The impact of discussing preoperative fasting with patients.
Abstract: Patients awaiting surgery are often fasted preoperatively well in excess of the recommended fasting times. Educated perioperative practitioners were asked to discuss preoperative starvation with patients. Preoperative starvation period for clear fluids was significantly reduced from a mean of 8 hours 30 minutes in the original audit, to 6 hours 10 minutes in this study of 113 patients (p < 0.001). Improving patient understanding of preoperative fasting can increase compliance with fasting recommendations.

KEYWORDS Preoperative / Starvation / Surgery
Subject: Preoperative care (Analysis)
Preoperative care (Methods)
Medical personnel (Practice)
Authors: Khoyratty, Saleem
Din, A.H.
Spendlove, Rachel
Teehan, Melissa
Arhi, Chanpreet
Modi, Bhavik N.
Brown, Katherine
Twigley, Alison
Ravichandran, D.
Pub Date: 08/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: August, 2011 Source Volume: 21 Source Issue: 8
Topic: Event Code: 200 Management dynamics
Product: Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 272168035
Full Text: Introduction

Elective adult surgery under general anaesthesia (GA) requires preoperative fasting to reduce the risk of aspiration pneumonia. Current recommendations are that healthy adults must fast for a minimum of six hours for food and two hours for clear fluids (ASA 1999, AAGBI 2001, RCN 2005) but a number of studies have shown that patients are fasting well in excess of these times (Pearse & Rajakulendran 2000, Maltby 2006).

Whilst the minimum fasting times are necessary for the safety of patients, excessive fasting is associated with increased postoperative nausea and vomiting (Adanir et al 2008), increased insulin resistance (Nygren 2006), and decreased patient satisfaction perioperatively (Bop et al 2009).

We have previously conducted an audit of 200 elective general surgery patients in a busy district general hospital (DGH) on the length of preoperative fasting and confirmed that patients were fasting for much longer than necessary (Khoyratty et al 2010). The second part of the audit presented here focuses on the impact of improved communication with patients regarding preoperative fasting times.

Methods

Having presented our original audit to the hospital Patient Safety Committee, we received approval to implement our proposed changes; those being improved patient education with regards to preoperative fasting times through written documentation, and verbal explanation given at the pre-assessment clinic. Patients at our DGH undergoing elective surgery attend a pre-assessment clinic performed by surgical house officers or specialist nurses. At this clinic patients have routine observations, swabs, bloods and other appropriate investigations (as per NICE guidelines). It also allows patients the chance to discuss any concerns relating to their surgery.

All surgical house officers and one specialist nurse practitioner who volunteered to participate in the audit were given training on preoperative fasting. This consisted of a 15 minute presentation (given by the lead author) on:

* the importance of appropriate preoperative fasting

* the consequences of over fasting

* ideal fasting start times for operating lists commencing at various times of the day

* the patients that would be excluded

* practicalities involved with disseminating the written information to the patients.

The participants subsequently discussed preoperative fasting with patients during the pre-assessment visit. Patients were encouraged to ask questions and an information leaflet (Figures 1 and 2) was given to reinforce the verbal information and to act as a reminder. Patients were informed that data was being captured with a view to improving preoperative fasting times, and their verbal consent to take this data was given.

All adults attending a pre-assessment clinic for a general surgical procedure under a general anaesthetic were included. Bariatric surgical patients were excluded due to their special fasting requirements. Data was collected five days a week for a three month period. Patients were followed-up on the day of their surgery preoperatively on the admission unit and were asked to confirm when they had started fasting for solid and clear fluids.

Data was analysed by the trust's statistician using SPSS. The Mann-Whitney U test was applied to all data as it was not normally distributed.

Results

One hundred and thirteen patients were included in this audit: 51 were scheduled on a morning operating list, 56 on an afternoon list and 6 on an evening list. The data from the second audit showed a mean preoperative fasting time for solids of 11.62 hours, and for clear fluids of 6.07 hours (see Table 1). These values were 12.35 hours and 8.51 hours respectively in the original audit. The difference was not significant for solids (p = 0.095, MannWhitney U-test) but was significant for fluids (p < 0.001).

Analysis was also performed on the morning list and afternoon list patients (Table 2) separately (but not the evening list patients as numbers were small). With morning patients the mean fasting time for solids (13.32 hours) was not significantly different from the original audit (12.69 hours) (p = 0.28) but the difference was significant for fluids (6.16 hours vs 8.59 hours, p < 0.001). For afternoon patients however, the difference was significant for both solids (10.01 hours vs 11.97 hours p=0.02) and fluids (6.26 hours vs 8.42 hours p<0.001).

Discussion

Appropriate preoperative fasting improves perioperative outcome (Nygren 2006, Adanir et al 2008, Bopp et al 2009). However, patients often fast for longer than required (Pearse & Rajakulendran 2000, Maltby 2006, Khoyratty 2010). Prolonged preoperative starvation can actually be counter-productive as it increases a patient's risk of postoperative nausea and vomiting (Adanir et al 2008), increases insulin resistance (Nygren 2006) and decreases patient satisfaction (Bopp et al 2009). With the current trend of aiming for improved perioperative outcomes, fast-track surgery, more rapid mobilisation and early discharges from hospitals, it is imperative that we educate patients so as to improve outcomes.

