Our SLP chat tonight, Monday, April 21, 2003, is being hosted by
Kathy Panther, M.S., CCC-SLP.  She will be addressing the topic
of The Frazier Water Protocol.  A copy of the Frazier Water Protocol
may be found at the bottom of this transcript. 

Kathy Panther received her B.A. in Speech and Hearing from the
University of Kentucky and her M.S. in Communicative Disorders from
the University of Louisville.  She is a speech pathologist with an
interest in neurogenic communication disorders and dysphagia.  Her
career has been spent in acute rehab and acute care.  Kathy joined
the speech pathology department at Frazier Rehab Institute in
Louisville in 1982.  She is currently the Inpatient Rehab Director
at Frazier and Jewish Hospital.  She has spoken extensively on
communication disorders, dysphagia, and rehab management. 

<Robin> Welcome!  We are chatting tonight with Kathy Panther, M.S., CCC-SLP, about
          The Frazier Water Protocol.  A copy of the Frazier Water Protocol may be found
          on the message board of this website and also at the bottom of this chat
<Robin> Glad you could all be here.
<Robin> Kathy, please start us off with some basic info about the protocol.
<Kathy_Panther> Our water protocol permits and encourages water between meals. 
          It began in 1984 due to observed and suspected noncompliance with liquid
          restrictions.  It is pulmonologist recommended although not all pulmonologists
          would agree. I can talk more about that.
<Kathy_Panther> The body is 60% water, and water in the lungs is quickly absorbed.
<Kathy_Panther> The ph is neutral, relatively bacteria free and won't obstruct the airway.
<AdrienneFSU> Can we start with a description of the protocol?
<Robin> Kathy, please explain which population this is meant for.
<Kathy_Panther> Sure, we permit water between meals to dysphagics who are known
          aspiratiors of thin liquids.
<Kathy_Panther> NPO patients are allowed water anytime.
<Kathy_Panther> Water intake is unrestricted prior to a meal.
<Kathy_Panther> Water is allowed 30 minutes after a meal.
<AdrienneFSU> Can you explain a little of the rationale for adopting this policy?
<Kathy_Panther> The rationale was that patients were generally noncompliant with liquid
<AdrienneFSU> I'm with ya there!
<Kathy_Panther> Patients would tell us what they were eating and drinking and they
          weren't getting pneumonia.  We scratched our heads on that and asked our
          pulmonologist, Dr. Judah Skolnick about this.
<Kory> interesting!
<Kathy_Panther> The basic rationale is simple, essentially, neutral ph, bacteria free
          relatively, no obstruction and is absorbed in body pool of water.  We are
          about 60% water.
<Kathy_Panther> We have been doing protocol since 1984.  We are an acute rehab setting. 
          To a limited degree we do the protocol in acute care, but much more conservatively.
<girlyblonde> I am dumb, why would someone get pneumonia?
<Kathy_Panther> SLPs have been operating under the assumption that anything in the lungs
          causes pneumonia.
<girlyblonde> oh
<Kathy_Panther> But this is being proven not to be true.
<Kathy_Panther> Aspiration and dysphagia are necessary but not sufficient conditions for
          development of pneumonia.
<Suzanne> Do you perform oral care before you give the water?
<AdrienneFSU> Great question Suzanne.
<Kathy_Panther> Regarding oral care - we don't routinely do oral care every time a
          patient is given water because they are moving about during the day and oral care
          isn't always possible or necessary.
<Kathy_Panther> If my clientelle was bed bound and not able to care for self, I would
          likely want to do oral care first. There are institutions that do that.
<AdrienneFSU> What about all the bacteria in the mouth?  Particularly as a result of
          some meds, or NPO?
<Kory> NPO?
<AdrienneFSU> "nothing by mouth" some type of feeding tube
<Kathy_Panther> Regarding bacteria, there are some mouths that are chock full of
          pathogenic bacteria, others are not.  You want to consider this and also the
          overall health of the patient, ie, their immuno competence.
<AdrienneFSU> ok, thanks
<mashaz> Kathy...what about infections in mouths?
<mashaz> Do you ever have patients that persistently have coated tongues?
