Patient suitability for free water protocols in acute stroke and general medicine: a qualitative study of clinician perceptions.
clinical decision-making
deglutition disorders
drinking
dysphagia
free water protocol
speech-language pathology
Journal
International journal of language & communication disorders
ISSN: 1460-6984
Titre abrégé: Int J Lang Commun Disord
Pays: United States
ID NLM: 9803709
Informations de publication
Date de publication:
05 2022
05 2022
Historique:
received:
28
09
2021
accepted:
09
02
2022
pubmed:
24
3
2022
medline:
20
4
2022
entrez:
23
3
2022
Statut:
ppublish
Résumé
The free water protocol (FWP) is an alternate management strategy for patients with dysphagia, who would otherwise be nil by mouth or prescribed thickened fluids, allowing them to drink and potentially aspirate water under strict guidelines to minimize the risk of adverse consequences. The FWP is not widely implemented in acute settings, and it is unclear whether this is due to the complexity of patient presentations, clinician decision-making or barriers related to the setting. To explore the perceptions and decision-making process of clinicians about using FWPs to manage dysphagia for patients admitted to acute stroke and general medicine. A qualitative, critical realist approach was adopted to allow for in-depth exploration of the perspectives of four dietitians, seven medical officers, eight registered nurses and 17 speech and language pathologists (SLPs) from three hospitals in a capital city of Australia. Data from semi-structured interviews were analysed using the Situated Clinical Decision-Making Framework (CDF). Participants were cautious about FWP for patients with neurological conditions, head and neck cancer, dementia, poor immunity, chronic or recurrent respiratory illness, and certain types of stroke. Medical status and the implications for aspiration were paramount, particularly respiratory status, oxygen supplementation, cognitive status, fatigue and mobility. Participants considered patient quality of life, preferences and choices for care, but indicated that factors influencing safety often outweighed patient preference for water. Indirect factors affecting decision-making included the roles of the multidisciplinary team, individual clinical experience and attitude to risk, and availability of supervision. Despite the benefits of FWPs in other settings, in acute stroke and general medicine, clinicians erred on the side of safety and, in most cases, would not implement an FWP. Future clinical research is needed to systematically design high-quality and feasible clinical trials to determine the benefits and safety of FWPs for patients with dysphagia in these settings. This would lay the foundations for guidelines to support the complex clinical decision-making regarding patient suitability for FWPs. What is already known on the subject FWPs are an alternate management strategy for patients with dysphagia, with systematic reviews recommending their use for adults in inpatient rehabilitation with a low risk of pneumonia. However, evidence from the acute setting is sparse, leaving clinicians unsure about which patients might benefit and which may inadvertently be exposed to increased risk by an FWP. What this paper adds to existing knowledge Participants from all interviewed disciplines agreed that SLPs lead the decision-making process and as such act as 'gatekeepers' for access to an FWP. The decision-making process is complex, and participants acknowledged that disease conditions and illnesses were often used as exclusionary criteria. Although participants reported favourably on the benefits of FWPs, their decision-making privileged risk aversion over patient preference in most settings, except for palliative care. Lack of clinical guidelines and research evidence in acute care settings, as well as the focus on risk aversion, appear to perpetually reinforce the avoidance of FWP in these settings. Of note, more senior clinicians acknowledged being more deliberately guided by patient preference; hence, leadership by senior clinicians appears critical for change in practice in this space. What are the potential or actual clinical implications of this work? If evidence about the safety of FWP in the acute settings is to be collected, a systematic approach to addressing the present barriers is warranted. This may allow rigorous clinical trials to proceed and potentially lead to best-practice guidelines for dysphagia management options for wider populations of patients.
Sections du résumé
BACKGROUND
The free water protocol (FWP) is an alternate management strategy for patients with dysphagia, who would otherwise be nil by mouth or prescribed thickened fluids, allowing them to drink and potentially aspirate water under strict guidelines to minimize the risk of adverse consequences. The FWP is not widely implemented in acute settings, and it is unclear whether this is due to the complexity of patient presentations, clinician decision-making or barriers related to the setting.
