- Email: [email protected]
Southern Hospitality: How We Changed the NPO Practice in the Emergency Department
PRACTICE IMPROVEMENT
SOUTHERN HOSPITALITY: HOW WE CHANGED THE NPO PRACTICE IN THE EMERGENCY DEPARTMENT Author: Traci D. Denton, BA, RN, CCRN, Nashville, TN
Earn Up to 8.0 CE Hours. See page 369. Problem: In the Vanderbilt Medical Center adult emergency
department, the practice has been to keep patients on “nothing by mouth” (NPO) status throughout their assessment, diagnostic, and treatment phases. As a result, most patients have NPO status for a period of several hours to days. The consequences are patient discomfort, hunger, thirst, dehydration, interruptions in routine medication schedules, poor glucose control, and compromised acid/base balance. The purpose of this project was to modify the NPO practice in the adult emergency department.
Methods: A survey of nursing staff perceptions demonstrated both staff and patient dissatisfaction with the NPO practice. Responses to postdischarge satisfaction surveys demonstrated that patients experienced some discomfort because of hunger or thirst. A search of the literature revealed that the American Society of Anesthesiologists (ASA) adopted guidelines in 1999 that patients should fast 6 hours from solids and 2 hours from liquids preoperatively. These guidelines were implemented in the adult emergency department using the Standard Rollout Process.
“N
othing by mouth (NPO) after midnight” is a common practice for patients undergoing diagnostic and surgical procedures with anesthesia. It has been a long-held theory that NPO status would prevent vomiting, aspiration, and death from aspiration pneumonia. Guidelines exist that spell out what patients can consume (solids versus liquids) and how long they need to be on NPO status before a procedure that requires anesthesia. 1,2 Yet many health care providers are
Traci D. Denton, Member, Middle Tennessee Chapter, is Adult Emergency Department RN-4, Vanderbilt University Medical Center, Nashville, TN. For correspondence, write: Traci D. Denton, BA, RN, CCRN, 9448 Highwood Hill Rd, Brentwood, TN 37027; E-mail: [email protected]. J Emerg Nurs 2015;41:317-22. Available online 2 May 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.12.001
July 2015
VOLUME 41 • ISSUE 4
Physician order sets for the emergency department and the ED chest pain unit were modified to reflect the ASA guidelines. Results: After implementation of the ASA guidelines, a follow-up survey of nursing staff showed increased staff and patient satisfaction. After implementation, the patient satisfaction survey demonstrated an increase in patients who reported “no discomfort” because of hunger or thirst. No adverse outcomes or delays were reported in relation to the change in NPO standards. This change in practice resulted in improved satisfaction for patents and staff. Implications for Practice: The ASA guidelines have been in existence for more than a decade. They are evidence based. The role of the nurse is to advocate for the patient. Nurses need to be proactive in determining the timing of procedures and asking physicians to give diet orders that are in accordance with the ASA guidelines. Key words: NPO; ASA guidelines; Standard rollout process; Practice change
unaware of these guidelines or do not feel comfortable allowing patients to consume liquids up to several hours before the procedure. This project was undertaken to reduce the length of time patients in the emergency department fasted during their ED stay. “NPO after midnight” has a long history in surgical care. The original purpose was to minimize the unpleasantness of vomiting, not the danger of aspiration. The first book on anesthesia (ether was being used), which was written in 1847 by Dr. J. Robinson, did not even mention fasting. In 1862, the first adverse reaction, a “new cause of death under chloroform” referencing a soldier who had vomited and died during surgery, was reported at a medical meeting in Edinburgh. 3 In 1853, British surgeon Sir Joseph Lister published simple, practical fasting guidelines: “While it is desirable that there should be no solid matter in the stomach when chloroform is administered, it will be found very salutary to give a cup of tea or beef-tea about two hours previously.” 4 He was the first to make a distinction between solid food and clear liquids. The evolution and subsequent
WWW.JENONLINE.ORG
317
PRACTICE IMPROVEMENT/Denton