<Kathy_Panther> We give water to NPO patients and we think this facilitates a healthier
<Kathy_Panther> Our patients sometimes have coated mouths, not the norm.  We are more
          careful with that patient and do insist on good oral care and treatment of any
<mashaz> Yes...but AFTER good oral care...the tongue is STILL coated
<Kathy_Panther> I would be more cautious with that patient.
<mashaz> ok thanks
<Robin> Does your facility routinely perform swallow studies to check for aspiration?
<Kory> good question!
<Kathy_Panther> Yes, we routinely do instrumental exams, FEES or VFSS.
<Robin> How you determine which patients should be on the protocol?
<Kathy_Panther> At Frazier on the rehab side, we do instrumental exams on all dysphagic
          patients.  We include all patients in our program.  Only a very few are excluded,
          those who cough miserably due to heightened sensation when aspirating.
<Kathy_Panther> Almost everyone is on protocol.  Remember in rehab our patients are
          moving all day and are prone to going home.
<Kathy_Panther> At jewish hospital, our acute care facility, we also do instrumentals,
          but these patients are very sick and we are cautious.  We might start with the
          ice chip protocol.
<Robin> So you use the protocol with patients even if there has been aspiration on the
          swallow studies?
<Kathy_Panther> Absolutely Robin.
<Robin> wow
<mashaz> interesting
<mashaz> and still they do not develop pneumonia?
<Kathy_Panther> We have hardly any pneumonia incidence.  Any we have had seems related
          to tube feedings.
<Kory> Pneumonia is related to tube feedings?
<Kathy_Panther> Yes, pneumonia is often related to tube feedings.
<Kathy_Panther> Reflux and bacteria tainted secretions are causes with tube feeders.
<Robin> How often are patients on the protocol monitored for aspiration?
<Kathy_Panther> Robin what do you mean by monitored?
<Robin> I mean, follow up swallow studies.
<Kathy_Panther> Inpatient rehab is now a fairly short stay so most only have 1 study or 2
          maybe, then an outpatient study.  We watch them in swallowing therapy every day
          drinking water and watching for signs of aspiration.
<Robin> A doctor's order must be obtained prior to using the protocol, correct?
<Kathy_Panther> We don't require the doctor's order at Frazier as its a blanket policy,
          but at Jewish in acute care we do.
<JoAnn> What about using the program with trach patients?
<Kathy_Panther> Yes we use the protocol with trach patients.
<AdrienneFSU> Just to be clear, do you recommend this protocol for any silent aspirator? 
          Or just those in rehab & mobile?
<Kathy_Panther> In the rehab setting its pretty much all aspirators, silent or otherwise. 
          At acute care, we look very closely at all risk factors as the acuity is high.
<Robin> Are there any other facilities, that you know of, that use the protocol as a
          blanket policy?
<Kathy_Panther> This has become much more common in last few years.  I get emails and
          calls from people all over who are doing this.  Protocols vary, some are blanket
          some are not.
<techey> I may have missed this - but do you limit the amount of water you give the
<Robin> Good question, techey.  Kathy, tell us again about the protocol...when water is
          allowed, the amount, etc.
<Kathy_Panther> For those who are PO, they are allowed water between meals, right up to
          the first bite of food, and then 30 minutes after a meal, no pills with water,
          and water is freely permitted, no limits.
<Kathy_Panther> NPO, of course, can have water anytime.
<techey> and no thickener?
<Kathy_Panther> No thickener in the water, ever.  Patients will have thickened liquids
          at their meals if they like, or may just get their hydration with water between
<Suzanne> I am very interested in this.  Last year, we sent our questionaires to about
          30 hospitals (acute and rehab) and only 1 was giving water.
<Robin> What type of questionaire, Suzanne?
<Suzanne> Just a simple questionaire asking if patients were given water between meals,
<Kathy_Panther> Suzanne, what part of the country is that?
<Suzanne> We sent them to various places (hospitals we could find addresses to).
<mashaz> Do you ever find that nurses or other rehab staff take advantage of the protocol
          and give water to patients at times like when they give meds, etc.?
<Kathy_Panther> Mashaz, I think the water and pill thing is ingrained nursing behavior,
          and it can be hard to break.  Sometimes nurses forget but I don't think they are
          intentionally giving the pills with water.
