‘Think Drink’ approach to minimize unnecessary preoperative fasting: 18 years audit experience
Article information
Abstract
Background
Fasting guidelines have long recommended that patients can have clear fluids until 2 h prior to surgery. Multiple audits in our institution showed that patients had prolonged fluid fasting duration, despite being given preoperative instructions. This paper presents the results of audits in our institution relating to fasting since 2004 and the outcome of interventions undertaken.
Methods
Audits conducted in 2004, 2008, 2018, 2021, and 2022 were reviewed, with a focus on fasting duration for clear fluids. Interventions that led to significant improvements were identified.
Results
The median fasting duration for clear fluids was 8 h, 8 h 42 min, and 7 h 42 min in 2004, 2008, and January 2018, respectively. The approach of giving patients a ‘welcome drink’ of water and allowing sips of water up to the time of being called upon to the theater was introduced in 2018 (Think Drink). This resulted in dramatic reduction of fasting duration to 2 h 15 min. However, repeat audit in 2021 showed slippage requiring additional interventions in the form of staff education for newcomers and reinforcement at staff huddles that reduced the fasting duration down to 2 h. There were no instances of aspiration or regurgitation after the introduction of Think Drink.
Conclusions
Allowing sips of water until being called to the theater with a Think Drink approach successfully reduced unnecessary fasting by patients. Staff and patient education were also required to sustain success. Fasting duration should be considered a ‘Quality of Service Indicator’ and periodic audit should be mandated.
Introduction
Preoperative fasting guidelines recommend that patients can drink clear fluids up to 2 h prior to surgery [1,2]. Clear fluids include water, fruit juices without pulp, clear tea, and black coffee. The Sprint National Anesthesia Project (SNAP-1) demonstrated that thirst in the perioperative period is one of the most common adverse sequelae of anesthesia reported by patients [3]. Incidence of headache and nausea is reduced when permitted to drink water until 2 h preoperatively [4] and National Institute for Health and Care Excellence (NICE) guidelines recommend doing so [2]. The recommended two-hour time limit for clear fluids has been in place for 25 years [5,6]. Translation of internationally advocated best practice in preoperative fasting to the clinical environment has been poor, and patients continue to fast for far longer than necessary. A study in 2018 showed that even with targeted approaches such as patient education and improved communication, the mean fasting time for fluids only came down to 5 h, with a range of up to 10 h [7].
The story was similar in our institution until very recently. The recognition of the need to reduce unnecessary fasting by patients was never in doubt, as evidenced by the trail of audits carried out over the years. This paper presents the results of the different audits looking at fasting duration in our institution over a period of 18 years, interventions undertaken, and their effects. The factors that influenced success were identified and addressed.
Materials and Methods
Audits conducted in our institution in relation to fluid fasting duration for adult surgical patients in 2004, 2008, 2018, 2021, and 2022 were reviewed. Our institution – Sandwell and West Birmingham NHS Trust – includes two district general hospitals: Birmingham City Hospital and Sandwell General Hospital. These serve an ethnically diverse and largely economically deprived population. Excluding the four Ophthalmic theaters situated in a separate block, there are a total of 20 operating theaters undertaking a variety of surgical procedures under various surgical specialties. Specialties such as Cardiothoracic surgery, Transplant, and Neurosurgery are not available. More than 30 000 surgical procedures are performed annually in our operating theaters. The audits had excluded patients undergoing emergency procedures and those under local anesthesia. As the majority of ophthalmic procedures were carried out under local anesthesia, these patients were also excluded. Patients with co-existing conditions such as diabetes and end-stage renal disease were included. Patients who were on an ‘Enhanced Recovery Pathway,’ that included a carbohydrate drink provided by the hospital, were included and were instructed to finish the drink 1 h prior to arrival at the hospital.
Our institution developed a central system of registering all audit projects from 2016 onwards. Any audit proposal had to be approved by the audit wing of the institutional Governance Department. The proposal had to outline the audit plan, specialty and staff involved, audit objectives, standards against which comparison was being made, methodology of data collection, and estimated completion date. If approved, the audit was given a unique audit number. Once the audit task was completed, the findings and recommendations were to be submitted to be recorded and stored centrally. The findings were expected to be presented at the specialty meeting.
The completed audits were looked into for available ‘patient information’ at the time the audit had been conducted, results relating to fluid fasting duration, and recommendations made. Where specific recommendations relating to patients and staff were implemented, these were included under ‘patient and staff information’ in the next audit. Median and average fasting duration are reported to minimize the effect of outliers. Patient and staff surveys were undertaken as part of the 2021 and 2022 audits in order to identify barriers to implementation and to identify improvements for the subsequent cycle.
Results
A total of six audit projects were conducted between 2004 and 2022. The main findings are summarized in Table 1.