AIMS
To explore the perceptions and decision-making process of clinicians about using FWPs to manage dysphagia for patients admitted to acute stroke and general medicine.
METHODS & PROCEDURES
A qualitative, critical realist approach was adopted to allow for in-depth exploration of the perspectives of four dietitians, seven medical officers, eight registered nurses and 17 speech and language pathologists (SLPs) from three hospitals in a capital city of Australia. Data from semi-structured interviews were analysed using the Situated Clinical Decision-Making Framework (CDF).
OUTCOMES & RESULTS
Participants were cautious about FWP for patients with neurological conditions, head and neck cancer, dementia, poor immunity, chronic or recurrent respiratory illness, and certain types of stroke. Medical status and the implications for aspiration were paramount, particularly respiratory status, oxygen supplementation, cognitive status, fatigue and mobility. Participants considered patient quality of life, preferences and choices for care, but indicated that factors influencing safety often outweighed patient preference for water. Indirect factors affecting decision-making included the roles of the multidisciplinary team, individual clinical experience and attitude to risk, and availability of supervision.
CONCLUSIONS & IMPLICATIONS
Despite the benefits of FWPs in other settings, in acute stroke and general medicine, clinicians erred on the side of safety and, in most cases, would not implement an FWP. Future clinical research is needed to systematically design high-quality and feasible clinical trials to determine the benefits and safety of FWPs for patients with dysphagia in these settings. This would lay the foundations for guidelines to support the complex clinical decision-making regarding patient suitability for FWPs.
WHAT THIS PAPER ADDS
What is already known on the subject FWPs are an alternate management strategy for patients with dysphagia, with systematic reviews recommending their use for adults in inpatient rehabilitation with a low risk of pneumonia. However, evidence from the acute setting is sparse, leaving clinicians unsure about which patients might benefit and which may inadvertently be exposed to increased risk by an FWP. What this paper adds to existing knowledge Participants from all interviewed disciplines agreed that SLPs lead the decision-making process and as such act as 'gatekeepers' for access to an FWP. The decision-making process is complex, and participants acknowledged that disease conditions and illnesses were often used as exclusionary criteria. Although participants reported favourably on the benefits of FWPs, their decision-making privileged risk aversion over patient preference in most settings, except for palliative care. Lack of clinical guidelines and research evidence in acute care settings, as well as the focus on risk aversion, appear to perpetually reinforce the avoidance of FWP in these settings. Of note, more senior clinicians acknowledged being more deliberately guided by patient preference; hence, leadership by senior clinicians appears critical for change in practice in this space. What are the potential or actual clinical implications of this work? If evidence about the safety of FWP in the acute settings is to be collected, a systematic approach to addressing the present barriers is warranted. This may allow rigorous clinical trials to proceed and potentially lead to best-practice guidelines for dysphagia management options for wider populations of patients.
Identifiants
pubmed: 35318783
doi: 10.1111/1460-6984.12713
doi:
Substances chimiques
Water
059QF0KO0R
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
630-644Informations de copyright
© 2022 Royal College of Speech and Language Therapists.
Références
Bernard, S., Loeslie, V. & Rabatin, J. (2015) Use of a modified Frazier water protocol in critical illness survivors with pulmonary compromise and dysphagia: a pilot study. American Journal of Occupational Therapy, 70, 1-5.
Braun, V. & Clarke, V. (2013) Successful qualitative research: a practical guide for beginners. Thousand Oaks, CA: Sage.
Carlaw, C., Finlayson, H., Beggs, K., Visser, T., Marcoux, C., Coney, D. et al. (2012) Outcomes of a pilot water protocol project in a rehabilitation setting. Dysphagia, 27, 297-306.
Carnaby, G.D. & Harenberg, L. (2013) What is “usual care” in dysphagia rehabilitation: a survey of USA dysphagia practice patterns. Dysphagia, 28, 567-574.
