Implementation and Analysis of a Free Water Protocol in Acute Trauma and Stroke Patients

Abstract

Background Free water protocols allow patients who aspirate thin liquids and meet eligibility criteria to have access to water or ice according to specific guidelines. Limited research is available concerning free water protocols in acute care settings. Objectives To compare rates of positive clinical outcomes and negative clinical indicators of a free water protocol in the acute care setting and to continue monitoring participants discharged into the hospital system's rehabilitation setting. Positive clinical outcomes were diet upgrade, fewer days to diet upgrade, and fewer days in the study. Negative clinical indicators were pneumonia, intubation, and diet downgrade. Methods A multidisciplinary team developed and implemented a free water protocol. All eligible stroke and trauma patients (n = 104) treated over a 3-year period were randomly assigned to an experimental group with access to water and ice or a control group without such access. Trained study staff recorded data on positive outcomes and negative indicators; statistical analyses were conducted with blinding. Results No significant group differences in positive outcomes were found (all P values were > .40). Negative clinical indicators were too infrequent to allow for statistical comparison of the 2 groups. Statistical analyses could not be conducted on the small number (n = 15) of patients followed into rehabilitation, but no negative clinical indicators occurred in these patients. Conclusions Larger-scale studies are needed to reach decisive conclusions on the positive outcomes and negative indicators of a free water protocol in the acute care setting. (Critical Care Nurse. 2019;39[3]:e9-e17)

Free Water Protocol

“…In den folgenden Jahren wurden einige, größtenteils kontrollierte Studien zum FWP durchgeführt (n = 8). Untersucht wurden unterschiedliche Patientenpopulationen, unter anderem Patienten nach Schlaganfall [8,9,10], Schädel-Hirn-Trauma [11,12] oder auch tracheotomierte und beatmete Patienten mit Critical-Illness-Polyneuropathie [13]. Die Schwere der neurologischen Störungen variierte, das FWP wurde sowohl bei leichter betroffenen Patienten [14] als auch bei Personen mit hohem Supervi-sionsbedarf bei der Umsetzung des Protokolls untersucht [11,15].…”

“…Auch die weiteren Studien zum FWP weisen Limitationen auf. Häufig wurden nur kleine Fallzahlen untersucht (beispielsweise 16 Patienten bei Pooyania et al [14]; eine Ausnahme ist die Untersuchung von Kenedi et al [12] mit je 52 Patienten in Studien-und Kontrollgruppe). Die Beobachtungszeiträume waren teilweise sehr kurz (beispielsweise 8 Tage bei Karagiannis et al [15]).…”

Patient suitability for free water protocols in acute stroke and general medicine: a qualitative study of clinician perceptions

“…The FWP specifies certain guidelines including regular oral care, which are designed to minimize risk of adverse consequences (Panther, 2005). Several randomized control trials (RCTs) have been conducted, the majority in the context of inpatient rehabilitation (Carlaw et al., 2012; Garon et al., 1997; Karagiannis et al., 2011; Karagiannis & Karagiannis, 2014; Murray et al., 2016), with only two in the acute care setting (Bernard et al., 2015; Kenedi et al., 2019). Two subsequent meta‐analyses concluded that FWPs do not increase the risk of developing lung complications and result in a numerical increase in fluid intake and improved quality of life for adults in inpatient rehabilitation with a low risk of pneumonia when compared with thickened fluids or nil by mouth (Kaneoka et al., 2017; Gillman et al., 2017).…”