widespread adoption of “NPO after midnight” for healthy patients with no risk factors undergoing elective surgery appears to have begun in the 1960s, when C.L. Mendelson published his study results involving hydrochloric acid instilled directly into the lungs of anaesthetized rabbits. The theory of “nothing on the day of surgery” was interpreted as “NPO after midnight,” and that practice took hold. There is no indication as to why the earlier distinction between liquids and solids was ignored. It was not until 1990 that the first calls for change from “NPO after midnight” gathered momentum. 3 It had been the practice of the Vanderbilt adult emergency department to keep patients who presented to the department on NPO status throughout the assessment, diagnostic, and treatment phases. As a result, the NPO status for most patients lasted for several hours to days. Consequences were patient discomfort, irritability, headache, hunger, thirst, dehydration, poor glucose control, and compromised acid/base balance. In addition, medications prescribed for both acute and chronic diseases such as infection, asthma, hypertension, diabetes, cardiac problems, and seizures, which should not be withheld, were not being administered during their ED visit. (Beta-blockers, however, should be withheld prior to cardiac testing procedures because diagnostic tests are heavily influenced by their effects. 5) Extended NPO status could have negative effects on the patient’s physical status. This practice also was related to a high level of patent dissatisfaction. Thus, a literature search was conducted to determine the most appropriate fasting guidelines based on current evidence. A literature search revealed that in 1999 the American Society of Anesthesiologists (ASA) published Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. 1 These guidelines suggest that healthy patients undergoing elective procedures should fast 6 hours from solids and 2 hours from clear liquids. These more liberal recommendations were based on retrospective studies showing that pulmonary aspiration occurs only rarely as a complication of modern anesthesia and that none of those cases of aspiration led to serious pulmonary complications or death. In addition, evidence showed that gastric pH values and volumes actually were higher with an extended period of NPO status than with adherence to the ASA guidelines. 1 Despite evidence-based guidelines, the standard order “NPO after midnight” remains in effect. These practice guidelines were updated in 2011 for elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. 2 The current recommendation is 8 hours of fasting for fried or fatty foods, 6 hours for nonhuman milk or a light
318
JOURNAL OF EMERGENCY NURSING
meal, and 2 hours for clear liquids. Examples of clear liquids include but are not limited to water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. These liquids should not include alcohol. 2 Patients preparing for cardiac testing should not ingest caffeine from 12 to 24 hours prior to their procedure. 6 The recommendations suggest a history, examination, and interview that should include pertinent assessment of gastroesophageal reflux disease, dysphagia symptoms, or other gastrointestinal motility disorders, along with the potential for difficult airway management and metabolic disorders (eg, diabetes mellitus) that may increase the risk of regurgitation and pulmonary aspiration. 1,2 A carbohydrate-rich beverage given before anesthesia and surgery alters the metabolism from the overnight fasted state to the fed state, thus reducing the catabolic response (insulin resistance) after surgery, which may have implications for postoperative recovery. 7 These guidelines have been in existence for more than a decade, yet providers are still using the blanket statement “NPO after midnight” without regard to individual patient history, daily routines and meal times, the specific procedure, or the time of the scheduled procedure. This project was undertaken to improve patient safety and satisfaction by bringing the extended NPO practice used in our adult emergency department more in line with the ASA NPO guidelines. Method
Use of the Standard Rollout Process 8 is a requirement for proposed changes in the adult emergency department (Figure 1). New initiatives are identified, clearly written, and prioritized into a strategic plan. A start date for the initiation of the rollout is established. The rollout process includes (1) identification of stakeholders, (2) meeting with stakeholders, (3) performing a good/average/poor (GAP) and strengths/weaknesses/opportunities/threats (SWOT) analysis, (4) developing an action plan, (5) communicating that plan, (6) identifying metrics to evaluate change, and (7) implementing the action plan. The rollout process also includes a debriefing and allows for necessary adjustments to the action plan. 8 To ascertain that a problem existed, a 10-question survey was developed for the nursing staff (Figure 2). This survey of the nursing staff demonstrated both staff and patient dissatisfaction with the practice; 67.5% of the 39 nurses surveyed reported frustration with keeping patients on NPO status for no definite purpose/procedure, 73.2% reported that their patients complained of hunger, and 80.5% reported that their patients complained of thirst.
