Nil per os, Latin for take nothing by mouth or NPO, is used to indicate when it is medically necessary for a person to refrain from eating and drinking. Ask any nurse and he or she would state that the phrase to uttered numerous times in the length of a career. For patients in the acute care setting, there is nursing and nursing support staff aiding in the adherence of this directive. The nurse warns the client prior to the set time ordered so they are aware that this is their last chance to eat and drink, and once the time comes all food and drink items are removed from sight to ensure that there are no temptations. The nursing and nursing support staff continue to monitor that the patient does not partake in anything by mouth during the overnight hours ensuring that the scheduled test or procedure occurs as planned. However, in the outpatient the situation is much different.
On any given evening, if a person awakes throughout the night they may eat and drink freely with little to no repercussions. When a person is scheduled for an outpatient procedure or surgery, it is imperative that they remain NPO, just as the client in the acute care setting previously described. These outpatient clients are still at home in their own beds surrounded by foods and drinks of their choosing and not partaking for some, is easier said than done. For many clients, the mere mention that they will have to remain without food or drink for an extended period of time elicits an immediate desire to eat or drink. Outside of the controlled hospital environment, these outpatient clients can give into the temptations surrounding them, not taking into consideration why these guidelines are in place. This can become problematic upon arrival to the Ambulatory Surgery Center.
Upon admission to the Ambulatory Surgery Center, the client is assessed, medications are reconciled, an IV is started, labs are drawn, and the patient is prepped for the operating room. After verifying your identity, the next question likely to be asked is “When did you last eat and drink?” The nurse knows that part of a patient’s preoperative education included when to initiate preoperative fasting. The answer to this question is imperative as it can be the client’s “golden ticket” to the operating room. Not remaining NPO for the proper amount of time can lead to case delays and cancellations on the day of surgery.
Case cancellations and delays, regardless of reason, cause increased cost for the facility and can lead to ineffective use of hospital resources and staff leading to loss of income. The extent of cost to the facility varies by what point in process the cancellation occurs with “the most damaging cancellations with regard to inefficient and costly use of medical resources [occurring] after the patient has been prepared for the operating room” (Chang, Chen, Chen, Poon & Liu, 2014. p. 1). A study presented at the 2012 American Society of Anesthesiologists’ Annual Conference from the Tulane University Medical Center found that 6.7% of scheduled surgical cases in 2009 were cancelled, costing the facility nearly $1 million (McCook, 2012). The same study cited that for the 225 cancelled cases, the average revenue lost per case was $2924 among ten specialties (McCook, 2012). In the Ambulatory Surgery Unit at Fairmont Regional Medical Center (FRMC), the majority of case cancellations and delays occur from inadequate length of NPO status.
The American Society of Anesthesiologists (ASA) dictates approved guidelines for NPO guidelines from which each facility may adopt. In 2009, the ASA shortened the number of hours for preoperative fasting, however, many ambulatory surgery centers, including the one at FRMC, are still abiding by the by the previous guideline of NPO after midnight (Mathias, 2011). With preoperative fasting failure being a top contributor to day of surgery delay and cancellation at FRMC, it is import to investigate how changing the NPO guidelines currently in place to those suggested by ASA would impact day of surgery cancellations due to fasting failure.
The purpose of this paper is to review the implementation of new outpatient preoperative NPO guidelines for Fairmont Regional Medical Center Ambulatory Surgery Unit and investigate the effects it has on patient compliance and surgical cancellation rates. The paper is structures by first introducing the problem, completing a literature review, defining the change theory chosen, implementing the change, and evaluating the effectiveness of the change. When the number of day of surgery cancellations due to NPO failure was defined as a problem, a literature about the topic was completed to discover evidence based research findings. The Lippitt Change Theory, consisting of the Seven Step Change, is discussed as it relates to this change project. The actual implementation of the change is detailed from the creation of SMART goals to the explanation of each step of the change process. Finally, the effects of the change are evaluated through chart review of preoperative education, patient interview, and rate of day of surgery cancellations related to NPO failure.
