Ice, Ice, Baby: How many ice chips is too much?
Oh, ice chips! Those tiny, glistening nuggets of joy can relieve a parched throat or a tidal wave of panic for a clinician worried about aspiration. I recently received a question about the "right" amount of ice chips to recommend for a patient with severe dysphagia. You see, there's no magical formula, no scientifically-backed "ice chip equation" to tell us exactly how many are safe. It's like trying to figure out how many sprinkles are too many on a cupcake – it's a matter of taste, right? (and, in our case, safety!). But instead of leaving things murky as they so often are in our field, let's consider how to determine what might be best for your patient.
While the Ice Chip Protocol by Dr. Langmore and Dr. Pisegna is a fantastic resource and one of the few articles on the topic, it focuses more on utilizing ice chips during FEES than setting universal ice chip limits. So, what is available regarding research to help us answer this question? Not much. Ok, so what's a diligent SLP to do? Fear not, my friend. Let's put on our detective caps and do some investigations.
Embrace Your Inner Ice Chip Detective
Think of yourself as Sherlock Holmes, but instead of hunting down criminals, you're on the case of the perfect ice chip prescription.
Channel your inner experience: Just like Sherlock draws on his vast knowledge of past cases, you have a wealth of clinical wisdom to tap into. What's worked in the past? Which patients have been ice chip champions, and who struggled? Don't have experience? Start with caution (very small amounts) and ease your way forward bit by bit as tolerated and with the medical team's support.
Take notes: Sherlock doesn't arrive at a scene empty-handed. If you notice, he carries a bunch of stuff with him. One of those things you've probably seen is a magnifying glass (which, regrettably, is not so helpful for us here), but he also carries a pencil and a notebook (which is very old-fashioned and a bit endearing, I know). With your notepad (or laptop), consider documenting key variables before, during, and after you've initiated ice chips on the patient. Some examples include risk factors for aspiration pneumonia, cognition, ability to self-feed, respiratory status, and risks of aspiration. You can include anything that you feel is important in general and specifically for each patient. More on this at the end.
Every patient is a unique icy snowflake: (See what I did there?) A frail elderly patient with a history of recurrent aspiration pneumonia is a different story than a robust individual recovering from a tonsillectomy. The amount of ice chips you give them will then depend on how stable they are, their alertness level, past medical history, and how they've done in the past on a similar recommendation.
Know your terrain: Just like Sherlock knows the streets of London, you know the ins and outs of your facility. Are you in an acute care hospital where patients are medically complex? Or a rehab center where folks are generally more stable? What is the staff-to-patient ratio? Does the family visit often? Will someone be available to help facilitate ice chips and support the safety strategies you've implemented? Context is key.
Data is Your Watson
Sherlock has Watson by his side; you have data! We take notes on each patient to accumulate data and help us see the bigger picture. Of course, it would be nice to have a randomized controlled trial with 10,000 subjects to tell us exactly how many ice chips are recommended for our patients in our setting, but it would also be nice to live forever and own a time machine. Since none of these things appear on our horizon, we can create our own research study with our own patients.
Document, document, document: If a patient has a decline in status that might be related to the ice chips, note how many ice chips they had, what their cognitive state was, and any other relevant factors (as discussed above). Over time, you'll learn what variables need to be strongly considered before moving forward with ice chips and to help you determine exactly how many to start with.
Look for patterns: Over time, you'll start to see trends. Patients with certain diagnoses or medications may be more likely to have difficulties. This information is gold. The more data you get, the more it will help you tell the future. While never perfect, it can improve your judgments and decrease mishaps.
Ditch the Fuzziness!
Imagine telling Sherlock, "The suspect was of average height, had somewhat brown hair, and liked to eat sandwiches." He'd give you a side eye and tell you to buzz off. Similarly, avoid vague instructions for your team members, such as "safely provide small amounts of ice chips as tolerated."
Instead, be precise and clear: "1-2 ice chips per spoon no more than 10 spoons, only when awake, alert, and responsive and with direct supervision. Discontinue if s/s of aspiration are observed." This clarifies what's needed, leaves no room for interpretation, and keeps our patients safe.
The Ice Chip Adventure Continues!
Navigating the world of ice chips can feel like climbing a mountain, but with careful observation, data collection, and clear communication, you'll be a summit-reaching, ice chip-conquering SLP in no time.
Keep those questions coming – Leave a comment below.
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