Preoperative fluid restrictions: hospital policy and clinical practice

A pragmatic cluster randomised trial evaluating three implementation interventions

Background

Implementation research is concerned with bridging the gap between evidence and practice through the study of methods to promote the uptake of research into routine practice. Good quality evidence has been summarised into guideline recommendations to show that peri-operative fasting times could be considerably shorter than patients currently experience. The objective of this trial was to evaluate the effectiveness of three strategies for the implementation of recommendations about peri-operative fasting.

Methods

A pragmatic cluster randomised trial underpinned by the PARIHS framework was conducted during 2006 to 2009 with a national sample of UK hospitals using time series with mixed methods process evaluation and cost analysis. Hospitals were randomised to one of three interventions: standard dissemination (SD) of a guideline package, SD plus a web-based resource championed by an opinion leader, and SD plus plan-do-study-act (PDSA). The primary outcome was duration of fluid fast prior to induction of anaesthesia. Secondary outcomes included duration of food fast, patients’ experiences, and stakeholders’ experiences of implementation, including influences. ANOVA was used to test differences over time and interventions.

Results

Nineteen acute NHS hospitals participated. Across timepoints, 3,505 duration of fasting observations were recorded. No significant effect of the interventions was observed for either fluid or food fasting times. The effect size was 0.33 for the web-based intervention compared to SD alone for the change in fluid fasting and was 0.12 for PDSA compared to SD alone. The process evaluation showed different types of impact, including changes to practices, policies, and attitudes. A rich picture of the implementation challenges emerged, including inter-professional tensions and a lack of clarity for decision-making authority and responsibility.

Conclusions

This was a large, complex study and one of the first national randomised controlled trials conducted within acute care in implementation research. The evidence base for fasting practice was accepted by those participating in this study and the messages from it simple; however, implementation and practical challenges influenced the interventions’ impact. A set of conditions for implementation emerges from the findings of this study, which are presented as theoretically transferable propositions that have international relevance.

Trial registration

ISRCTN18046709 - Peri-operative Implementation Study Evaluation (POISE).

A review of the evidence for the impact of improving nutritional care on nutritional and clinical outcomes and cost

BACKGROUND

The association between malnutrition and poor clinical outcome is well-established, yet most research has focussed on the role of artificial nutritional support in its management. More recently, emphasis has been placed on the provision of adequate nutritional care, including nutritional screening and the routine provision of food and drink. The aim of this literature review is to establish the evidence for the efficacy of interventions that might result in improvements in nutritional and clinical outcomes and costs.

METHODS

A structured literature review was conducted investigating the role of nutritional care interventions in adults, and their effects on nutritional and clinical outcomes and costs, in all healthcare settings. Ten databases were searched electronically using keywords relating to nutritional care, patient outcomes and healthcare costs. High quality trials were included where available.

RESULTS

Two hundred and ninety-seven papers were identified and reviewed. Of these, only two randomised, controlled trials and six other trials were identified that addressed the major issues. A further 99 addressed some aspects of the provision of nutritional care, although very few formally evaluated nutritional or clinical outcomes and costs.

CONCLUSIONS

This review reveals a serious lack of evidence to support interventions designed to improve nutritional care, in particular with reference to their effects on nutritional and clinical outcomes and costs. The review suggests that screening alone may be insufficient to achieve beneficial effects and thus more research is required to determine the most cost-effective interventions in each part of the nutritional care pathway, in a variety of healthcare settings and across all age ranges, to impact upon nutritional and clinical outcomes.

Preoperative fasting: knowledge and perceptions

Preoperative patient fasting is an essential element of the patient preparation process, but patients 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 erroneous perceptions about patient knowledge regarding the rationale for fasting and compliance with instructions. Clinicians expressed concern about the effects of excessive fasting but were reluctant to relax the policy.

Older people and hypothermia: the role of the anaesthetic nurse

Older clients are at increased risk during surgical intervention because of age-related system changes and comorbid conditions. However, recent advances in surgical and anaesthetic techniques, together with modern monitoring technology and the proliferation of ambulatory surgery, have reduced mortality in older patients undergoing surgery. Nevertheless, inadvertent hypothermia in older clients remains problematic. Therefore, an understanding of specific diseases prevalent in old age, coupled with a comprehensive knowledge of the physiological impact of ageing in all body systems, underpins the role of the anaesthetic nurse.

Preoperative fasting: old habits die hard

OVERVIEW

Prolonged preoperative fasting is a time-honored tradition. The typical order of "npo after midnight" (or no liquid or food after 12 am on the day of surgery) has been challenged in recent years-so much so that in 1999 the American Society of Anesthesiology (ASA) revised its practice guidelines for preoperative fasting in healthy patients undergoing elective procedures. The newer, more liberal recommendations, based on studies showing that pulmonary aspiration occurs only rarely as a complication of modern anesthesia, allow the consumption of clear liquids up to two hours before elective surgery, a light breakfast (tea and toast, for example) six hours before the procedure, and a heavier meal eight hours beforehand. There is a well-known lag between the dissemination and implementation of practice guidelines, so the authors sought to determine whether the publication of the revised ASA recommendations had changed preoperative fasting practices. They interviewed 155 patients in one hospital about their preoperative fasting, comparing instructed, actual, and ASA-recommended fasting durations for liquids and solids. Their findings demonstrate that the majority of patients continued to receive instructions of npo after midnight for both liquids and solids, whether they were scheduled for early or late surgery. On average, the patients fasted from liquids and solids for 12 and 14 hours, respectively, with some patients fasting as long as 20 hours from liquids and 37 hours from solids. These fasts were significantly longer than those recommended by the ASA, indicating that inappropriate preoperative fasting is an issue that demands attention. The authors conclude that more collaboration between nurses and physicians is needed to assure that fasting instructions are consistent with the ASA guidelines and that patients understand these directives.