Are you writing too many NPO orders?

HOW OFTEN are patients in your hospital kept NPO? If your institution is anything like the academic center where that question was recently studied, the answer is: too often and for too long.

Deanne Kashiwagi, MD, a hospitalist at Mayo Clinic in Rochester, Minn., is lead author of the study, which appeared in the January issue of the Journal of Hospital Medicine. Dr. Kashiwagi and her research colleagues analyzed 1,200 NPO orders written on Mayos general medicine service in 2013.

They broke most of those orders down by indication (imaging study, operation or procedure), and found that the median NPO duration for most patients was 12.7 hours.

“Could we change the practice of NPO after midnight to NPO after 4 a.m. or 6 a.m.?”

~ Deanne Kashiwagi, MD
Mayo Clinic

Almost three-fourths (71.6%) of NPO orders were started at midnight, and half the patients admitted to the general medicine service experienced some period of fasting over their course of hospitalization. Was Dr. Kashiwagi surprised by that high percentage?

“I wasn’t,” she says. “This is one of those interventions that we were trained to do and continue to practice, even though no one has any recollection of why or whether keeping patients NPO that long has any benefit. That’s why we decided to dig into it.” Dr. Kashiwagi spoke with Today’s Hospitalist.

Why is it important to get fasting orders right?
On the one hand, if a patient has eaten within the suggested NPO time frame for a study or procedure, the procedure is going to be cancelled. We’re obviously concerned about length of stay in hospital medicine, and cancellations definitely affect that.

But on the flip side, there’s patient experience. If we keep patients fasting longer than necessary, that can increase their dissatisfaction. It can also put them at risk from a nutritional standpoint, particularly for patients with prolonged hospital stays who are kept NPO multiple times. And there are clearly problems with patients who have diabetes and hypoglycemia.

You write that yours is the first study to analyze NPO orders across multiple interventions. Did you find nothing else in the literature?

We did find clinicians who had looked at their own institutions and had tried QI projects to either decrease the number of patients made NPO or shorten NPO duration. Both of those are great targets.

We also tried to find consistent practice guidelines or research into optimal fasting periods for different interventions and procedures. In much of what we read, NPO orders were characterized as a “just-in-case” practice, particularly for patients admitted after hours who were going to be in the hospital overnight. The thinking seemed to be that, “Just in case these patients need something in the morning, I’ll make them NPO at midnight.”

So if that automatic “after midnight” cutoff leads to patients fasting unnecessarily or for too long, what’s a more reasonable approach?
If you look at the range for most procedures that require NPO status before proceeding, it’s about two to four hours. So even if you assume that all your studies will be done early in the morning, could we change the practice of NPO after midnight to NPO after 4 a.m. or 6 a.m.? That would at least give patients more flexibility to have some nourishment prior to a test or procedure.

In the study, you did break down NPO orders by indication, but you also mentioned a lack of robust evidence on optimal NPO times per indication. How did you determine that range?
We picked up the phone and started calling our colleagues at Mayo in different specialties, including radiology and procedures, to find out what our local NPO practices were.

One big lesson learned from radiology was that patients don’t even need to be NPO for a paracentesis or thoracentesis. That became an opportunity to collaborate with colleagues and determine local practice, then decide how to change. In our case, a colleague ended up having the radiology order screen for those two procedures changed so that patients don’t even have to be NPO. So that was a win

Your study also found that about 20% of NPO orders were for procedures or tests cancelled due to a change in care plan or scheduling barriers. The study noted that cancellations often occurred after a subspecialist or attending weighed in. How do you tackle that high rate?
In a teaching institution, you’ll have to make exceptions for the fact that clinical decisions may change when a more senior person comes in during the morning. So you may need to decide what your tolerance level will be in terms of cancellations. It would certainly help if, instead of making everyone NPO after midnight, you adjust their time fasting.

As for an institutional fix, would it be possible for your GI procedure area to keep one morning slot open for overnight admissions? Fixes like that would help.

So you’d need to try to arrange such slots department by department?
Yes, which is a significant effort. Perhaps that’s why practice has evolved to make everybody NPO after midnight.

Are your surgeons and anesthesiologists on the same page as you in terms of wanting to reduce NPO orders and duration?
They are. And with so many of us in our group doing perioperative care and surgical comanagement, this comes up in our discussion groups of how far ahead of surgery patients need to be made NPO.

Just having done this study has raised everybody’s awareness. We are making many more calls to colleagues to see if a patient needs to be NPO.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.