“Who has just these two orders when they choose to put in an NPO for their patients: midnight or now, and that's it?” ACP Member Andrew Higdon, MD, asked his audience at Hospital Medicine 2018. Several hands were raised.
“That's how it was for us too,” he said. “And that got us thinking, ‘Is this really what we should be doing? Surely there's a better way.’”
Since 1999, the American Society of Anesthesiologists (ASA) has recommended preoperative fasting for only two hours, with patients allowed to ingest clear liquids before that. “These are recommendations that are 20 years old, but everybody's always doing NPO at midnight still,” which often leads to dehydration, said Dr. Higdon, chief resident of quality and patient safety at the VA Medical Center through the University of Kentucky College of Medicine.
He looked at data from five inpatient medicine teams at his institution (four led by residents) that placed NPO orders between June and August 2017 and found that overall, NPOs were 16.23 hours long on average (13.98 hours for bronchoscopies and 11.67 hours for cardiac catheterizations), which was “nowhere near the ideal.” In response, he and his colleagues developed a process to reduce NPO duration.
How it works
The first step was to get everyone on board: hospitalists, proceduralists, nurse managers, nurses, dietitians, and the IT team. The physicians performing cardiac catheterizations and bronchoscopies agreed to participate after reviewing the literature supporting the safety of changing NPO orders, Dr. Higdon said.
Senior resident leaders from the hospital medicine track then changed the electronic health record (EHR) to ask clinicians who enter an NPO order about the type of procedure (cardiac catheterization, bronchoscopy, or other). Those who select bronchoscopy or cardiac catheterization are directed to a new “Clear Liquid Diet until 0800” order, which initiates a clear liquid diet at midnight that becomes NPO at 8 a.m., said Dr. Higdon.
“We don't have NPO at midnight on there anymore [for those procedures]. We took it off to make it a durable, hard-stop intervention, so you can't get around it easily,” he said, noting that the option for NPO at midnight is still available for other procedures.
From October 2017 through February 2018, the medicine services had a slight overall increase in average NPO duration (17.69 hours), but average NPO duration for bronchoscopies and cardiac catheterizations decreased to 9.75 and 9.04 hours, respectively, reported Dr. Higdon, whose abstract won the Society of Hospital Medicine's Research, Innovations, and Vignettes competition.
When physicians used the new order, average NPO duration dropped substantially—to 5.98 hours for bronchoscopies and 6.47 hours for cardiac catheterizations. But use of the new clear liquid graduated diet was not common.
“We only had about 30% of people actually use the 0800 order, which I'm not happy to report, which tells us we have a lot more work to do,” said Dr. Higdon.
Getting clinicians on board was a challenge, which is why the team focused on only on heart catheterizations and bronchoscopies, Dr. Higdon said. “We wanted to get enough safety data to actually show that this is effective and safe,” he said, adding that presenting the ASA guidelines and safety data from a 2003 Cochrane review, which found that two hours of preoperative fasting is associated with a lower risk of aspiration compared to four hours, got more people to embrace the initiative.
Dr. Higdon said the next steps are to expand the project to more procedures, such as esophagogastroduodenoscopy, colonoscopy, and interventional radiography procedures. However, the timing of other procedures is more varied compared to cardiac catheterizations and bronchoscopies, which never happen before 8 a.m., he said, so the orders may need to be changed to allow for more flexible timing.
“On expansion, we're going to have to look into that a little bit more....We can certainly start venturing into even morning versus afternoon for simplicity of orders' sake,” Dr. Higdon said.
He also wants to improve the NPO order in the EHR. Currently, a submenu is produced when the order is selected. “I hate submenus. More clicks make me angry,” Dr. Higdon said. “[We want to] get rid of the submenu altogether to have evidence-based, guideline-driven care delivered in one click.”
Words of wisdom
“Patients want a shorter NPO, guidelines say we need a shorter NPO, and the safety data say we need a shorter NPO. So why don't we? In Lexington, we are slowing the inpatient fasting epidemic,” Dr. Higdon said.