Results of Audit Over the Years Showing Fasting Duration for Clear Fluids and Interventions
October 2004 – No institutional audit registration system existed.
• Patient information: Written fasting instructions mentioned fasting guidance of 3 h for clear fluids prior to arrival at the hospital.
• Audit results: Patients were asked to complete a questionnaire relating to fasting. Responses from 64 patients were received, but 11 were excluded due to incomplete or absent information. The median fasting time was 8 h for clear fluids. About 35% of the patients had fasted for more than 12 h.
• Recommendations: To remind ward nursing and medical staff about the guidelines and re-audit.
November 2008 – No institutional audit registration system existed.
• Patient information: Written fasting instructions to patients specified that they could drink water up to 2 h prior to arrival at the hospital.
• Audit results: Patients were asked to complete a questionnaire relating to fasting. Responses from 62 patients were received, but two were excluded due to incomplete information. More than 95% of patients fasted 4 h or more from clear fluids with a median duration of 8 h 42 min. Twenty-nine percent of patients fasted more than 12 h from clear fluids. Two of the three fasting patients with diabetes were given intravenous fluid infusions. Despite letters specifying the fasting intervals being sent to every patient, 15% of patients mentioned that they had not received information about fasting duration. About 60% chose to fast more than 12 h despite the information. The duration of unnecessary fasting was longer when compared to 2004.
• Recommendations: To remind ward nursing and medical staff to advise patients on when to have their last meal and drink, to think about intravenous fluids in emergency patients who have been fasting >12 h, and for re-audit to include a patient survey about their experience of fasting.
January 2018 – Audit registration number 477.
• Patient information: Written fasting instructions to patients specified that they could drink water up to 2 h prior to arrival.
• Audit results: The auditor individually spoke to the 78 patients to ask about the fasting duration. The average fasting duration for clear fluids was 7 h 42 min, with the longest being 20 h. Seventy-five percent of the patients had a clear fluid fasting duration of more than 4 h, with one in six patients fasting more than 12 h.
• Recommendations: It was recommended that the hospital fasting guideline be revised to allow water up to being called for surgery.
In light of findings from the 2004, 2008 and 2018 audits, the hospital guideline on preoperative fasting was revised after a consensus view in the department. It was recommended that patients be offered a ‘welcome drink’ of water on arrival (for day surgery patients) and be allowed to take sips of water until they were called for surgery. P atients undergoing day surgery arrived at 0730 h for morning theater lists and at 12 noon for afternoon theater lists. The project was called ‘THINK DRINK’ and was implemented in May 2018. Patients had access to water at their bedside. The only exceptions were patients with intestinal obstruction and those who could not take fluids orally. Posters were displayed in relevant areas and the staff were encouraged to report all instances of perioperative regurgitation or aspiration.
October 2018 – Audit registration number 731.
• Patient and staff information: Written fasting instructions to patients specified that they could drink water up to 2 h prior to arrival. A ‘welcome drink’ of water (typically 150 ml but with no specified limit) was offered to all patients on arrival, along with an explanation from the nursing staff that unlimited sips of water were permitted up till being called to the theater. Think Drink Posters (Figs. 1–3) were displayed on nursing desks, in anesthesia rooms, staff coffee rooms, and in the patient bays. These further reinforced the fasting guidelines using the 0-2-6 approach (Figs. 1 and 2).
Think Drink guideline poster outlining adult fluid fasting guidance.
Think Drink guideline poster outlining pediatric fluid fasting guidance.
Think Drink poster displayed in the patient and staff areas.
• Audit results: The auditor individually spoke to 45 patients to ask about the fasting duration. This conversation happened in the recovery room once the patients were awake and prior to transfer to the ward environment. The median fasting time for clear fluids was 2 h with an average of 2 h 15 min. The shortest interval was 45 min, and the longest interval was 5 h. This audit confirmed the success of Think Drink. There were no reported instances of regurgitation or aspiration.
• Recommendations: Re-audit in about three years’ time.
November 2021 – Audit registration number 1803a.
• Patient and staff information: Written fasting instructions to patients specified that they could drink water up to 2 h prior to arrival. A ‘welcome drink’ of water (typically 150 ml but with no specified limit) was to be provided to the patients on arrival, giving the opportunity for the staff to explain that unlimited sips of water are permitted until being called to the theater. All patients had water supplied by the hospital. THINK DRINK Posters (Figs. 1–3) were displayed on nursing desks, in anesthesia rooms, staff coffee rooms, and in the patient bays. These further reinforced the fasting guidelines using the 0-2-6 approach (Figs. 1 & 2).
• Audit results: The auditor individually spoke to 99 patients in the recovery room to ask about fasting duration. The median fasting time for clear fluids was 3 h with an average of 4 h 30 min. The shortest fasting duration was 20 min and the longest fasting duration was 19 h. Seventy percent of patients were aware of Think Drink. There were no reported instances of regurgitation or aspiration.