Carrión, S., Cabré, M., Monteis, R., Roca, M., Palomera, E., Serra-Prat, M. et al. (2015) Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital. Clinical Nutrition, 34, 436-442.
Cocks, N. & Ferreira, H. 2013. What information do UK speech and language therapists use when making oral versus nonoral feeding recommendations for adults with oropharyngeal dysphagia? Dysphagia, 28, 43-57.
Crary, M.A., Humphrey, J.L., Carnaby-Mann, G., Sambandam, R., Miller, L. & Silliman, S. (2013) Dysphagia, nutrition, and hydration in ischemic stroke patients at admission and discharge from acute care. Dysphagia, 28, 69-76.
Croskerry, P. (2009) Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Advances in Health Sciences Education, 14, 27-35.
Custers, E. (2015) Thirty years of illness scripts: theoretical origins and practical applications. Medical Teacher, 37, 457-462.
Custers, E., Boshuizen, H. & Schmidt, H. (1998) The role of illness scripts in the development of medical diagnostic expertise: results from an interview study. Cognition and Instruction, 16, 367-398.
Effros, R.M., Darin, C., Jacobs, E.R., Rogers, R.A., Krenz, G. & Schneeberger, E.E. (1997) Water transport and the distribution of Aquaporin-1 in pulmonary air spaces. Journal of Applied Physiology, 83, 1002-1016.
Esmaeili, M., Ali Cheraghi, M. & Salsali, M. (2014) Barriers to patient-centered care: a thematic analysis study. International Journal of Nursing Knowledge, 25, 2-8.
Garon, B.R., Engle, M. & Ormiston, C. (1997) A randomized control study to determine the effects of unlimited oral intake of water in patients with identified aspiration. Neurorehabilitation and Neural Repair, 11, 139-148.
Gillespie, M. & Peterson, B. (2009) Helping novice nurses make effective clinical decisions: The Situated Clinical Decision-Making Framework. Nursing Education Perspectives, 30, 164-170.
Gillman, A., Winkler, R. & Taylor, N. 2017. Implementing the free water protocol does not result in aspiration pneumonia in carefully selected patients with dysphagia: a systematic review. Dysphagia, 32, 345-361.
Hansen, E.C. (2006) Successful qualitative health research: a practical introduction. Crow's Nest NSW: Allen and Unwin.
Jones, O., Cartwright, J., Whitworth, A. & Cocks, N. (2017) Dysphagia therapy post stroke: an exploration of the practices and clinical decision-making of speech-language pathologists in Australia. International Journal of Speech-Language Pathology, 1-12
Kallio, H., Pietilä, A.-M., Johnson, M. & Kangasniemi, M. (2016) Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. Journal of Advanced Nursing, 72, 2954-2965.
Kaneoka, A., Pisegna, J.M., Saito, H., Lo, M., Felling, K., Haga, N. et al. (2017) A systematic review and meta-analysis of pneumonia associated with thin liquid vs. thickened liquid intake in patients who aspirate. Clinical Rehabilitation, 31, 1116-1125.
Karagiannis, M., Chivers, L. & Karagiannis, T. (2011) Effects of oral intake of water in patients with oropharyngeal dysphagia. BMC Geriatrics, 11, 1.
Karagiannis, M. & Karagiannis, T. (2014) Oropharyngeal dysphagia, free water protocol and quality of life: an update from a prospective clinical trial Hellenic Journal of Nuclear Medicine, 1, S26-S29.
Keller, H., Chambers, L., Niezgoda, H. & Duizer, L. (2012) Issues associated with the use of modified texture foods. The Journal of Nutrition, Health & Aging, 16, 195-200.
Kenedi, H., Campbell-Vance, J., Reynolds, J., Foreman, M., Dollaghan, C., Graybeal, D. et al. (2019) Implementation and analysis of a free water protocol in acute trauma and stroke patients. Critical Care Nurse, 39, e9-e17.