VOLUME 41 • ISSUE 4
July 2015
Denton/PRACTICE IMPROVEMENT
FIGURE 1 Standard rollout process. GAP, Good/average/poor; NPO, nothing by mouth; SWOT, strengths/weaknesses/opportunities/threats.
Physician buy-in was critical to successfully change this practice in the emergency department. The medical director of the adult emergency department and the ED cardiologist were identified as critical stakeholders. After being presented with the patient and staff satisfaction survey results and supporting literature, the ED medical director and the ED cardiologist gave their full support to the implementation of the ASA guidelines in the department. With their assistance and insistence, the physician order sets for the emergency department and the ED chest pain unit admission orders were modified to reflect the ASA fasting recommendations. The ED orders stated that “Nurses are to ask physician for a diet order after testing is complete.” The ED chest pain unit
July 2015
VOLUME 41 • ISSUE 4
admission orders specify that patients can have a light meal until 2 AM and clear liquids until 6 AM. The start date for the new order sets was October 1, 2010. The GAP and SWOT analyses identified that culture or “habit” was the main threat to this practice change. An additional threat was the potential increase in food and beverages required from nutrition services. The GAP analysis laid out the steps necessary to achieve a successful practice change. The action plan, with accountabilities and timelines, was developed from the GAP analysis. A communication plan was developed that included written and face-to-face communication about the change in NPO guidelines in the adult emergency department. In
WWW.JENONLINE.ORG
319
PRACTICE IMPROVEMENT/Denton
FIGURE 2 Survey. Nothing by mouth (NPO) practice in the adult ED RN survey.
accordance with the Standard Rollout Process, the proposed change was communicated in 7 ways over at least 7 days. Throughout September 2010, the adult ED staff was educated on the NPO initiative through presentations in staff meetings, the Unit Board meeting, and change of shift reports. Flyers were posted throughout the unit, informational e-mail messages were sent to nursing staff through the nurse educator, and informational e-mail messages were sent to the medical staff through the medical director. Metrics selected to evaluate the NPO status change included patient satisfaction and adverse events related to the practice change. In June 2010, 2 questions were added to the patient satisfaction survey used throughout the organization (provided by Professional Research Consultants, Inc [PRC], Omaha, NE). The questions added were: (1) “During this emergency room visit, did doctors, nurses, or staff limit what (you/your family member) could eat or drink?” and (2) “And would you say (you/your family member) experienced ‘A Lot of Discomfort,’ ‘Some Discomfort,’ or ‘No Discomfort’ due to hunger or thirst?” Follow-up with the medical director and cardiologist was performed at regular intervals to monitor for adverse events related to NPO status, specifically, the incidence of pulmonary aspiration and delays in performing a procedure. Four months after implementation, the nursing staff was surveyed again about nurse and patient satisfaction with NPO guidelines.
Results
On October 1, 2010, the ASA preoperative guidelines were implemented in the adult emergency department after 7
320
JOURNAL OF EMERGENCY NURSING
days of information delivery as per the Standard Rollout Process, after the change in the physician order sets, and after individual staff education on the initiative. For the month prior to the implementation of the staff education on the revised NPO guidelines (August 2010), of 201 respondents to the PRC survey, 34.8% of patients reported that limits were placed on what they could eat or drink, and 41.3% of those patients surveyed reported “some” or “a lot” of discomfort with thirst or hunger. Patient satisfaction data were examined for 15 months after the implementation of the revised NPO standards. The data regarding the perceptions of NPO practice by patients showed little change. In July 2011, 41.5% of those surveyed (200) reported limits placed on what they could eat or drink, and 44% reported “some” or “a lot” of discomfort with thirst or hunger. Follow-up conversations with the ED medical director and cardiologist were conducted in November 2010 and May 2011 and are repeated every 6 months. Both physicians confirmed that there had been no reported adverse outcomes or delays for ED or cardiology procedures since implementation of the revised guidelines. At 4 months after implementation, a repeat survey of the RN perceptions of the NPO practice was conducted. The response from 19 nurses revealed a decrease in nursing frustration. Nurses reported that their patients had a decrease in hunger and thirst complaints. They also reported a decrease in difficulty with glucose control. Withholding of routine medications was reported to have decreased. Nurses reported a decrease in workload associated with being able to feed patients, but an increase in workload associated with being able to give patients clear liquids. There was a reported
VOLUME 41 • ISSUE 4
July 2015
Denton/PRACTICE IMPROVEMENT
decrease in the likelihood of asking for diet orders. This finding may be due to the fact that diet parameters are now included in the physician order sets. After implementation, night shift staff reported patient satisfaction with being able to sleep without feeling hungry or thirsty, and the day shift staff reported the absence of patient complaints of hunger and thirst when they began their shift, all of which contributed to increased staff satisfaction. However, in 2012 it was noted that the practice of withholding solids and liquids from patients after midnight, despite the written orders to the contrary, was resurging. In the 2 years since the implementation of the NPO practice change, there had been a greater than 50% turnover in nursing staff. The results of an informal verbal staff survey revealed a lack of knowledge regarding the ASA NPO guidelines. To remedy this deficit, the NPO information was added to the required annual competency review and comprehension was evaluated with a test question. This same information is presented to all new nursing staff during their orientation to the adult emergency department.
