The Frazier Free Water Protocol, now known as the “Frazier Water Protocol,” allows some patients who aspirate on thin liquids to stay hydrated without increasing the 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.
What Is The Frazier Water Protocol?
The Frazier Water Protocol is a set of parameters that allow some patients on NPO or thickened liquid to safely drink unthickened water.
When done right, following the protocol can decrease dehydration and its side effects (UTI, impaired cognition, sepsis) and improve oral health and quality of life without increasing the risk of aspiration pneumonia (Panther, 2005; Gillman et al., 2017; Remijn et al., 2022).
Patients must complete good oral care at least 2 times per day and meet certain criteria to use the protocol. More on that below.
Is The Frazier Free Water Protocol Safe?
With proper oral care, the Frazier Water Protocol is 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.
When coupled with a dysphagia treatment plan, the Frazier Water Protocol can help patients stay hydrated and enjoy a better quality of life.
Keep scrolling for more on who should (and shouldn’t) use it.
(Panther, 2005; Gillman et al., 2017).
More Dysphagia Articles:
Who Can Use The Frazier Water Protocol?
The Frazier Water Protocol was designed for some patients on NPO or thickened liquids.
Before Implementing the Frazier Water Protocol
- Complete an assessment
- Initiate speech therapy treatment
Who Should NOT Use the Frazier Water Protocol?
Patients need a certain level of cognition, strength, endurance, and physical health to successfully and safely follow the Frazier Water Protocol.
So who should NOT use the Frazier Water Protocol? Patients who:
- Can’t remain awake and alert while drinking
- Are impulsive or have severe cognitive impairments
- Have degenerative neurological dysfunction
- Have absent pharyngeal swallow response (per instrumental assessment)
- Can’t consistently get out of bed
- Can’t maintain an upright posture while drinking
- Experience excessive discomfort, coughing, or choking when drinking
- Have current or suspected aspiration pneumonia or acute pulmonary issues
- Have thrush or oral bacterial infection
- Are dependent and don’t have caregivers to provide good oral care
- A physician ordered strict NPO, including no ice chips or water
The Frazier Water Protocol Guidelines
- Complete good oral care at least 2 times per day
- The body can safely 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!
- Oral care before the first meal. Always complete good oral care before the first meal of the day
- No water while eating. Patients may not drink unthickened water while eating*
- Only drink thickened liquids while eating, if indicated
- Wait 30 minutes. Patients must wait 30 minutes after eating to drink unthickened water
- This allows any residual food or thickened liquid residue to clear.
- Drink thin water. Patients can drink thin water throughout the day. If needed for patient safety, given water only when requested and in small volumes (one cup, teaspoon, etc.)
- No medications with water. Patients cannot take medications with water
- The pill will go where the water carries it. For your patient, this may mean straight into their lungs. To avoid this, add medications to applesauce, yogurt, or pudding (or thicken liquid medications)
- Use swallowing strategies as needed while drinking water
*Patients on NPO may drink water during and directly after meals
What Is Good Oral Care?
Most patients should perform oral care at least twice daily, morning and night. Some may also need oral care before and/or after oral intake to avoid bacteria entering the airway.
Encourage dentist visits every 6 months for cleaning and check-ups.
As needed, treat xerostomia and consider a mouthwash to reduce bacteria.
Here are the steps to performing good oral care:
- Gather your supplies. Supplies you may need:
- Disposable gloves
- Toothbrush with soft bristles
- Toothpaste
- Water
- Clean cups
- Tongue depressor
- Penlight
- Floss
- Suction (if severe dysphagia and unable to manage secretions)
- A small basin
- Oral swabs (e.g. Toothette®)
- Position the patient as upright as possible
- Some patients may benefit from leaning forward over a basin to allow water, toothpaste, and saliva to drain out of their mouth
- Have good lighting. Keep a penlight or flashlight handy
- Brush/Swab.
- Assist if they can’t complete independently
- Clean all surfaces of the teeth, inside the cheeks, along the gum lines, the palate, on top of and under the tongue
- Remove dentures to clean the gums and palate. Properly clean dentures.
- Check with a light
- Periodically check to ensure they/you are removing as much debris, buildup, and/or dried secretions as possible
- Have patients spit
- If using toothpaste, have the patient spit into the basin/sink after brushing
- Floss
- Moisturize if needed. Keep oral mucosa moist with an alcohol-free moisturizing mouthwash, spray, or gel such as Biotène® dry mouth products.
Tips for Success
- Educate caregivers. Provide a Frazier Water Protocol handout that includes:
- Why their loved one can drink water only between meals (not coffee, tea, soda, juice, etc.)
- The steps of 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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References
- Benigas, J.E. (n.d.) Water Protocols: From Theory to Practice. Medbridge. https://www.medbridgeeducation.com/courses/details/water-protocols-from-theory-to-practice-jeanette-benigas
- Gillman, A., Winkler, R., & Taylor, N. F. (2017). Implementing the Free Water Protocol does not Result in Aspiration Pneumonia in Carefully Selected Patients with Dysphagia: A Systematic Review. Dysphagia, 32(3), 345–361. https://doi.org/10.1007/s00455-016-9761-3
- Panther, K. The Frazier Free Water Protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(1), 4-9. https://doi.org/10.1044/sasd14.1.4
- Remijn, L., Sanchez, F., Heijnen, B. J., Windsor, C., & Speyer, R. (2022). Effects of Oral Health Interventions in People with Oropharyngeal Dysphagia: A Systematic Review. Journal of clinical medicine, 11(12), 3521. https://doi.org/10.3390/jcm11123521