Frazier Free Water Protocol for Adult Speech Therapy

The Frazier Free Water Protocol, now known as the “Frazier Water Protocol” is a way to help certain patients who aspirate on thin liquids to stay hydrated and decrease their risk of aspiration pneumonia. It was named after Frazier Rehabilitation Hospital, where it was developed.

In this post, you’ll find the step-by-step protocol plus tips on how to use it successfully. For ready-made dysphagia handouts, check out The Adult Speech Therapy Starter Pack!

* Treating dysphagia requires high levels of training and skill; this information is intended for Speech-Language Pathologists or other qualified therapists with the appropriate training and competency to work with adults with dysphagia.

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Is The Frazier Free Water Protocol Safe?

frazier free water protocol

Evidence suggests that, with proper oral care, this protocol can be safe for many who aspirate on thin liquids!

Because our bodies are made up of water and because water has a neutral pH and little bacteria, our lung mucosal tissue can absorb small amounts of clean, aspirated water without harm.

In partnership with a dysphagia treatment plan, the Frazier Water Protocol can help patients to stay hydrated and enjoy a better quality of life.

Keep scrolling for more on who should—and shouldn’t—use it.

Who Is The Frazier Water Protocol For?

frazier water protocol

The Frazier Water Protocol was designed for some patients who are NPO or on thickened liquids.

Before Implementing the Frazier Water Protocol

Who Shouldn’t Use the Frazier Water Protocol?

Patients need a certain level of cognition, strength, endurance, and physical health in order to successfully and safely follow the Frazier Water Protocol.

So who isn’t a good candidate?

  • Patients who can’t remain awake and alert while drinking
  • Impulsive patients or those with severe cognitive impairments
  • Patients with degenerative neurological dysfunction
  • Patients with absent pharyngeal swallow response (per instrumental assessment)
  • Patients who can’t consistently get out of bed
  • Patients who can’t maintain an upright posture while drinking
  • Patients who experience: excessive discomfort, coughing, or choking when drinking
  • Patients with current or suspected aspiration pneumonia or acute pulmonary issues
  • Patients with thrush or oral bacterial infection
  • Dependent patients without caregivers to provide good oral care

The Frazier Water Protocol

frazier free water protocol
  1. Complete good oral care at least 2 times per day
    • The body can handle a little bit of clean aspirated water. Since the water they sip has to go through their oral cavity first, make sure that the oral cavity is clean with good oral care!

  2. Always complete good oral care before the first meal of the day

  3. Patients may not drink unthickened water while eating*
    • Only drink thickened liquids while eating

  4. Patients must wait 30 minutes after eating to drink unthickened water
    • This allows any residual food or thickened liquid residue to clear.

  5. If appropriate for patient safety, water may only be allowed when requested and in small volumes (one cup, teaspoon, etc.)

  6. Patients cannot take medications with water
    • The pill will go where the water carries it, and for your patient, that may mean straight to their lungs. To avoid this, add medications to applesauce, yogurt, or pudding (or thicken liquid medications)

  7. Use swallowing strategies as needed while drinking water

*Enterally-fed patients may drink water during and directly after meals

What Is Good Oral Care?

what is good oral care? adult speech therapy
  • Brush at least 2 times per day. Use a soft toothbrush (not a swab)
  • Suction. Suction oral secretions as needed to decrease bacteria
  • Moisturize. Keep oral mucosa moist with an alcohol-free moisturizing mouthwash, spray, or gel such as Biotène® dry mouth products.

Dentures should be removed at least twice per day to clean with a toothbrush then rinse in water. They should be soaked overnight in denture solution then cleaned with a toothbrush and rinsed again before going back in the mouth.

Tips for Success

frazier free water protocol
  • Educate caregivers! Provide a handout that includes:

    • Why their loved one can drink water only between meals (not coffee, tea, soda, juice, etc.)
    • The Frazier Water Protocol, modified for each patient’s unique needs
    • When their loved one does (or doesn’t) qualify to use the protocol

  • Inform the rest of the staff
    • Use a personalized wristband (“No thin liquids except cups of water between meals”), posted signs, educational posters, staff in-service, etc.

Adult Speech Therapy Materials

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  1. Benigas, J.E. (n.d.) Water Protocols: From Theory to Practice. Medbridge.

  2. Gillman A, Winkler R, Taylor NF. Implementing the Free Water Protocol does not Result in Aspiration Pneumonia in Carefully Selected Patients with Dysphagia: A Systematic Review. Dysphagia. 2017;32:345-361
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