Implications for Practice
The ASA guidelines have been in existence for more than a decade. They are evidence based. The role of the nurse is to advocate for the patient. Nurses need to be proactive in determining the timing of procedures and asking physicians to give diet orders that are in accordance with the ASA guidelines. Physicians need to be accountable for writing orders that are evidence based and not antiquated theories based on anecdotal reports. Patients need to be sent to procedures in the best psychological and physiological states possible.
Conclusion
Implementing a practice change in a clinical setting requires clear identification of the problem, stakeholder buy-in, a comprehensive communication plan, and continued monitoring to sustain the practice change. Using the Standard Rollout Process, the NPO practice in the adult emergency department was changed. This change resulted in increased nursing staff satisfaction, decreased patient complaints of hunger and thirst, and no adverse events related to pulmonary aspiration or delay in procedures due to feeding patients according to the guidelines. Patients received their routine medications and had improved glucose control and hydration. The lack of improvement in patient responses to hunger and thirst on the standard PRC survey may be due to a negative impression of any withholding of food or drink at any time or for any duration during their visit.
July 2015
VOLUME 41 • ISSUE 4
There were limitations to data collection for this project. Only a small sample of nurses participated in the survey, although 50% did respond. A larger number of responding nurses and a longer duration of preimplementation data may have strengthened the design of the project. The use of an investigator-developed survey for nursing staff is a limitation as well; however, no validated tools exist to capture this information. The Standard Rollout Process works. It is an effective tool in the dissemination of information to a large staff with diverse schedules and job descriptions. There is continued pushback from consulting and admitting physicians who continue to place the order “NPO after midnight.” The change has given the nurses an evidence-based standard to use as reference, and our ED attending/faculty physicians support nurses in challenging those physician orders. Sustaining practice change can be challenging. Preventing the drift back to the old practice of “NPO after midnight” requires vigilance in monitoring the practice and having strategies in place to orient new staff and reorient the existing staff. Monitoring staff education, compliance, and inclusion of the ASA guideline in orientation, as well as annual competencies, may improve the sustained use of this evidence-based practice. Acknowledgments I thank Nancy Wells, DNSc, RN, FAAN, for her assistance with this article. Karin League, MSN, RN, and Brent Lemonds, MS, RN, EMT-P for their permission to include the Standard Rollout Process.
REFERENCES 1. Task Force on Preoperative Fasting, American Society of Anesthesiologists. 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. 1999;90:896–905. 2. The American Society of Anesthesiologists Committee on Standards and Practice Parameters. Practice guidelines for preoperative fasting and the use of pharmacological agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiology. 2011;114:495–511. 3. Maltby JR. Fasting from midnight—the history behind the dogma. Best Pract Res Clin Anaesthesiol. 2006;20(3):363–378. 4. Lister J. On anaesthetics. Holmes System of Surgery. 3rd ed. London: Longmans Green and Co; 1883. 5. Sicari R. Anti-ischemic therapy and stress testing: pathophysiologic, diagnostic and prognostic implications. Cardiovasc Ultrasound. 2004;2:14. 6. Kovacs D, Pivonka R, Khosla PG, Khosla S. Effect of caffeine on myocardial perfusion imaging using single photon emission computed tomography during adenosine pharmacologic stress. Am J Ther. 2008;15(5):431–434.
