Assignment: Preoperative Fasting
Assignment: Preoperative Fasting
Optimal surgical, anesthesia, andnursing outcomes depend onadequate patient preparation. Preoperative fasting is an essential ele- ment of the patient preparation pro- cess. The goal of fasting is to empty the stomach, thereby reducing the risk of aspiration of stomach contents during the anesthetic period.
Before 1999, the traditional, general guideline for preoperative fasting was that patients should be NPO after mid- night on the day of surgery. In 1999, after examining rele’ant research find- iiigs, the American Society of Anesthesi- ologists (ASA) released new, more lenient preoperative fasting guidelines for healthy, nonpregnant patients. The new guidelines called for preoperative fasting from clear fluids for two hours before any procedure that requires seda- tion or anesthesia as well as fasting from solid foods for at least six hours before anesthesia or sedation is administered. The ASA recommends that these guide- lines be modified for any patient with a condition that affects gastric emptying as well as for patients with potential air- way management issues.’
At a community hospital near Boston, Massachusetts, one staff RN in the Pread- mission Testing area became aware that surgical patients at the facility seemed to be fasting for excessive lengths of time, a perception that was echoed by other perioperative nurses on staff. The hospital was beginning its journey toward Magnet status, and hospital administrators were implementing a nursing research and clinical inx’estigation program. At the urging of the director of nursing staff development and nursing research, the staff RN who had originally identified the problem and a clinical nurse special-
ist in the Surgical Services Department decided to conduct a clinical investiga- tion of preoperahve fasting at this facility. The pLirpose of fhis clinical project was to determine whether patients were fasting excessively and, if so, to explore the atti- tudes and beliefs of surgical patients and their care providers to determine why patients still fast excessively despite re- search findings advocating shorter pre- operative fasting periods and updated fasting guidelines from the ASA.
Many anesthesiologists have changed their practice and no longer require the traditional eight-hour fast before elective surgery. In a national survey of 1,337 ASA members, 94% of the respondents were aware of new literature recom- mending shorter fasting periods before elective surgery, and 68% of those had changed their practice.-
ABSTRAQ PREOPERATIVE PATIENT EASTING is an essential element of the patient preparation process, but pa- tients may be fasting for excessive lengths of time.
INVESTIGATORS AT ONE FACILITY used semi- structured interviews to explore the knowledge and beliefs of patients, nurses, and anesthesia care providers regarding the practice of preoperative patient fasting.
FINDINGS INDICATE that some patients had excessive fasting times, and practitioners had erro- neous perceptions about patient knowledge regard- ing the rationale for fasting and compliance with instructions. Clinicians expressed concern about the effects of excessive fasting but were reluctant to relax the policy. AORN} 86 (October 2007) 609- 617. © AORN, Inc, 2007.
. lnc.2f)07 OCTOBER 2007, VOl 85, NO 4 • AUIÍN lOUkN.-M • 6 0 9
OCTOBER 2007, VOL 86, NO Baril — Portman
One reason for excessive preoperative
patient fasting could be related to a
general mistrust on the part of
practitioners that patients will
understand and comply with their
Pandit et aP studied the practices of anesthesi- ologists in the United States and found that 627(1 of participating anesthesiologists had an institu- tional policy in place that allowed patients to ingest clear liquids two to three hours before elective surgery. Thirty-five percent of partici- pants allowed patients to ingest a light breakfast six hovirs before surgery. The researchers deter- mined that the key factors affecting how long patients fast include hospital policy, nurse and anesthesia care provider kiiowledge of current research findings, and patient education regard- ing the length of and rationale for fasting.
Lengthy preoperative fasts have been com- mon. Crenshaw and Winslow^ found that pa- tients fasted for an average of 12 to 14 hours, with some fasting for more than 20 hours. Tra- ditional preoperative fasting instructions (ie, NPO after midnight) were common practice at the time their study was undertaken. Pearse and Rajakulendran’̂ also found excessive fast- ing times in their study. The average fasting time was 12 to 14 hours with an overall range of 4.5 to 20 hours. It appeared that patients were beginning the preoperative fast long before the instructed time.
The literature also revealed several possible reasons for excessive preoperative fasting. One reason is that there seems to be a general mis- trust on the part of practitioners that patients will understand and comply with a fasting policy. One study found that anesthesiologists and surgeons believed that if patients were told that they could ingest clear liquids, they
might also consume solid foods.* Patients’ lack of knowledge regarding the
rationale for preoperative fasting is another factor that may contribute to excessive fasting. Chapman’ found that 85″^ of surgical patients received no explanation for fasting, SI”/» were unaware of the reason for preoperative fasting, and 50% thought the reason for fasting was to reduce vomiting. Only 187« of patients associ- ated vomiting with possible aspiration of gas- tric contents. In addition, Hung’̂ found that surgical patients not only did not know the reason for preoperative fasting, but they also were not comfortable asking their health care providers about it because they did not want to be perceived as demanding.
