Outcomes of a pilot water protocol project in a rehabilitation setting

There is considerable clinical interest in the risks and benefits of offering oral water intake, in the form of water protocols, to patients with thin-liquid dysphagia. We describe the design and implementation of a water protocol for patients in a rehabilitation setting with videofluoroscopically confirmed thin-liquid aspiration. The GF Strong Water Protocol (GFSWP) is an interdisciplinary initiative, with roles and accountabilities specified for different members of the interprofessional health-care team. Rules of the water protocol specify mode of water access (independent, supervised), the implementation of any safe swallowing strategies recommended on the basis of the patient's videofluoroscopy, and procedures for evaluating and addressing oral care needs. Trial implementation of the water protocol in 15 participants showed that they remained free of adverse events, including pneumonia, over the course of an initial 14-day trial and continuing until discharge from the facility (range = 13-108 days). Seven participants were randomly assigned to a 14-day control phase in which they received standard care (without water access). Fluid intake measures taken after the oral water intake phase were increased (mean = 1,845 cc; 95% confidence interval: 1,520-2,169 cc) compared to those in the control phase (mean = 1,474 cc; 95% CI: 1,113-1,836 cc), with oral water intake measures comprising, on average, 563 cc (range = 238-888 cc) of the total post water trial fluid intake values. Fluid intake increased at least 10% of the calculated fluid requirements in 11/15 participants who received oral water access. These participants reported favorable quality-of-life outcomes, measured using the Swal-QOL. These findings support the implementation of the GFSWP, including its exclusion criteria, rules, and plans of care, for rehabilitation patients who aspirate thin liquids.