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7. Ljungqvist O, Soreide E. Preoperative fasting. Br J Surg Soc. 1990;90(4):400–406.
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8. League K, Lemonds B. The standard rollout process, Nashville, TN: Vanderbilt Medical Center; 2009.
VOLUME 41 • ISSUE 4
July 2015
SOUTHERN HOSPITALITY: HOW WE CHANGED THE NPO PRACTICE IN THE EMERGENCY DEPARTMENT Author: Traci D. Denton, BA, RN, CCRN, Nashville, TN
Earn Up to 8.0 CE Hours. See page 369. Problem: In the Vanderbilt Medical Center adult emergency
department, the practice has been to keep patients on “nothing by mouth” (NPO) status throughout their assessment, diagnostic, and treatment phases. As a result, most patients have NPO status for a period of several hours to days. The consequences are patient discomfort, hunger, thirst, dehydration, interruptions in routine medication schedules, poor glucose control, and compromised acid/base balance. The purpose of this project was to modify the NPO practice in the adult emergency department.
Methods: A survey of nursing staff perceptions demonstrated both staff and patient dissatisfaction with the NPO practice. Responses to postdischarge satisfaction surveys demonstrated that patients experienced some discomfort because of hunger or thirst. A search of the literature revealed that the American Society of Anesthesiologists (ASA) adopted guidelines in 1999 that patients should fast 6 hours from solids and 2 hours from liquids preoperatively. These guidelines were implemented in the adult emergency department using the Standard Rollout Process.
“N
othing by mouth (NPO) after midnight” is a common practice for patients undergoing diagnostic and surgical procedures with anesthesia. It has been a long-held theory that NPO status would prevent vomiting, aspiration, and death from aspiration pneumonia. Guidelines exist that spell out what patients can consume (solids versus liquids) and how long they need to be on NPO status before a procedure that requires anesthesia. 1,2 Yet many health care providers are
Traci D. Denton, Member, Middle Tennessee Chapter, is Adult Emergency Department RN-4, Vanderbilt University Medical Center, Nashville, TN. For correspondence, write: Traci D. Denton, BA, RN, CCRN, 9448 Highwood Hill Rd, Brentwood, TN 37027; E-mail: [email protected]. J Emerg Nurs 2015;41:317-22. Available online 2 May 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.12.001
July 2015
VOLUME 41 • ISSUE 4
Physician order sets for the emergency department and the ED chest pain unit were modified to reflect the ASA guidelines. Results: After implementation of the ASA guidelines, a follow-up survey of nursing staff showed increased staff and patient satisfaction. After implementation, the patient satisfaction survey demonstrated an increase in patients who reported “no discomfort” because of hunger or thirst. No adverse outcomes or delays were reported in relation to the change in NPO standards. This change in practice resulted in improved satisfaction for patents and staff. Implications for Practice: The ASA guidelines have been in existence for more than a decade. They are evidence based. The role of the nurse is to advocate for the patient. Nurses need to be proactive in determining the timing of procedures and asking physicians to give diet orders that are in accordance with the ASA guidelines. Key words: NPO; ASA guidelines; Standard rollout process; Practice change
unaware of these guidelines or do not feel comfortable allowing patients to consume liquids up to several hours before the procedure. This project was undertaken to reduce the length of time patients in the emergency department fasted during their ED stay. “NPO after midnight” has a long history in surgical care. The original purpose was to minimize the unpleasantness of vomiting, not the danger of aspiration. The first book on anesthesia (ether was being used), which was written in 1847 by Dr. J. Robinson, did not even mention fasting. In 1862, the first adverse reaction, a “new cause of death under chloroform” referencing a soldier who had vomited and died during surgery, was reported at a medical meeting in Edinburgh. 3 In 1853, British surgeon Sir Joseph Lister published simple, practical fasting guidelines: “While it is desirable that there should be no solid matter in the stomach when chloroform is administered, it will be found very salutary to give a cup of tea or beef-tea about two hours previously.” 4 He was the first to make a distinction between solid food and clear liquids. The evolution and subsequent
WWW.JENONLINE.ORG
317
PRACTICE IMPROVEMENT/Denton
