Ice Chip Protocol — SLP Step-by-Step Guide

What It Is

Candidacy — Who Gets This Protocol?

• Suspected severe dysphagia or unknown swallowing ability
• Currently NPO or tube-fed
• Clinician not confident patient can safely swallow thin liquids
• Advanced pulmonary disease or high aspiration risk
• Patients who haven't swallowed food/liquid for an extended period (tube-fed patients have reduced spontaneous swallow frequency per Crary & Groher, 2006)

• Active respiratory distress
• Poor oral hygiene (must clean mouth before proceeding)
• Significantly reduced consciousness/responsiveness
• Medical instability

Equipment

• Ice chips (standard hospital ice chip machine)
• Spoon or gloved finger for delivery
• Penlight and tongue blade
• Suction available at bedside
• Cup of water for oral hygiene rinse
• FEES scope setup if performing instrumentally (preferred)

Step-by-Step Protocol

STEP 1 — Chart Review & Pre-Assessment

• Review diagnosis, medical history, respiratory status, aspiration risk factors, current diet/feeding status, and recent imaging
• Check oral hygiene status and dental health
• Note any contraindications (trach, active pneumonia, etc.)
• Confirm physician/NP/PA order in the EMR (required per institutional protocol)

STEP 2 — Patient & Care Partner Interview

• Determine current swallowing complaints, onset, and history
• Ask about fatigue with eating, coughing/choking, wet/gurgly voice, regurgitation
• Assess cognition, alertness, and ability to follow directions

STEP 3 — Oral Mechanism Exam

• Assess lips, tongue, jaw, palate, and dentition for structure and function
• Check facial symmetry and cranial nerve function (CN V, VII, IX, X, XII)
• Assess oral secretion management — is the patient managing saliva?
• Evaluate oral hygiene — clean the mouth before giving any bolus

STEP 4 — Oral Hygiene (Mandatory Pre-step)

• Brush or swab the teeth, gums, and tongue
• Remove debris and reduce bacterial load
• This is critical — it minimizes the risk of aspiration pneumonia if trace aspiration occurs
• Suction as needed

STEP 5 — Baseline Observation (FEES preferred)

• Scope to hypopharynx/larynx before giving any bolus
• Assess secretion status using the New Zealand Secretion Scale (NZSS)
• Document location, amount, and spontaneous clearance of secretions
• Assess vocal fold mobility and laryngeal anatomy

STEP 6 — First Ice Chip Trial

• Place 1 small ice chip (approximately 5 mm or smaller) on the center of the tongue using a spoon or gloved finger
• Instruct: "I'm going to place a small piece of ice on your tongue. Try to swallow it when you feel it."
• Observe for:
  • Oral containment (does it fall out?)
  • Lingual manipulation
  • Initiation of a swallow
  • Laryngeal elevation (palpate externally or observe via FEES)
  • Coughing, throat clearing, wet/gurgly voice quality
  • Any overt signs of aspiration

STEP 7 — Observe and Document Response

• Did the patient swallow? (volitional vs. reflexive)
• Was there coughing or choking?
• Under FEES: Did penetration or aspiration occur? Was it cleared?
• Secretion status change: Did swallowing improve secretion management?
• Voice quality: Is voice wet or gurgly post-swallow?

STEP 8 — Progression (if tolerated)

• Increase to 2–3 chips per trial
• May advance to a small teaspoon of ice chips
• Do NOT advance to thin liquids or purees in the same session without instrumental confirmation
• If the goal is purely assessment: stop after gathering sufficient data
• If the goal is therapeutic stimulation: continue as patient tolerates, up to clinical limits

STEP 9 — Trial of Compensatory Strategies (as indicated)

• If impairment is identified, trial strategies:
  • Chin tuck (reduced aspiration with anterior bolus diversion)
  • Effortful swallow (increase pharyngeal pressure)
  • Double swallow / multiple swallows (clear residue)
  • Head turn toward weak side (for unilateral pharyngeal weakness)

STEP 10 — End of Session / Decision Point

STEP 11 — Documentation

1. Medical history and dysphagia history
2. Oral mechanism exam findings
3. Cognitive status / alertness at time of evaluation
4. Oral phase findings
5. Pharyngeal phase findings
6. Whether ice chip trials were performed and patient response
7. Presence/absence of aspiration or penetration signs
8. Assessment/diagnosis (e.g., R13.10 dysphagia unspecified, or specify phase)
9. Recommendations: NPO, oral hygiene program, diet level, instrumental referral, therapy goals
10. Billing: CPT 92610 (clinical swallow eval); CPT 92612/92616 if FEES was performed

Key Clinical Pearls

• The ice chip protocol is not a clearance for thin liquids. A safe ice chip trial justifies continued careful evaluation — not automatic diet upgrade.
• FEES is the preferred instrumental modality for this protocol because you can assess secretions at baseline, watch the pharyngeal phase in real time, and guide the trial without radiation.
• Oral hygiene is non-negotiable — it is the safety foundation underpinning all water/ice protocols.
• For tube-fed patients, ice chips may also serve as swallow stimulation therapy to maintain or rebuild swallow frequency over time.
• The protocol is based on evidence that clean water aspiration in small amounts is unlikely to cause pneumonia if pulmonary defense mechanisms are intact (Holas et al., 1994; Robbins et al., 2008).