File - MiSuk Robinson Professional Nursing Portfolio

Standardizing Preoperative NPO Guidelines to Improve Patient Safety and Satisfaction
MiSuk Robinson
Ferris State University NURS 440
Preoperative fasting or NPO (nothing per os) has been a standard of care for surgical patients
since the mid 1800s to reduce the risk of vomiting associated with anesthesia (Crenshaw, 2013).
Patients are often given conflicting preoperative instructions from the surgeon, clinic staff, and
surgery personnel. Cases are either delayed or cancelled due to noncompliance with NPO
guidelines resulting in decreased patient satisfaction and increased risk of adverse patient
outcomes. Implementing standardized NPO guidelines according to the American Society of
Anesthesiologists (ASA) will improve patient safety and satisfaction.
Keywords: NPO guidelines, preoperative fasting, preoperative instructions
Standardizing Preoperative NPO Guidelines to Increase Patient Safety and Satisfaction
Preoperative fasting has been a standard of care since the mid 1800s to reduce the risk of
vomiting and aspiration in surgical patients (Crenshaw, 2013). Current practices do not always
follow the ASA (American Society of Anesthesiologists) guidelines for preoperative fasting for
healthy patients scheduled for elective surgeries. Many patients are still being instructed to not
eat or drink after midnight regardless of when their surgery is scheduled the next day. Patients
are often given conflicting instructions between the surgeon, office staff, and surgery personnel.
Friends and family often provide misinformed advice based on personal experiences.
Instructions may vary by procedure, type of anesthesia, and patient’s risk factors. Many patients
do not have a clear understanding of the fasting guidelines, the reasons why it is important to be
compliant, and the risk of adverse safety outcomes when the instructions are not followed.
Standardizing NPO guidelines will increase patient compliance, safety, and satisfaction.
Collaborative Team
Implementation of standardized NPO guidelines must be a collaborative effort. Members
of the team must represent every area that a patient may receive preoperative instructions. The
surgeon and office staff usually provides the initial preoperative instructions. If medical
clearance is required for surgery the patient may need to follow up with their primary care
provider. The patient may also get preoperative instructions from their primary care doctor and
staff. If the surgery center or hospital utilizes a pre-procedure call nurse then the patient will get
preoperative instructions again. The anesthesiologist has the final say in regards to what is
acceptable for NPO status. These guidelines would also impact inpatients being scheduled for
surgery so nurses on the medical-surgical departments should also be involved. Any process
change should include input from Quality and Risk department. Implementing effective change
not only requires educating patients but also healthcare providers.
Team Members
Surgery Chief of Staff / representative
Anesthesiology Chief of Staff / representative
Medical Chief of Staff / representative
Pre-procedure call nurse
Surgery Director / representative
Medical-surgical Director / representative
Primary Care Provider Liaison
Quality and Risk representative
Nursing educator
Data Collection
Design and perform data collection
I would have all members review the current NPO policy for elective surgeries. At our
institution the policy states NPO 8 hours for general anesthesia or sedation and at least 2 hours
for clear liquids. However, most patients are still instructed “Nothing to eat or drink after
midnight” for both inpatient and outpatient cases. I would start with a flow chart diagram. By
charting the entire patient process from primary care providers, referral to all participating
surgeons, scheduling the surgery, pre-procedure call, pre-registration, and arrival to the surgery
department should identify all the areas that a patient may receive preoperative instructions. I
would also include the inpatient process. Next would be to identify what instructions are given
at each step. I would contact each of the primary care providers and participating surgeons’
office for a sample of their preoperative fasting instructions. A short survey of nursing staff
about NPO policy would provide a baseline of staff knowledge. Chart audits would provide
information on average NPO status of surgical patients, how many cases were delayed or
cancelled due to noncompliance of NPO guidelines, and how many cases of aspiration during
anesthesia induction or anytime during the surgery. I would also address why patient’s are still
being instructed to be “NPO after midnight” regardless of surgery time for both inpatient and
outpatient surgeries.
Goal for Improvement
The primary goal would be to increase patient compliance with NPO guidelines. This
would be accomplished by developing standardized instructions that would be given to patients
scheduled for elective surgeries (see Appendix A). Verbal and written instructions should
include what time the surgery is scheduled, when the last time they can eat and drink, what
constitutes clear liquids (give examples), what constitutes a light meal (give examples), and what
medications should be taken the day of surgery.
Strategies for Implementing Change
1. Update and revise NPO policy according to ASA guidelines (see Appendix A).
2. Develop patient education handouts based on the ASA guidelines to be used in the
physician’s office, surgery department, and inpatient units so patients are given the same
3. Provide staff and physician education: provide copies of the revised policy, provide
current research information at staff meetings, and provide patient education handouts.
4. Post laminated NPO guidelines for staff on the medical-surgical units and surgery
Evaluation of Change
1. Increase the number of patients who have been allowed to have clear liquids 2
hours before surgery.
2. Monitor the number of cases that are delayed or cancelled due to noncompliance
with NPO policy.
3. Monitor patient satisfaction surveys.
Support and Analysis
In spite of current research there are three common myths about preoperative fasting:
1. Overnight fasting from all solids and liquids is the best way to reduce the risk of
pulmonary aspiration.