widespread adoption of “NPO after midnight” for healthy patients with no risk factors undergoing elective surgery appears to have begun in the 1960s, when C.L. Mendelson published his study results involving hydrochloric acid instilled directly into the lungs of anaesthetized rabbits. The theory of “nothing on the day of surgery” was interpreted as “NPO after midnight,” and that practice took hold. There is no indication as to why the earlier distinction between liquids and solids was ignored. It was not until 1990 that the first calls for change from “NPO after midnight” gathered momentum. 3 It had been the practice of the Vanderbilt adult emergency department to keep patients who presented to the department on NPO status throughout the assessment, diagnostic, and treatment phases. As a result, the NPO status for most patients lasted for several hours to days. Consequences were patient discomfort, irritability, headache, hunger, thirst, dehydration, poor glucose control, and compromised acid/base balance. In addition, medications prescribed for both acute and chronic diseases such as infection, asthma, hypertension, diabetes, cardiac problems, and seizures, which should not be withheld, were not being administered during their ED visit. (Beta-blockers, however, should be withheld prior to cardiac testing procedures because diagnostic tests are heavily influenced by their effects. 5) Extended NPO status could have negative effects on the patient’s physical status. This practice also was related to a high level of patent dissatisfaction. Thus, a literature search was conducted to determine the most appropriate fasting guidelines based on current evidence. A literature search revealed that in 1999 the American Society of Anesthesiologists (ASA) published Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. 1 These guidelines suggest that healthy patients undergoing elective procedures should fast 6 hours from solids and 2 hours from clear liquids. These more liberal recommendations were based on retrospective studies showing that pulmonary aspiration occurs only rarely as a complication of modern anesthesia and that none of those cases of aspiration led to serious pulmonary complications or death. In addition, evidence showed that gastric pH values and volumes actually were higher with an extended period of NPO status than with adherence to the ASA guidelines. 1 Despite evidence-based guidelines, the standard order “NPO after midnight” remains in effect. These practice guidelines were updated in 2011 for elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. 2 The current recommendation is 8 hours of fasting for fried or fatty foods, 6 hours for nonhuman milk or a light
318
JOURNAL OF EMERGENCY NURSING
meal, and 2 hours for clear liquids. Examples of clear liquids include but are not limited to water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. These liquids should not include alcohol. 2 Patients preparing for cardiac testing should not ingest caffeine from 12 to 24 hours prior to their procedure. 6 The recommendations suggest a history, examination, and interview that should include pertinent assessment of gastroesophageal reflux disease, dysphagia symptoms, or other gastrointestinal motility disorders, along with the potential for difficult airway management and metabolic disorders (eg, diabetes mellitus) that may increase the risk of regurgitation and pulmonary aspiration. 1,2 A carbohydrate-rich beverage given before anesthesia and surgery alters the metabolism from the overnight fasted state to the fed state, thus reducing the catabolic response (insulin resistance) after surgery, which may have implications for postoperative recovery. 7 These guidelines have been in existence for more than a decade, yet providers are still using the blanket statement “NPO after midnight” without regard to individual patient history, daily routines and meal times, the specific procedure, or the time of the scheduled procedure. This project was undertaken to improve patient safety and satisfaction by bringing the extended NPO practice used in our adult emergency department more in line with the ASA NPO guidelines. Method
Use of the Standard Rollout Process 8 is a requirement for proposed changes in the adult emergency department (Figure 1). New initiatives are identified, clearly written, and prioritized into a strategic plan. A start date for the initiation of the rollout is established. The rollout process includes (1) identification of stakeholders, (2) meeting with stakeholders, (3) performing a good/average/poor (GAP) and strengths/weaknesses/opportunities/threats (SWOT) analysis, (4) developing an action plan, (5) communicating that plan, (6) identifying metrics to evaluate change, and (7) implementing the action plan. The rollout process also includes a debriefing and allows for necessary adjustments to the action plan. 8 To ascertain that a problem existed, a 10-question survey was developed for the nursing staff (Figure 2). This survey of the nursing staff demonstrated both staff and patient dissatisfaction with the practice; 67.5% of the 39 nurses surveyed reported frustration with keeping patients on NPO status for no definite purpose/procedure, 73.2% reported that their patients complained of hunger, and 80.5% reported that their patients complained of thirst.
