Identify Stakeholders
Patients
Eliminating Needless NPO in the ED
Standard Rollout Process
Department Standard Rollout
Process
Families
ED Staff
ED Facility
ED Leadership Team
Nutrition Services
By September
15, 2010
Perform GAP
Analysis
(see next page)
Perform SWOT
Analysis
(see next page)
By October 1, 2010, The ASA (American Society of Anesthesiologists)
preoperative fasting guidelines will be implemented for Adult Emergency
Department patients. Guidelines suggest that healthy, non-pregnant
patients should fast six hours from solids and two hours from liquids.
Patient characteristics
Project initiated
with State of
Nursing Address
and ED Presentation
by Brent Lemonds
May 2010
MUST HAVES
( x ) Incorporate evidenced based practice
( x ) Flow chart process
( x ) Identify metrics for evaluation
(x ) Identify who needs education on initiative
(x ) Assign Accountability and clear timeline
(x ) Develop plan for sustained success
( x ) Identify Methods for content delivery (Figure 1)
(x ) Consider Change Theory for implementation
Develop
Action Plan
Debrief
Communicate
Plan
Implement
Action Plan
2/5/2016 Page 1
Changes
Need to
Be
made?
Adjust
Action
Plan
(Figure 1)
MUST PICK AT LEAST 7
WAYS TO DELIVER
INFORMATION FOR AT
LEAST 7 DAYS
( ) Webinservice
(x ) Leader rounding on
initiative
( x ) Post metrics and
measurements
(x ) Change of Shift Report
( ) Formal inservice to staff
(x ) E-Mail to Staff
(x ) E-Mail to Physicians
( ) Add to Initial Competencies
( ) Add to Annual
Competencies
( x ) Cover in Staff Meetings
(x ) Cover in Unit Board
Meeting
(x ) Send out in Friday
Communication from Manager
x) Post flyers on initiative on
unit
( ) Recruit unit champions /
superusers from staff to
promote initiative
( ) Show video of role playing
best practice
©2009 Karin League & Brent Lemonds
Vanderbilt Medical Center
GAP ANALYSIS
Directions: Consider organizations mission, vision, strategy,
and objectives.
CURRENT STATE
GAP
FUTURE STATE
Pt is placed on
NPO status upon
admission to ED
and held without
fluids or solids
until after
procedures and
results.
Lack of education
regarding ASA
Guidelines
Procedure times
are identified and
patients given
solids up to six
hours prior to
procedure and
clear liquids up
until two hours
prior to procedure.
Patients placed on
extended NPO
status are
uncomfortable,
thirsty, hungry,
dehydrated, have
compromised
acid/base balance,
interrupted routine
medication
schedule and poor
glucose control.
Lack of education
regarding ASA
Guidelines
Patients have
increased comfort
levels, are
hydrated prior to
procedures, able to
receive routine
medications and
have better
glucose control.
2/5/2016 Page 2
2/5/2016 Page 3
STRENGTHS
Increases patient satisfaction
Increases family satisfaction
Increases staff satisfaction
Evidence Based Practice
WEAKNESSES
Long held perception that
keeping patients NPO
preoperatively for extended
periods is essential to
prevent aspiration. There is
no evidence to support this
theory.
OPPORTUNITIES
THREATS
This project addresses the
Physicians not willing to
Innovation Pillar
change
Applies evidence based
Nursing staff not willing to
practice in the clinical setting change
Educates staff regarding ASA Increased nutrition cost to
guidelines
department
Keeps patients homeostatic
and better prepared for
procedures
Multi-disciplinary
2/5/2016 Page 4
Must Haves
Incorporate evidence based practice
Anderson, M, Comrie R. (2009, July). Adopting preoperative fasting guidelines. AORN, 90(1):
73-80
Brady M., Kinn S., Stuart P, (2004, April). Preoperative fasting for adults to prevent perioperative
complications. Evidence Based Nursing, 7(2) :44.
Brewer JP, Bosse G, Seifert S, Prochnow L, Martin J, Schleppers A., Geldner G, Soreide E, Spies C. (2009,
September). Pre-operative fasting: a nationwide survey of German anaesthesia departments. Acta
Anaesthesiol Scand. Epub ahead of print.
Cote, Charles J. M.D., (1990, April). NPO after Midnight for Children-A Reappraisal. The Journal of
Anesthesiology. 72 (4) 589-592.
Crenshaw, Jeannette T., Winslow, Elizabeth H., (2002, May). Preoperative Fasting: Old Habits Die
Hard: Research and published guidelines no longer support the routine use of ‘NPO after midnight’, but
the practice persists. American Journal of Nursing. 102(5) 36-44.
Jarvela K, Maaranen P, Sisto T., (2008, July). Pre-operative oral carbohydrate treatment before
coronary bypass surgery . Acta Anaesthesiol Scand. Epub 2008 May 12.
Ljungqvist O, Soreide E., (1990, April). Preoperative fasting. British Journal of Surgery Society Ltd.,
90(4):400-6.
Meisner M., Ernhofer U., Schmidt J., (2008, September). [Liberalisation of preoperative fasting
guidelines: effects on patient comfort and clinical practicability during elective laparoscopic surgery of
the lower abdomen]. Zentralbl Chir. 133(5):479-85. Epub 2008 Oct. 15.
