Assignment: Anesthetists Knowledge

PATRICE BARIL, MS, RN, CNOR; HARRIET PORTMAN, BSN, RN, CAPA

Optimal surgical, anesthesia, andnursing outcomes depend onadequate patient preparation. Preoperative fasting is an essential ele- ment of the patient preparation pro- cess. The goal of fasting is to empty the stomach, thereby reducing the risk of aspiration of stomach contents during the anesthetic period.

Before 1999, the traditional, general guideline for preoperative fasting was that patients should be NPO after mid- night on the day of surgery. In 1999, after examining rele’ant research find- iiigs, the American Society of Anesthesi- ologists (ASA) released new, more lenient preoperative fasting guidelines for healthy, nonpregnant patients. The new guidelines called for preoperative fasting from clear fluids for two hours before any procedure that requires seda- tion or anesthesia as well as fasting from solid foods for at least six hours before anesthesia or sedation is administered. The ASA recommends that these guide- lines be modified for any patient with a condition that affects gastric emptying as well as for patients with potential air- way management issues.’

At a community hospital near Boston, Massachusetts, one staff RN in the Pread- mission Testing area became aware that surgical patients at the facility seemed to be fasting for excessive lengths of time, a perception that was echoed by other perioperative nurses on staff. The hospital was beginning its journey toward Magnet status, and hospital administrators were implementing a nursing research and clinical inx’estigation program. At the urging of the director of nursing staff development and nursing research, the staff RN who had originally identified the problem and a clinical nurse special-

ist in the Surgical Services Department decided to conduct a clinical investiga- tion of preoperahve fasting at this facility. The pLirpose of fhis clinical project was to determine whether patients were fasting excessively and, if so, to explore the atti- tudes and beliefs of surgical patients and their care providers to determine why patients still fast excessively despite re- search findings advocating shorter pre- operative fasting periods and updated fasting guidelines from the ASA.

LITERATURE REVIEW

Many anesthesiologists have changed their practice and no longer require the traditional eight-hour fast before elective surgery. In a national survey of 1,337 ASA members, 94% of the respondents were aware of new literature recom- mending shorter fasting periods before elective surgery, and 68% of those had changed their practice.-

ABSTRAQ PREOPERATIVE PATIENT EASTING is an essential element of the patient preparation process, but pa- tients 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 erro- neous perceptions about patient knowledge regard- ing the rationale for fasting and compliance with instructions. Clinicians expressed concern about the effects of excessive fasting but were reluctant to relax the policy. AORN} 86 (October 2007) 609- 617. © AORN, Inc, 2007.

. lnc.2f)07 OCTOBER 2007, VOl 85, NO 4 • AUIÍN lOUkN.-M • 6 0 9

OCTOBER 2007, VOL 86, NO Baril — Portman

One reason for excessive preoperative

patient fasting could be related to a

general mistrust on the part of

practitioners that patients will

understand and comply with their

fasting instructions.

Pandit et aP studied the practices of anesthesi- ologists in the United States and found that 627(1 of participating anesthesiologists had an institu- tional policy in place that allowed patients to ingest clear liquids two to three hours before elective surgery. Thirty-five percent of partici- pants allowed patients to ingest a light breakfast six hovirs before surgery. The researchers deter- mined that the key factors affecting how long patients fast include hospital policy, nurse and anesthesia care provider kiiowledge of current research findings, and patient education regard- ing the length of and rationale for fasting.

Lengthy preoperative fasts have been com- mon. Crenshaw and Winslow^ found that pa- tients fasted for an average of 12 to 14 hours, with some fasting for more than 20 hours. Tra- ditional preoperative fasting instructions (ie, NPO after midnight) were common practice at the time their study was undertaken. Pearse and Rajakulendran’̂ also found excessive fast- ing times in their study. The average fasting time was 12 to 14 hours with an overall range of 4.5 to 20 hours. It appeared that patients were beginning the preoperative fast long before the instructed time.

The literature also revealed several possible reasons for excessive preoperative fasting. One reason is that there seems to be a general mis- trust on the part of practitioners that patients will understand and comply with a fasting policy. One study found that anesthesiologists and surgeons believed that if patients were told that they could ingest clear liquids, they

might also consume solid foods.* Patients’ lack of knowledge regarding the

rationale for preoperative fasting is another factor that may contribute to excessive fasting. Chapman’ found that 85″^ of surgical patients received no explanation for fasting, SI”/» were unaware of the reason for preoperative fasting, and 50% thought the reason for fasting was to reduce vomiting. Only 187« of patients associ- ated vomiting with possible aspiration of gas- tric contents. In addition, Hung’̂ found that surgical patients not only did not know the reason for preoperative fasting, but they also were not comfortable asking their health care providers about it because they did not want to be perceived as demanding.

Another possible reason for lengthy fasting times is concern about rapidly changing surgi- cal schedules. In a study by Green et al,*” anes- thesiologists cited the economic impact of delays and cancellations on the surgical sched- ule as a reason for their reluctance to relax fast- ing guidelines.

An additional factor that contributes to ex- cessive fasting times may be related to health care facilities’ policies on fasting. The absence of a formal fastüig policy or staff members’ inade- quate knowledge of the policy has been found to affect fasting times.”‘” Chapman” interviewed anesthetists, surgical nurses, and patients scheduled for elective surgery regarding their knowledge of recommended preoperative fast- ing guidelines. In the study facility, there was no formal policy for preoperative fasting, and the average fasting time was 11 hours. Half of the anesthetists were aware of current research findings and recommended two- to three-hour liquid fasts; however, participating nurses were unaware of these findings. Chapman attributes the nurses’ knowledge deficit to the fact that at the time her study was performed, most of the published research regarding preoperative fast- ing appeared in medical journals rather than nursing journals.”