VOLUME 41 • ISSUE 4
July 2015
Denton/PRACTICE IMPROVEMENT
FIGURE 1 Standard rollout process. GAP, Good/average/poor; NPO, nothing by mouth; SWOT, strengths/weaknesses/opportunities/threats.
Physician buy-in was critical to successfully change this practice in the emergency department. The medical director of the adult emergency department and the ED cardiologist were identified as critical stakeholders. After being presented with the patient and staff satisfaction survey results and supporting literature, the ED medical director and the ED cardiologist gave their full support to the implementation of the ASA guidelines in the department. With their assistance and insistence, the physician order sets for the emergency department and the ED chest pain unit admission orders were modified to reflect the ASA fasting recommendations. The ED orders stated that “Nurses are to ask physician for a diet order after testing is complete.” The ED chest pain unit
July 2015
VOLUME 41 • ISSUE 4
admission orders specify that patients can have a light meal until 2 AM and clear liquids until 6 AM. The start date for the new order sets was October 1, 2010. The GAP and SWOT analyses identified that culture or “habit” was the main threat to this practice change. An additional threat was the potential increase in food and beverages required from nutrition services. The GAP analysis laid out the steps necessary to achieve a successful practice change. The action plan, with accountabilities and timelines, was developed from the GAP analysis. A communication plan was developed that included written and face-to-face communication about the change in NPO guidelines in the adult emergency department. In
WWW.JENONLINE.ORG
319
PRACTICE IMPROVEMENT/Denton
FIGURE 2 Survey. Nothing by mouth (NPO) practice in the adult ED RN survey.
accordance with the Standard Rollout Process, the proposed change was communicated in 7 ways over at least 7 days. Throughout September 2010, the adult ED staff was educated on the NPO initiative through presentations in staff meetings, the Unit Board meeting, and change of shift reports. Flyers were posted throughout the unit, informational e-mail messages were sent to nursing staff through the nurse educator, and informational e-mail messages were sent to the medical staff through the medical director. Metrics selected to evaluate the NPO status change included patient satisfaction and adverse events related to the practice change. In June 2010, 2 questions were added to the patient satisfaction survey used throughout the organization (provided by Professional Research Consultants, Inc [PRC], Omaha, NE). The questions added were: (1) “During this emergency room visit, did doctors, nurses, or staff limit what (you/your family member) could eat or drink?” and (2) “And would you say (you/your family member) experienced ‘A Lot of Discomfort,’ ‘Some Discomfort,’ or ‘No Discomfort’ due to hunger or thirst?” Follow-up with the medical director and cardiologist was performed at regular intervals to monitor for adverse events related to NPO status, specifically, the incidence of pulmonary aspiration and delays in performing a procedure. Four months after implementation, the nursing staff was surveyed again about nurse and patient satisfaction with NPO guidelines.