Krekeler, B.N., Broadfoot, C.K., Johnson, S., Connor, N.P. & Rogus-Pulia, N. (2018) Patient adherence to dysphagia recommendations: a systematic review. Dysphagia, 33, 173-184.
Langmore, S.E., Terpenning, M.S. & Schork, A. (1998) Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13, 69.
Martino, R., Beaton, D. & Diamant, N. (2010) Perceptions of psychological issues related to dysphagia differ in acute and chronic patients. Dysphagia, 25, 26-34.
Martino, R., Foley, N., Bhogal, S., Diamant, N., Speechley, M. & Teasell, R. (2005) Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke, 36, 12, 2756-2763.
McAllister, S., Tedesco, H., Kruger, S., Ward, E. C., Marsh, C. & Doeltgen, S. H. 2020. Clinical reasoning and hypothesis generation in expert clinical swallowing examinations. International Journal of Language & Communication Disorders, online first. 55, 4, 480-492.
McCurtin, A., Brady, R., Coffey, K. & O'Connor, A. 2020. Clarity and contradictions: speech and language therapists' insights regarding thickened liquids for post-stroke aspiration. International Journal of Therapy and Rehabilitation, 27, 1-15.
McCurtin, A., Healy, C., Kelly, L., Murphy, F., Ryan, J. & Walsh, J. (2018) Plugging the patient evidence gap: what patients with swallowing disorders post-stroke say about thickened liquids. International Journal of Language & Communication Disorders, 53, 30-39.
Melgaard, D., Rodrigo-Domingo, M. & Mørch, M.M. (2018) The prevalence of oropharyngeal dysphagia in acute geriatric patients. Geriatrics, 3, 15.
Monajemi, A., Rostami, E., Savaj, S. & Rikers, R. (2012) How does patient management knowledge integrate into an illness script? Education for Health, 25, 153-159.
Morley, J.E. 2020. Oral frailty. The Journal of Nutrition, Health & Aging, 24, 683-684.
Murray, A., Mulkerrin, S. & O'Keeffe, S. (2019) The perils of ‘risk feeding’. Age and Ageing, 48, 478-481.
Murray, J., Doeltgen, S., Miller, M. & Scholten, I. (2016) Does a water protocol improve the hydration and health status of individuals with thin liquid aspiration following stroke? A randomized controlled trial. Dysphagia, 31, 424-433.
Murray, J., Scholten, I. & Doeltgen, S. (2018) Factors contributing to hydration, fluid intake and health status of inpatients with and without dysphagia post stroke. Dysphagia. 33 5, 670-683.
National Institute for Health and Care Excellence (NICE). (2019) Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE guideline [NG128] [Online]. Available at: https://www.nice.org.uk/guidance/ng128/chapter/Recommendations-for-research [Accessed 5 December 2021].
Newman, R., Vilardell, N., Clavé, P. & Speyer, R. (2016) Effect of bolus viscosity on the safety and efficacy of swallowing and the kinematics of the swallow response in patients with oropharyngeal dysphagia: White paper by the European Society for Swallowing Disorders (ESSD). Dysphagia, 31, 232-249.
O'Keeffe, S.T. (2018) Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified? BMC Geriatrics, 18, 167.
Panther, K. (2005) The Frazier free water protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14, 4-9.
Patton, M.Q., 2014. Qualitative research and evaluation methods: Integrating theory and practice. Sage publications.
Rumbach, A., Coombes, C. & Doeltgen, S. (2018) A survey of Australian dysphagia practice patterns. Dysphagia, 33, 216-226.
Trede, F. & Higgs, J. (2008) Collaborative decision making. In:Clinical Reasoning in the Health Professions, edited by Higgs, J., Jones, M.A., Loftus, L. & Christensen, L. Elsevier 2008 Third edn. 43-54.
Whelan, K. (2001) Inadequate fluid intakes in dysphagic acute stroke. Clinical Nutrition, 20, 423-428.