2. Gastric emptying is the same for solids, full liquids, and clear liquids.
3. Ingesting clear liquids up to two hours before surgery increases the risk of vomiting and
aspiration (Crenshaw, 2013).
Vomiting was very common with chloroform anesthesia in the mid 1800s, but British surgeon,
Joseph Lister, published these instructions: “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-broth about 2 hours previously.” (Crenshaw, 2013, p. 39). Statistics from
2002 indicate that the risk of aspiration is only 0.006% (Crenshaw, 2013). Many risks
associated with anesthesia induction have been minimized with newer and safer anesthetic
medications. Recent research has shown that clear liquids actually increases gastric emptying
and decreases the acidity of the gastric secretion if ingested two hours prior to surgery
(Crenshaw, 2013). A randomized control study in 2003 showed no greater risk for vomiting,
aspiration, or increased morbidity when clear liquids were ingested up to 90 minutes prior to
surgery (Crenshaw, 2013). These results were not affected by general anesthesia or sedation nor
the volume of clear liquids ingested.
The average length of preoperative fasting is 11-14 hours if patients are instructed to not
eat or drink after midnight. Prolong fasting increases patient discomfort with feelings of thirst,
hunger, anxiety, drowsiness, or dizziness. Dehydration, insulin resistance, post-op
hyperglycemia, muscle wasting, and decrease immune response may result from prolong fasting
(Crenshaw, 2013). The standard of care in Britain, Ireland, and Scandinavia is to encourage
carbohydrate-rich clear liquids the night before and two hours before surgery (Crenshaw, 2013).
This protocol has shown to decrease insulin resistance, nausea & vomiting, and loss of muscle
strength therefore decreasing hospital length of stay (Crenshaw, 2013).
Noncompliance of the NPO guidelines can be addressed by better patient education.
Implementing the ASA guidelines (see Appendix A) consistently within the healthcare system
will decrease confusion among patients and staff. One study indicated that almost 30% of
patients interviewed believed that NPO meant solid foods only (Kramer, 2000). The three most
common reasons that patients are noncompliant are due to conflicting information, not
understanding the instructions, and not remembering all the details (Kramer, 2000). The health
belief model proposes that people will be more compliant if:
1. People believe that they are at risk if not compliant.
2. People believe they are at risk for serious side effects.
3. People know what to do to avoid risk for serious side effects.
4. Compliance would also reduce the risk of complications (Kramer, 2000).
Detailed preoperative instructions that are consistently reinforced will promote compliance.
Explaining why patients should not eat solid food before surgery, giving examples of what
constitutes clear liquids versus full liquids, and emphasizing patient safety will increase
compliance with the NPO guidelines. Allowing patients to drink clear liquids two hours before
surgery will increase patient comfort without compromising patient safety.
The quality improvement process must also address why healthcare providers still
support “nothing to eat or drink after midnight” in contradiction of the ASA guidelines that have
been published since 1998 (Kramer, 2000). Many surgery departments state that the longer
fasting times are needed to prevent delays and cancellations in the surgery schedule. If patients
are allowed to drink two hours before surgery then they cannot be moved up if an earlier case
cancels. One study showed that the number of cancellations actually decreased by 5% in two
years after implementing detailed patient education for NPO instructions (Mathias, 2011). Many
providers find it easier to provide a generic instruction (nothing to eat or drink after midnight)
instead of taking the time to provide specific instructions.
Patient safety should be the basis for all clinical policies. Current research has shown
that the risk of aspiration is very small to begin with for surgical patients. Standardizing the
NPO instructions according to ASA guidelines would increase patient compliance, patient safety,
and satisfaction. Collaborative education through out the healthcare system is needed to change
long held health beliefs for preoperative fasting. Consistent and detailed NPO instructions for
patients and families will minimize confusion and promote compliance.
American Society of Anesthesiologists (ASA). (2011). 2011 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: An updated report by the
American Society of Anesthesiologists Committee on Standards and Practice Parameters.
Anesthesiology, 114, 495-511.
Crenshaw, J. T. (2013). Preoperative fasting: Will the evidence ever be put into practice?,
American Journal of Nursing, 111(10), 38-43.
Kramer, F. M. (2000). Patient perceptions of the importance of maintaining NPO status.
American Association of Nurse Anesthetists Journal, 68(4), 321-328.
Mathias, J. M. (2011). Why aren’t NPO guidelines being followed?, OR Manager, 27(10, 1-3).
Appendix A: Summary of Fasting and Pharmacologic Recommendations
Summary of Fasting Recommendations
Ingested Material Minimum Fasting Period
Clear liquids 2 h
Breast milk 4 h
Infant formula 6 h
Nonhuman milk 6 h
Light meal 6 h
These recommendations apply to healthy patients who are undergoing elective
procedures. They are not intended for women in labor. Following the Guidelines
does not guarantee complete gastric emptying. The fasting periods noted above
apply to patients of all ages.
Examples of clear liquids include water, fruit juices without pulp, carbonated
beverages, clear tea, and black coffee. Because nonhuman milk is similar to
solids in gastric emptying time, the amount ingested must be considered when
determining an appropriate fasting period.
A light meal typically consists of toast and clear liquids. Meals that include fried
or fatty foods or meat may prolong gastric emptying time. Additional fasting time
(e.g., 8 h or more) may be needed in these cases. Both the amount and type of
food ingested must be considered when determining an appropriate fasting
period (ASA, 2011)