Results
On October 1, 2010, the ASA preoperative guidelines were implemented in the adult emergency department after 7
320
JOURNAL OF EMERGENCY NURSING
days of information delivery as per the Standard Rollout Process, after the change in the physician order sets, and after individual staff education on the initiative. For the month prior to the implementation of the staff education on the revised NPO guidelines (August 2010), of 201 respondents to the PRC survey, 34.8% of patients reported that limits were placed on what they could eat or drink, and 41.3% of those patients surveyed reported “some” or “a lot” of discomfort with thirst or hunger. Patient satisfaction data were examined for 15 months after the implementation of the revised NPO standards. The data regarding the perceptions of NPO practice by patients showed little change. In July 2011, 41.5% of those surveyed (200) reported limits placed on what they could eat or drink, and 44% reported “some” or “a lot” of discomfort with thirst or hunger. Follow-up conversations with the ED medical director and cardiologist were conducted in November 2010 and May 2011 and are repeated every 6 months. Both physicians confirmed that there had been no reported adverse outcomes or delays for ED or cardiology procedures since implementation of the revised guidelines. At 4 months after implementation, a repeat survey of the RN perceptions of the NPO practice was conducted. The response from 19 nurses revealed a decrease in nursing frustration. Nurses reported that their patients had a decrease in hunger and thirst complaints. They also reported a decrease in difficulty with glucose control. Withholding of routine medications was reported to have decreased. Nurses reported a decrease in workload associated with being able to feed patients, but an increase in workload associated with being able to give patients clear liquids. There was a reported
VOLUME 41 • ISSUE 4
July 2015
Denton/PRACTICE IMPROVEMENT
decrease in the likelihood of asking for diet orders. This finding may be due to the fact that diet parameters are now included in the physician order sets. After implementation, night shift staff reported patient satisfaction with being able to sleep without feeling hungry or thirsty, and the day shift staff reported the absence of patient complaints of hunger and thirst when they began their shift, all of which contributed to increased staff satisfaction. However, in 2012 it was noted that the practice of withholding solids and liquids from patients after midnight, despite the written orders to the contrary, was resurging. In the 2 years since the implementation of the NPO practice change, there had been a greater than 50% turnover in nursing staff. The results of an informal verbal staff survey revealed a lack of knowledge regarding the ASA NPO guidelines. To remedy this deficit, the NPO information was added to the required annual competency review and comprehension was evaluated with a test question. This same information is presented to all new nursing staff during their orientation to the adult emergency department.
Implications for Practice
The ASA guidelines have been in existence for more than a decade. They are evidence based. The role of the nurse is to advocate for the patient. Nurses need to be proactive in determining the timing of procedures and asking physicians to give diet orders that are in accordance with the ASA guidelines. Physicians need to be accountable for writing orders that are evidence based and not antiquated theories based on anecdotal reports. Patients need to be sent to procedures in the best psychological and physiological states possible.
Conclusion
Implementing a practice change in a clinical setting requires clear identification of the problem, stakeholder buy-in, a comprehensive communication plan, and continued monitoring to sustain the practice change. Using the Standard Rollout Process, the NPO practice in the adult emergency department was changed. This change resulted in increased nursing staff satisfaction, decreased patient complaints of hunger and thirst, and no adverse events related to pulmonary aspiration or delay in procedures due to feeding patients according to the guidelines. Patients received their routine medications and had improved glucose control and hydration. The lack of improvement in patient responses to hunger and thirst on the standard PRC survey may be due to a negative impression of any withholding of food or drink at any time or for any duration during their visit.
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There were limitations to data collection for this project. Only a small sample of nurses participated in the survey, although 50% did respond. A larger number of responding nurses and a longer duration of preimplementation data may have strengthened the design of the project. The use of an investigator-developed survey for nursing staff is a limitation as well; however, no validated tools exist to capture this information. The Standard Rollout Process works. It is an effective tool in the dissemination of information to a large staff with diverse schedules and job descriptions. There is continued pushback from consulting and admitting physicians who continue to place the order “NPO after midnight.” The change has given the nurses an evidence-based standard to use as reference, and our ED attending/faculty physicians support nurses in challenging those physician orders. Sustaining practice change can be challenging. Preventing the drift back to the old practice of “NPO after midnight” requires vigilance in monitoring the practice and having strategies in place to orient new staff and reorient the existing staff. Monitoring staff education, compliance, and inclusion of the ASA guideline in orientation, as well as annual competencies, may improve the sustained use of this evidence-based practice. Acknowledgments I thank Nancy Wells, DNSc, RN, FAAN, for her assistance with this article. Karin League, MSN, RN, and Brent Lemonds, MS, RN, EMT-P for their permission to include the Standard Rollout Process.
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8. League K, Lemonds B. The standard rollout process, Nashville, TN: Vanderbilt Medical Center; 2009.
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