The aim of this audit was to determine whether improved communication between healthcare professionals and patients can help to reduce excessive preoperative fasting times. The results show that healthcare professionals can play a vital role in lowering preoperative fasting times, and that this can be effectively achieved at preassessment without incurring any additional costs.

It is very difficult to improve solid intake fasting times for patients on morning lists, as shown by our results. This would require patients to get up in the early hours of the morning to consume food before the commencement of the recommended six hour fast. However, the evidence suggests that patient well-being is more closely related to fasting times for liquids rather than solids (Smith et al 1997, Adanir et al 2008).

We presented the results of our original audit to the anaesthetic department at Luton & Dunstable Hospital, and outlined various proposals to improve preoperative fasting times. These included improving patient education, improving education of nursing staff and junior doctors, making water readily available in the preoperative waiting area and prescribing a glass of water to any in-patients for elective surgery. We decided with the anaesthetic department and the hospital Patient Safety Committee that improving preoperative education would be the most efficient and cost-effective way to improve fasting times. However our results show that there is room for further improvement and implementing some of the other changes we have suggested may bring fasting times closer to the ideals stated.

We have shown that patient education about the benefits of appropriate preoperative fasting can improve fasting times. We recommend that, in hospitals with routine preassessment clinics, staff are trained to provide patients with information about the benefits of avoiding excessive fasting, as well as providing patients with written information. This should improve perioperative outcomes.

No competing interests declared

References

Adanir T, Aksun M, Ozgurbuz U, ALtin F, Sencan A 2008 Does preoperative hydration affect postoperative nausea and vomiting? A randomized controlled trial Journal of Laparoendoscopic & Advanced Surgical Techniques 18 (1) 1-4

American Society of Anesthesiologists 1999 Task Force on Preoperative Fasting. Practice guidelines for preoperative fasting and the use of pharmacological agents to reduce the risk of pulmonary aspiration Anesthesiology 90 896- 956

Association of Anaesthetists of Great Britain and Ireland 2001 Preoperative assessment: the role of the anaesthetist London, AAGBI Available from: www.aagbi.org/sites/default/files/preoperativeass01.p df [Accessed June 2011]

Bopp C, Hofer S, Klein A et al 2009 A liberal preoperative fasting regimen improves patient comfort and satisfaction with anesthesia care in day-stay minor surgery Minerva Anestesiologica Feb 4

Khoyratty S, Modi BN, Ravichandran D 2010 Preoperative starvation in elective general surgery Journal of Perioperative Practice 20 (3) 100-102

Maltby JR 2006 Fasting from midnight - the history behind the dogma. Best practice and research Clinical Anaesthesiology 20 (3) 363-378

Nygren J 2006 The metabolic effects of fasting and surgery. Best practice and research Clinical Anaesthesiology 20 (3) 429-438

Pearse R, Rajakulendran Y 2000 Preoperative fasting and administration of regular medications in adult patients presenting for elective surgery. Has the new evidence changed practice? European Journal of Anaesthesiology 17 (4) 219-220

Royal College of Nursing 2005 Perioperative fasting in adults and children. Practice guideline London, RCN Available from: www.rcn.org.uk/publications/pdf/guidelines/Periopera- tiveFastingAdultsandChildren-002779.pdf [Accessed June 2011]

Smith AF, Vallance H, Slater RM 1997 Shorter preoperative fluid fasts reduce postoperative emesis British Medical Journal 314 (7092) 1486

Correspondence address: D Ravichandra, Consultant Surgeon, Luton & Dunstable Hospital, Lewsey Road, Luton, LU4 0DZ.

Email: ravi_surgery@hotmail.com

About the authors

Saleem Khoyratty MA, MB BS

CT1, St Richard's Hospital Chichester

Asmat Din MA, MB BS

CT1, Surgery, Addenbrookes Hospital, Cambridge

Rachel Spendlove BA, MBChB

GPVTS ST1, Watford General Hospital, Watford

Melissa Teehan BSc, MB BS

GPVTS ST1, Field House Medical Group, Grimsby

Chanpreet Arhi BSc, MB BS, MRCS

Surgical SHO, Conquest Hospital, Hastings

Bhavik N Modi MA, MB BS, MRCP

ST1, Hammersmith Hospital, London

Katherine Brown FRCS

Consultant, Luton and Dunstable Hospital NHS Trust, Luton

Alison Twigley MBBS, FRCA

Consultant Anaesthetist, Luton and Dunstable Hospital NHS Trust, Luton

Duraisamy Ravichandran FRCS, PhD

Consultant General Surgeon, Luton and Dunstable Hospital NHS Trust, Luton
Table 1--Overall audit results

                  Initial      Re-audit   Reduction
               audit (hours)   (hours)     (hours)
Solids             12.35        11.62        0.67
Clear fluids       8.51          6.07        2.44 *
                                           p <0.001

Level of significance p = <0.005

Table 2 Breakdown of results between morning and afternoon lists

                         Initial    Re-audit   Change
                         autdit     (hours)    (hours)
                         (hours)
Morning--Solid           12.69      13.32      +0.63
Morning--Clear fluid      8.59       6.16      -2.43 * p < 0.001
Afternoon--Solid         11.97      10.01      -1.96 * p = 0.02
Afternoon--Clear fluid    8.42       6.26      -2.16 * p < 0.001

Level of significance p = <0.005
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