transit times in order to prevent aspiration (Atherton, Bellis-Smith, Cichero, & Suter, 2007; Felt, 1999; Ku, Ma, McConnel, & Cerenko, 1990; Lazarus et al., 1993; Robbins et al., 2002), in reality there is limited evidence to support the use of thickened fluids in eliminating risk of aspiration or the complications of aspiration (Andersen, Beck, Kjaersgaard, Hansen, & Poulsen, 2013; Robbins et al., 2002). Furthermore, patient compliance can be poor (Garcia, Chambers, & Molander, 2005; Macqueen, Taubert, Cotter, Stevens, & Frost, 2003; Shim & Han, 2013) and poor compliance with thickened fluids results in increased risk of dehydration (Cichero, 2013) as well as patient discomfort and reduced quality of life (Garcia, Chambers, & Molander, 2005; Macqueen, Taubert, Cotter, Stevens, & Frost, 2003). A more recent development in dysphagia management has been the introduction of “free water protocols” which several authors propose as a means to improve patient compliance and comfort, and to minimise risk of dehydration by providing water between meals (Carlaw et al., 2012; Frey & Ramsberger, 2011; Garon, Engle, & Ormiston, 1997; Gillman et al., 2017; Karagiannis & Karagiannis, 2014; Karagiannis, Chivers, & Karagiannis, 2011; Murray, Doeltgen, Miller, & Scholten, 2016; Pooyania, Vandurme, Daun, & Buchel, 2015). Water is considered a safe oral option for hydration as a small amount of water taken into the lungs is absorbed, water is pH neutral and free from bacteria or contaminants (Carlaw et al., 2012; Panther, 2005). When considering a FWP, a set of clear exclusion and inclusion criteria is essential to minimise patient risk. Carlaw and colleagues (2012) provide detailed inclusion and exclusion criteria for patients suitable for a FWP and found no adverse events following the implementation of a FWP in a rehabilitation unit, with a subsequent increase in fluid intake by subject evident over a 2-week trial period (Carlaw et al., 2012).

KEYWORDS DYSPHAGIA FREE WATER PROTOCOL HYDRATION IMPLEMENTA- TION ORAL CARES THIS ARTICLE HAS BEEN PEER- REVIEWED

Maria Schwarz (top) and Inger Kwiecien

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JCPSLP Volume 20, Number 3 2018

Journal of Clinical Practice in Speech-Language Pathology