Murphy, Glenn S, Auit, Michael L., Wong, Hak Yui, Szokoi, Joseph W., (2000, February). The effect of
a new NPO policy on operating room utilization. Journal of Clinical Anesthesia. 12(1):48-51.
Maltby, J. Roger, (2006, September). Fasting from midnight – the history behind the dogma. Best
Practice & Research Clinical Anaestesiology. 20(3):363-378.
Scarlett M, Crawford-Sykes A, Nelson M., (2002, December). Preoperative starvation and pulmonary
aspiration. New perspectives and guidelines. West Indian Medical Journal . 51(4):241-5.
2/5/2016 Page 5
Soreide E, Ljungqvist O., (2006, September) Modern preoperative fasting guidelines: a summary of the
present recommendations and remaining questions. Best Pract Res Clin Anaesthesiol. 20(3):483-91.
Spies CD, Breuer JP, Gust R, Wichmann M, Senkal M, Kampa U, Weissauer W. Schleppers A. Soreide E,
Martin E, Kaisers U, Falke KJ, Haas N, Kox WJ, . (2003, November). [Preoperative fasting. An update],
Anaesthesist. 52(11):1039-45.
Stuart PC, (2006, September). The evidence base behind modern fasting guidelines. Best Pract Res
Clin Anaesthesiol. 20 (3):457-69.
Yuill KA, Richardson RA, Davidson HI, Garden OJ, Parks RW. (2005, February). The administration of an
oral carbohydrate-containing fluid prior to a major elective upper-gastrointestinal surgery preserves
skeletal muscle mass postoperatively—a randomized clinical trial. Clinical Nutrition. 24(1):32-7.
2/5/2016 Page 6
Flowchart the Process
ED Prolonged NPO Improvement Project
Monday, June 14, 2010
Procedure is
scheduled
Yes
Give solids until 6
hours prior to
procedure
Give clear liquids
until 2 hours prior
to procedure
Patient able to
take meds
approved before
procedure with a
sip of water.
Better glucose
control, Better
hydration. Better
comfort and
satisfaction
2/5/2016 Page 7
No
Is Time slot
Available
NPO as ordered
Identify metrics for evaluation: PRC data, NPO staff survey
(Before and after implementation), nurse driven patient
outcomes, patient satisfaction, nurse retention rates.
Identify who needs education on initiative:
Patients
Families
staff
leadership team
Nurse champions
Faculty
Residents
Assign accountability and clear timeline:
Action
Person Assigned
Timeline
Status
PRC question formulated
and submitted
Traci Denton RN with help
from Brent
June 2010
complete
Survey Monkey NPO survey
distributed to ED nursing
staff
Traci Denton RN
July 2010
In progress
Evaluate NPO Survey
results
Traci Denton RN
August 1, 2010
Set up meeting with Ian
Jones MD to present plan
Traci Denton RN
July 27,2010
Set up meeting with Dr.
Moran and Dr. Jones to
present plan
Traci Denton RN
August 10, 2010
Present plan in September
Traci Denton RN
September 13, 15
2/5/2016 Page 8
Action
Person Assigned
Timeline
staff meetings
Member of management
and 17
team conducting meetings
Present plan in September
Unit Board meeting
Traci Denton RN
September 28,
2010
Evaluate response to PRC
question
Traci Denton with help
from Gary
October 1, 2010
Place plan in spindle report
x 7 days
Traci Denton RN
September 27October 3, 2010
Send out in Friday
Communication
Janice Sisco RN as
submitted by Traci Denton
RN
September 24,
2010 and October
1. 2010
Communicate to Physicians
via email
Traci Denton RN with
assistance in distribution
September 27,
2010
Post flyers on unit
Traci Denton RN
September 27,
2010
Evaluate response to PRC
question post
implementation
Traci Denton with help
from Gary
November 1, 2010
(and monthly x 6
months)
Repeat NPO survey to
nursing staff and evaluate
post implementation results
Traci Denton RN
November 1, 2010December 1, 2010
2/5/2016 Page 9
Status
Develop plan for sustained success: sustained success will be achieved through
ongoing leader rounding for outcomes, incorporation of education into orientation pathway, at least
yearly education to staff, sharing of outcomes data with staff linking them to the initiative.
Identify Methods of Content Delivery: See figure 1 for summary.
Change Theory:
Stetler Model Theory-
This theory integrates EBP with research.
There are five phases: 1) Preparation
2) Validation
3) Comparative evaluation and decision making
4) Translation and Application
5) Evaluation
http://74.6.239.67/search/cache?ei=UTF-8&p=Stetler+Model+Theory&fr=yfp-t152&u=courseweb.edteched.uottawa.ca/nsg6133/Course_Modules/Module_PDFs/StetlerMarram.pdf&w=stetler+model+theory+theories&d=DwzyEd29TeE2&icp=1&.intl=us&sig=gA
rTsgbpYybXu1qZMKbNfw--
Knowledge Translation
-provides a framework that may be helpful in considering the challenges that clinicians are likely
to face when attempting to implement evidence based practice.
- exchange, synthesis, and ethically sound application of knowledge within a complex system of
interactions among researchers and users to accelerate capture of the benefits of research.
Rogers Diffusion of Innovations-
2/5/2016 Page 10
-Behavioral theory that describes the process the user goes through in the adaptation/rejection
of new ideas, practices, and technology.
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