Another possible reason for lengthy fasting times is concern about rapidly changing surgi- cal schedules. In a study by Green et al,*” anes- thesiologists cited the economic impact of delays and cancellations on the surgical sched- ule as a reason for their reluctance to relax fast- ing guidelines.
An additional factor that contributes to ex- cessive fasting times may be related to health care facilities’ policies on fasting. The absence of a formal fastüig policy or staff members’ inade- quate knowledge of the policy has been found to affect fasting times.”‘” Chapman” interviewed anesthetists, surgical nurses, and patients scheduled for elective surgery regarding their knowledge of recommended preoperative fast- ing guidelines. In the study facility, there was no formal policy for preoperative fasting, and the average fasting time was 11 hours. Half of the anesthetists were aware of current research findings and recommended two- to three-hour liquid fasts; however, participating nurses were unaware of these findings. Chapman attributes the nurses’ knowledge deficit to the fact that at the time her study was performed, most of the published research regarding preoperative fast- ing appeared in medical journals rather than nursing journals.”
Seymour” conducted a study of nurses and anesthetists to assess their knowledge of hospital policy. She reported that less-experienced physi- ciaiis and nurses did not realize that the hospital had a preoperative fasting policy, but 50% of sen- ior nurses and all anesthesia attending physicians
6 1 0 • AORNJOURNAL
Bari! — Portman OCTOBER 2007. VOL 86, NO 4
were aware of the policy. Patients at this facility still fasted excessively, however, with fasting times ranging from 3.5 to 17.75 hours.
Excessive fasting can lead to patient dis- comfort and may even increase morbidity of surgical patients.” Some researchers suggest that the ritualistic approach to preoperative fasting be reevaluated through collaboration between nurses and anesthesia care providers to allow for more flexible fasting instructions based on current research findings.”‘”
A clinical investigation was conducted at a 200-bed community hospital in a suburb north of Boston. The project participants included anesthesiologists, certified registered nurse anesthetists (CRNAs), registered nurses, and surgical patients. All anesthesia care providers im the permanent staff as well as RNs working in the Preadmission Testing Department, Day Surgery Department, and OR were eligible for inclusion in the project. The patient population included men and women with no history of cognitive deficits who were scheduled for elec- tive surgery and had an ASA Physical Status Classification score of 1 or 2. An ASA score of 1 indicates a normal, healthy patient whose only medical problem is the condition for which surgery is being per- formed. An ASA score of 2 indicates a patient who has at least one medical condition that is under control and does not pose a significant threat to his or her health.”
The investigators developed a series of open-ended inter- view questions that they asked oí eligible patients (n = 34), nurses (n – 15), and anesthesia care providers (n = 12). The content of these interview questions was based on empir- ical data found during the liter- ature review. All participants signed a consent form inform-
ing them of the investigators’ intent to tape- record the interviews, and they were given assurances of confidentiality. Patients were interviewed on the day of surgery either preop- erativeiy or postoperatively. Nurses and anes- thesia care providers were interviewed at a time that was con’enient for them.
All interviews were tape-recorded and tran- scribed word for word. The investigators then analyzed the transcripts to identify themes and major ideas. Tlie tapes and transcripts were kept in a locked area at all times and were destroyed after the data were analyzed.
The average length of the preoperative fast in this clinical project was similar to those noted in the studies performed by Crenshaw and Winsiow^ and Pearse and Raja ku lend ran,’ both of which found an average patient fasting time of 12 to 14 hours, with some patients fast- ing as long as 20 hours. Patients in the current clinical investigation reported fasting for five to 23 hours before surgery, with a mean fasting time of 11.70 hours. Sixty-seven percent of patients fasted for at least 12 hours, and 50% fasted for more than 14 hours (Figure 1).
Time spent fasting
Figure 1 • Length of preoperative fasting times for patient participants.
OCTOBER 2007, VOL 86, NO 4 Baril — Portman
The participants voiced many recurring ideas related to preoperative fasting during the interviews. These included • practitioner concerns about patient compli-
ance with instructions, • confusion among practitioners regarding
who is responsible for instructing patients about the preoperative fast,
• knowledge deficits among patients regard- ing the rationale tor fasting,
• knowledge deficits among practitioners regarding hospital policy on preoperative fasting, and
• practitioner concerns that patients would be confused if allowed to consume clear liq- uids before surgery. 11
From the many different ideas , i that emerged from the inter- ‘ views, the investigators iden- tified three overarching themes: perceptions, safety concerns, and knowledge.
One overarching theme the investigators identified was practitioners’ perceptions re- garding patients’ knowledge about why they need to fast, the extent to which patient noncompliance with fasting affects the surgical schedule, and the effectiveness of the current hospital fasting policy. The interviews revealed that anesthesia care providers’ and nurses’ perceptions were simi- i [ lar on some topics but differed on others.
PATIENTS’ KNOWLEDGE ABOUT FASTING. Anesthesia care providers’ perceptions demonstrated a belief that patients lacked sufficient knowledge about the preoperaHve fasting process. One anesthesia care provider commented, “I think most patients have no clue why they have to fast.” Another stated, “I don’t think they understand NPO.”