<AdrienneFSU> Are you still not allowed to give meds with water on the protocol?
<Kathy_Panther> Right, no meds with water.  the meds must be crushed or placed in
          applesauce, yogurt etc. or thickened.
<AdrienneFSU> Because of aspirating the pill?
<Kathy_Panther> exactly
<AdrienneFSU> ok
<JoAnn> How do you ensure good oral care "anytime" for NPO patients?
<Robin> JoAnn, we did address oral care earlier in the chat, but maybe Kathy could make
          a brief comment about your question.
<Kathy_Panther> People that I've talked to express great concern about oral care and
          rightly so.  Its hard to ensure, but we've campaigned hard on it and our nursing
          department believes in it.
<Kathy_Panther> There is more literature coming out these days to support this.  Some
          articles have recently been referenced on the dysphagia list serv.
<Robin> Kathy, do many of the NPO patients using the protocol progress to oral feedings?
<Kathy_Panther> Yes, many of our patients do progress to oral feedings.  We have a big
          neuro population and quite a few debilitated, cardiac patients that end up
          progressing well
<Kathy_Panther> I'd like to discuss dehydration a bit if thats all right.
<Robin> Yes, please do!
<Kathy_Panther> Dehydration is something I think we overlooked in our early days of
          protecting the airway from aspirated material.
<Kathy_Panther> Our population is prone to dehydration by being ill, having compromised
          mobility, perhaps decreased vision or communication, etc.  Some of our
          recommendations slow down rate of intake and decrease fluid intake, ie, thick
<Kathy_Panther> Older patients are more likely to have anorexia than younger ones, and a
          person with poor food intake also takes fluids poorly often.
<Kathy_Panther> So we're setting our patients up for dehydration sometimes by restricting
          their fluids.  Patients do not like thick liquids as a rule.
<mashaz> yes
<Robin> Yes, this is true.
<AdrienneFSU> What are some common signs of dehydration?
<Kathy_Panther> Dehydration can lead to confusion, lethargy, constipation, acute renal
          failure, weight loss, fever, increased falls, UTI, decreased progress and
          participation in therapies.
<Kathy_Panther> So we need to contribute to their hydration as well as protecting their
<Kathy_Panther> The dehydrated patient becomes immuno suppressed.
<Kathy_Panther> and then the cycle of illness and decline gets rolling
<Kathy_Panther> You know research has shown that we aspirate our saliva in our sleep.
<Kathy_Panther> But most of us don't suffer ill effects because our immuno competence
          is good.
<Kathy_Panther> So you have to look at the overall risk factors with your patients
          before deciding to restrict from good old healthy water.
<Robin> So the sips of water can be a lifesaver for these dehydrated patients.
<Kathy_Panther> You are so right.
<Robin> Do you find that most doctors are agreeable to this protocol?  In your facility,
          yes, but what about in other facilities?
<Robin> Aren't many people more concerned about the aspiration risk and liability?
<Kathy_Panther> The doctor thing is variable.  People tell me they have doctors who love
          it and others who refuse.  We have a couple of pulmonologists in Dr. Skolnick's
          practice who refuse.
<lberrett> In which case would you not allow sips of water?
<Kathy_Panther> lberrett I don't follow.
<Robin> In other words, which NPO patients are too risky to use the protocol on..right
<lberrett> Well, if the patient is a severe aspiration risk, alertness, etc.
<Kathy_Panther> Thanks, lets talk about aspiration pneumonia risk factors.  I'll list
          what Susan langmore has published.
<Kathy_Panther> #1 is dependence for feeding, then dependent for oral care, presence of
          2+ medical problems, reduced activity level, oral/dental disease, tube feeding,
          GER, esophageal dysmotility, aspiration of food, pharyngeal delay, low spillage
          point, excess residue, and xerostomia.
<Robin> Thanks for that info Kathy
<lberrett> Then, based on Langmore's risks for aspiration, would you not place a patient
          on the protocol if they demonstrate these risk factors?
<Kathy_Panther> Lberrett, I would look very closely at people who have that high risk
          profile and also look at their labs to see what their immuno compromise is.
<Suzanne> Do you look at the immuno compromise or does the doctor/nurse?  I wouldn't
          know what to look at or for.
