Scientific title:
A feasibility study of the implementation of a Free Water Protocol for stroke survivors with dysphagia in an acute stroke unit setting
Sheffield Teaching Hospitals NHS Foundation Trust
Principal investigator:
Dr Sabrina Eltringham
Grant value:
Research ID:
SA PDF 23\100001
Research area:
Start date:
Monday 4 September 2023
End date:
Friday 1 September 2028
5 years
Year awarded:

Why is this research needed?

About half of stroke survivors experience swallowing difficulties, also known as dysphagia.

People with dysphagia are at increased risk of problems such as choking, malnutrition and pneumonia. Dysphagia can also affect quality of life, for example because it can make it difficult to enjoy mealtimes with family.

When stroke survivors are in the early stages of recovery in an acute stroke ward, the risks of dysphagia are often managed by thickening liquids, which move more slowly in the mouth, making them easier and safer to swallow.

As a Speech and Language Therapist who helps stroke survivors rehabilitate their swallow, Sabrina has often heard from her patients that the 'sludgy' texture of thickened liquids is horrible. Thickened liquids are so unappealing that they can cause stroke survivors to reduce their fluid intake and become dehydrated, which in turn makes it harder to recover from the stroke.

However, there is a possible alternative, the Free Water Protocol (FWP). The FWP gives stroke survivors the option to drink unthickened water between meals, as long as there aren't any small particles of food remaining in their mouth that could be breathed in along with the water.

The FWP has the potential to help reduce dehydration, more quickly rehabilitate the swallow reflex, and improve quality of life for stroke survivors with dysphagia.

The National Institute for Health and Care Excellence has recently recommended that research be done on the FWP because the evidence for it is promising but limited. It's also not clear whether it's possible to adopt it on acute stroke wards in the UK. Acute stroke nurses, stroke survivors and loved ones will need education on how the FWP works, as well as training on oral care. It is possible that nurses may not have capacity to deliver the FWP, or that very recent stroke survivors may still be too unwell to make use of it.

During her Postdoctoral Fellowship, Sabrina wants to address some of these uncertainties by trialling it on a stroke ward, creating a training programme and finding out what stroke survivors, loved ones, and staff think about it.

What are the aims of this research?

First, Sabrina will review the existing research on the FWP, such as trials that have taken place in other countries. Alongside this, she will carry out interviews and focus groups, and run a national survey of stroke nurses and other acute stroke healthcare workers to understand what factors need to be considered when implementing the FWP and what training is needed. She will then use her early findings to develop workshops in which stroke healthcare professionals and stroke survivors will work together to codesign the implementation strategy and a training programme.

Sabrina will then offer the training programme to staff working on the acute stroke ward at Sheffield Teaching Hospitals. She will also offer training to informal caregivers like family members so that they are ready to carry on supporting stroke survivors with the FWP once they are discharged from hospital.

Once training is underway, Sabrina and her team will trial the FWP, recruiting 30 stroke survivors to take part while they're on the acute stroke ward. Afterwards, she will interview patients, staff and loved ones, and survey patients to understand what worked and what could be improved.

What is the benefit of this research?

Sabrina's Postdoctoral Fellowship is a proof-of-principle study which will provide much-needed evidence on whether the FWP is a viable alternative to thickened liquids on the acute stroke ward. By the end of the Fellowship, she will have a much clearer idea of whether it's something that staff can deliver, whether it helps with hydration and other health concerns, and - most importantly - whether it's something that stroke survivors want.

If Sabrina's work indicates the answer to all these questions is 'yes', she plans to run a larger trial across multiple hospitals.

Ultimately, Sabrina says, "Potential impacts of this research could include improving stroke survivors' hydration and quality of life, cutting the time stroke survivors need to spend in hospital through earlier rehabilitation of the swallow reflex, and lowering costs to the NHS by reducing complications associated with dehydration and the need for artificial nutrition like tube feeding."

What PSP priorities does this research link to?

From 2019 to 2021, we worked with the James Lind Alliance on the Stroke Priority Setting Partnership (PSP). During the PSP process, we collaborated with people with lived experience of stroke and stroke professionals to find out what they thought were the top priorities in stroke research. From this, we identified the top ten priorities in two areas: prevention, diagnosis and short-term care, and rehabilitation and long-term care.

Now, when researchers apply to us for funding, we require that their work addresses at least one of these priorities, or a priority from the Childhood Neurological Disabilities PSP Top 10 as it relates to childhood stroke.

Sabrina’s project addresses the following priority from the Stroke PSP:

  • Prevention and acute care 8: How can we reduce complications of stroke?
  • Rehab and long-term care 10: Improving stroke survivor and carer experiences of the stroke treatment and care pathway

Meet the researcher

Portrait photo of Dr Sabrina Eltringham

Sabrina is a researcher and Speech and Language Therapist at Sheffield Teaching Hospitals NHS Foundation Trust. She says, "I’m responsible for assessing and managing adults with complex swallowing and communication problems. I combine my clinical role with undertaking applied clinical research. This research will help to answer a specific question related to my day-to-day clinical practice."

We previously funded Sabrina's PhD, during which she investigated how different treatments for swallowing problems could affect the risk of developing chest infections like pneumonia.

Sabrina’s supervisors are Professor Craig Smith (University of Manchester and Salford Royal Hospitals NHS Foundation Trust), Professor Sue Pownall (Sheffield Teaching Hospitals NHS Foundation Trust) and Professor Liz Lightbody (University of Central Lancashire).

Speech and Language Therapist Nicola Martindale, who is an early career researcher, is working with Sabrina on aspects of this project including delivering training and monitoring progress. Later on, Sabrina will support a Speech and Language Therapy Assistant and a Clinical Trials Assistant to get involved in research through her Fellowship.

Sabrina says, "A key objective for me as a clinical academic is to strengthen the links between clinical practice and research through mentoring and creating learning opportunities for others. I want to be an inspiring role model and support more junior colleagues who are embarking on their own research journeys."