Trauma list fasting times audit – the water sip challenge

Trauma list fasting times audit – the water sip challenge

An audit of trauma list fasting times conducted at Queen Elizabeth Hospital, Woolwich, by Claire Daly and co-workers

For safety reasons, patients should not eat or drink immediately before anaesthesia. This is known to reduce the incidence of regurgitation and pulmonary aspiration of gastric contents [1]. Fluid deprivation can be unpleasant for children, but also for adults [2]. Shortening the fluid fast may lead to less anxiety pre-operatively and less post-operative nausea and vomiting [3], and new guidelines now actively encourage patients to drink two hours prior to anaesthesia [2]. Evidence for this was recently reviewed in a Cochrane meta-analysis, which found there was no increased likelihood that patients who received clear fluids up to two hours prior to anaesthesia were at an increased risk of adverse outcome than those who were fasted for longer. Results showed nearly identical stomach pH and gastric fluid volumes [4].

Due to the often unpredictable nature of the trauma list, it was noticed that many patients were coming to trauma theatre with prolonged fasting times. The patients were often elderly and frail or paediatric cases, in whom prolonged fasting can significantly worsen cardiovascular parameters.

Aims

The main aims of this audit were to compare pre-operative fasting times for trauma surgery patients against AAGBI guidelines, to highlight areas for improvement in clinical practice and attempt to move away from the traditional ‘nil by mouth from midnight’ approach. An additional aim was to improve the efficiency of trauma theatre, encouraging direct and frequent communication between theatre and the ward on timings of surgery, providing early indications of delay and/or cancellations.

AAGBI Fasting Guidelines (2001) [5]

The AAGBI recommends the minimum fasting periods based on the American Society of Anaesthesiologists (ASA, 1999) guidelines:

  • six hours for solid food, infant formula, or other milk
  • four hours for breast milk
  • two hours for clear non-particulate and non-carbonated fluids

Standards

Patients should:

  • be offered food until 2am, and 6am light breakfast if to be operated in afternoon; and
  • be given water until 6am, and if applicable throughout the day until two hours before surgery.

Method

An initial prospective audit was conducted over a three-week period in April 2014. Data were collected by the anaesthetic team using a questionnaire on all patients presenting to theatre on the trauma list. Questions included actual fasting times for food and water; when patients were given information about fasting times; and whether they were receiving IV fluids or felt thirsty. Clear fluids were defined as non-particulate and non-carbonated fluids, or black tea and coffee with no more than one-fifth of milk.

The results of this audit were collated and presented at the local joint anaesthetic/orthopaedic clinical governance day. The main outcome was to implement a 6am drink of water to be prescribed for all trauma patients on the list for that day, and if appropriate for them to receive water up to two hours pre-operatively. Changes were implemented in the form of a poster for wards, and teaching sessions with the surgical ward nurses and orthopaedic juniors.

A re-audit was completed using the same data collection tool over a prospective three-week period in July 2014.

Results

A total of 37 patients were audited in the initial data collection period. The average time fasted for food was 15 hours, and the average time fasted for water was 10 hours. Half (50%) of patients had not had water for 10–20 hours prior to their arrival in theatre. Almost three-quarters (73%) of patients received information as to when they could eat or drink until. Of those, 18 were told ‘midnight’.

A total of 31 patients were audited in the re-audit period. The average time fasted for food showed minimal improvement at 14 hours. The average time fasted for water did show some improvement at 8 hours, but was still markedly over the recommended 2 hours. The results showed more patients than previously were being offered and/or given water at 6am on the day of surgery. Nine patients had water at 6am on the day of surgery and three patients at 10am. Two patients were given water at 6am on the original day of surgery but were cancelled and water was not re-prescribed.

However, the results highlighted that fasting status was not being regularly reviewed throughout the day, which contributed to the prolonged, unnecessary fasting time seen. Also, contrasting messages were still being given to patients regarding fasting times, with only 28% being told food until 2am and water until 6am.

Recommendations

Ongoing education of junior orthopaedic staff and ward nurses at teaching sessions and upgrading of the fasting guidelines posters within surgical wards is required in order to consistently implement the changes so that water is regularly prescribed at 6am on the day of surgery. Regular reviews of the list order throughout the day are also key for reducing fasting times. Once all these changes are implemented there will be another re-audit in six month’s time.

This poster was presented at the SETSA meeting which took place in October. Claire Daly won the poster presentation prize for her audit on trauma list fasting times.

References

  1. Smith A. (2012) Pre-operative fasting in adults. Raising the Standard: a compendium of audit recipes (third edn), Royal College of Anaesthetists
  2. Smith, J., et al. (2011) Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur. J. Anaesthesiol. 28, 556–569
  3. Smith, A.F., Vallance, H. & Slater, R.M. (1997) Shorter preoperative fluid fasts reduce postoperative emesis. Br. Med. J. 314, 1486
  4. Brady, M., Kinn, S. & Stuart, P. (2003) Preoperative fasting for adults to prevent perioperative complications. Cochrane Database of Systematic Reviews. Issue 4. Art No: CD004423
  5. AAGBI (2001) Pre-operative assessment. The role of the anaesthetist. Section 10: Fasting Policies

Authors

Claire Daly is a CT1 (Anaesthetics), Danielle Factor is a consultant anaesthetist, Victoria Buswell is a CT2 (Anaesthetics) and Sandhya Lamichhane is a trauma coordinator. All are based at Queen Elizabeth Hospital, Woolwich, part of the Lewisham and Greenwich NHS Trust. The audit was conducted between April and July 2014.

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