<Robin> good question, Suzanne.
<Kathy_Panther> Dietitians are probably the best looking at the labs and determining if
          there is malnourishment.
<lberrett> Is there a limit to the amount of free water a patient can intake on this
<Kathy_Panther> No, we don't limit the free water.
<lberrett> Does free water also include ice chips?
<Kathy_Panther> Yes, we use ice chips a lot in acute care, especially in the ventilator
          care unit and ICUs.
<Robin> What do you do with that population in regard to the protocol?
<Kathy_Panther> We do allow water with trach patients.  Again, basically all in rehab
          and selected in acute care.
<mashaz> Do you use bottled water?
<Kathy_Panther> No, we use tap water.
<girlyblonde> Natural spring water?
<Kathy_Panther> Some may use spring or bottled water, but our water quality is good in
<mashaz> How can you ensure that tap water is low in bacteria?
<Kathy_Panther> Water generally only has about 100-1000 bacteria per ml.  Your clean
          saliva has about 1 million bacteria per ml.
<mashaz> Kathy...do you think it would be safe to use the free water protocol in a
          city where water isn't necessarily clean?
<Kathy_Panther> If you knew you had poor water quality I would be hesitant.  Is your
          water known to be dangerous?
<mashaz> Well...I just always assumed that the water in Philadelphia wasn't necessarily
          "clean"--I mean--I wouldn't drink it.
<Kathy_Panther> Well then that would be a consideration.
<Kathy_Panther> I'd use bottled water in that case, I guess.
<mashaz> Where could I get information about the bacteria in our water???
<Kathy_Panther> Our newspaper publishes info about our water quality and our water
          company has data.
<Robin> Mashaz, the city of Philadelphia water department should have that info.
<mashaz> thanks!
<AdrienneFSU> I'm not sure if this is a weird question... but are patients able to
          tell/feel when their lungs are filling up?  Like we would feel our stomach
<Kathy_Panther> Thats an interesting question Adrienne.  I don't know.
<AdrienneFSU> How is their thirst "quenched"?
<Kathy_Panther> Our patients seem to not complain of thirst.
<Kathy_Panther> I hear many SLPs complaining that their patients want water badly and
          complain of being very thirsty.
<Kathy_Panther> Although the elderly often don't have a strong "sense" of thirst any
          longer.  Another reason to offer water.
<AdrienneFSU> Is this sense of thirst more from a dry mouth?
<Kathy_Panther> The dry mouth probably does create that unsatiated feeling.
<Robin> We have been chatting for nearly an hour now!  Are there any more questions for
<lberrett> Do you have difficulties with staff giving other "thin" liquids, such as
          coffee, juice, etc.
<Kathy_Panther> Lberrett, good question.
<Kathy_Panther> Our staff is usually very compliant, we educate very thoroughly.
<lberrett> In the past I have observed staff to give patients snapple, etc. not
          understanding the research behind it.
<AdrienneFSU> How is patient compliance?  Patients don't start with juice or coffee?
<Kathy_Panther> I'm not going to kid anyone, I'm sure our patients are not %100 compliant. 
          But we don't hear about their sneaking of cokes, etc., like before we started the
<Kory> This is all very interesting!
<Kathy_Panther> It really is, it would be so hard to comply with our thick liquid
<Robin> Thank you so much for joining us Kathy!  We appreciate you sharing your expertise!
<AdrienneFSU> Thanks Kathy, you've opened another perspective for me!
<Kathy_Panther> Thanks to all of you! This has been fun.
<sharon> Thanks, where can I get a copy of the protocol?
<Robin> A copy of the Frazier Water Protocol may be found on the message board of this
          website and also at the bottom of this trancript once it is posted in our on-line
<lberrett> Thank-you
<Kory> Thank you!
<mashaz> Thank you Kathy!
<JoAnn> Thank you!
<meelinn> Thanks again Kathy!
<Kory> Where can we find Susan Langmore's info?
<Kathy_Panther> Susan published in the  Dysphagia journal.  Its on my bibliography which          
          will be added to this chat transcript once its posted in the archive.
<Kory> Thank you!
<Kathy_Panther> You're very welcome
<Robin> Thank you to all of you for joining us tonight!