Literature review
A review of the literature was conducted using the various databases made available through the Fairmont State University Library, including Ovid and ProQuest Nursing and Allied Health and a Google search for the current American Society of Anesthesiologists (ASA) nil er os or NPO guidelines. Terms used for the search included ‘ASA NPO guidelines’, ‘NPO’, ‘NPO guidelines’, and ‘patient education’. Articles were limited to those less than five years old, peer reviewed, and written in English. Additional support for this project was also sought from the cited references of chosen articles.
The current American Society of Anesthesiologists guidelines for preoperative fasting were put into effect in 2011 and remain largely unchanged from the initial shortening of NPO times put into practice in 1999. The research continues to support these shortened fasting time, however, the guidelines are not firm standards nor required, thus many facilities have yet to adopt them. Through the research conducted, the ASA has made recommendations on the following categories, clear liquids, breast milk, infant formula, non-human milk, light meal, and heavy meal. A summary of these recommendations can be viewed in Table 1 (American Society of Anesthesiologists, 2011). In numerous articles there is concern for compliance based on
TABLE 1. Summary of ASA Fasting Recommendations
Ingested material
Minimum fasting period in hours
Clear Liquids (for Adults and Children)
2
Breast Milk
4
Infant Formula
6
Non-human milk
6
Light Meal
6
Heavy Meal
8
Information summarized from American Society of Anesthesiologists, (2011). Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. Anesthesiology, 114(3), 495-511. Retrieved February 15, 2016, from http://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/practice-guidelines-for-preoperative-fasting.pdf
individualized definitions of each category, mainly clear liquids and light and heavy meal (Alison & George, 2014; Crenshaw, 2011; Mathias, 2011). This too was addressed by the American Society of Anesthesiologists guidelines for preoperative fasting. Examples for each category can be see in Table 2.
TABLE 2. Definitions of Ingested Material by Category
Ingested Material Category
Examples
Clear Liquids
Water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee.
Non-human milk
Cow’s milk or non-dairy milk product
Light Meal
Toast and a clear liquid
Heavy Meal
Fried or fatty foods, meats
Information summarized from American Society of Anesthesiologists, (2011). Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. Anesthesiology, 114(3), 495-511. Retrieved February 15, 2016, from http://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/practice-guidelines-for-preoperative-fasting.pdf
There is question as to when and if this new information will be placed into practice (Crenshaw, 2011; Mathias, 2011). According to the American Society of Anesthesiologists, the guidelines that have been in place in 1999, “may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies” (American Society of Anesthesiologists, 2011. p. 495). In an interview with OR Manager in 2011, Dr. Jeffrey L. Apfelbaum, then chairman of the ASA Committee on Standards and Practice Parameters, stated the he did not understand why more [practitioners] are not following [the current guidelines] (Mathias, 2011. p. 17). Two separate studies were conducted at the same institution just after publication of the new guidelines between November 1999 and May 2000 and two years after the institutional guidelines were revitalized between June and October 2004 to investigate the adoption and adherence of the new guidelines (Crenshaw, 2011, p. 40). In the first study, 91% of patients were instructed to remain NPO after midnight, while the follow-up quality improvement study found that 85% of patients were still told to be NPO after midnight, despite the implementation of institutional guidelines (Crenshaw, 2011. p. 40). But why is there resistance to changing guidelines to the new recommendations?
In the US there is a considerable amount of resistance to changing to the new guidelines (Anderson & Comrie, 2009; Crenshaw, 2011; Mathias, 2011). There are some healthcare providers in the United States that may be unaware of the current guidelines (Crenshaw, 2011) while still others feel that because there are groups of comorbidities that decrease gastric emptying rates, abiding my the longest NPO instructions, in a sense allowing the exceptions to make the rules, to simplify patient instruction (Mathias, 2011). Many physicians feel that patients would be confused if given separate instructions for fasting length for each of the categories (Crenshaw, 2011). Still other physicians feel that maintaining the lengthier preoperative fasting schedules, allows for greater flexibility in the surgical schedule should cancellations occur (Crenshaw, 2011).