• Recommendations: Template changes to the wording in pre-surgery letters to remove the two-hour clear fluid fasting guidance. Think Drink reinforcement and education sessions for the nursing staff at the morning huddle.
January 2022 – Audit registration number 1803b.
• Patient and staff information: Written fasting instructions to patients specified that they could have water to drink, with no time limit for water being stated. A ‘welcome drink’ of water (typically 150 ml but with no specified limit) was to be provided to the patients on arrival, giving the opportunity for the staff to explain that unlimited sips of water are permitted until being called to the theater. All patients were to have preoperative water supplied by the hospital by the bedside. Think Drink Posters (Figs. 1–3) were displayed on nursing desks, in anesthesia rooms, staff coffee rooms, and in the patient bays. These further reinforced the fasting guidelines using the 0-2-6 approach (Figs. 1 and 2). Additionally, the morning nursing huddle was used to emphasize and educate on Think Drink.
• Audit results: The auditor individually spoke to 153 patients in the recovery room to ask about the fasting duration. Median fasting duration for clear fluids was 2 h with an average of 3 h 48 min. Eighteen percent had fasted from clear fluids for more than 6 h. The shortest fasting duration was 0 min, and the longest fasting duration was 20 h. About 68% of the patients were aware of ‘Think Drink.’ Sixty-five percent of the patients had been offered the ‘welcome drink’ and 81% had access to water. Among the 43 staff members surveyed, the majority said that they were aware of Think Drink (83%), did not face any issues in implementing it (91%), and rated it an average of 9.2/10 when asked how beneficial the project was for patients. There were no reported instances of regurgitation or aspiration.
• Recommendations: Periodic audits and continuing staff education to sustain improved fluid fasting times.
Discussion
In patients deemed to be not adequately fasted, it is understandable that the medical and nursing staff are worried about the risk of aspiration, including in patients with conditions such as diabetes, end-stage renal disease, obesity, hiatus hernia, gastro-esophageal reflux, and opioid administration. However, it has been shown that pre-existing conditions are not an independent risk factor for aspiration [8]. The degree of gastric emptying after ingestion of fluids depends upon its caloric content, and ingested water has a half-life of about 15 min in the stomach [9]. In hospitals where patients were allowed to drink water less than 2 h before surgery, there was no increase in the incidence of complications [10].
The continuing prolonged fasting duration noted in the audit of January 2018 highlighted the fact that lack of information to patients or staff was not the primary cause. Letters to patients clearly mentioned the allowable time frames, and the majority of the staff were aware of the guidelines. It was felt that the nursing staff found it challenging to monitor the two-hour time frame due to unpredictable theater schedules and their other commitments. While the start time for surgery is generally predictable for the first patient on the list, or even the second, if the first procedure is expected to be brief, several factors complicate this predictability. These include changes in the order of the list, unforeseen delays in procedure duration, and the uncertainty surrounding patients scheduled later in the session. This led the nursing staff to err on the side of not offering clear fluids even if there was sufficient available time [11]. Considering the above factors, it was deemed that a strategy to allow water without a time limit would be more likely to succeed in reducing fasting duration without compromising patient safety. Hence the Think Drink approach was introduced, allowing sips of water up until being taken to the theater. This removed the need for the nursing staff to worry about the exact timing of water ingestion. Since the introduction of Think Drink, the need for intravenous fluids preoperatively is now restricted to patients who cannot have oral intake (e.g., bowel obstruction).
The audit in 2008 showed that the fasting duration remained high and had worsened compared to the 2004 audit. Despite this, there was a gap of 10 years before it was looked at again. It is unclear why the audit cycle was not completed, especially as fluid fasting times had increased. It is possible that lack of a mandated time frame for re-audit and not having fasting times as a ‘Quality of Service Indicator’ played a part. Currently, the audits done in our institution are based on perceived areas of deficiency. While the organization routinely monitors issues such as the incidence of procedure cancellations, theater utilization, and medicine expenditure, indicators of patient experience such as pain, vomiting, and fasting are only reviewed on an ad hoc basis. The Royal College of Anesthetists has published an Audit Compendium that lists suggestions for more than 100 audit projects in Anesthesia [12] that includes preoperative fasting. The compendium recommends ‘continuation of survey practice over time to ensure that standards do not slip and to demonstrate the effectiveness of intervention.’ However, it does not specify a recommended time interval for periodic audits. The Royal College of Anesthetists have initiated a program: The Anesthesia Clinical Services Accreditation (ACSA) that aims to engage anesthesia departments in quality improvement through peer review [13]. Participating departments benchmark their performance against a set of standards. The document mentions the need for a policy relating to the preoperative preparation of patients, including fasting. Such a policy has existed in our institution since 2000. It highlighted the recommended fasting duration from national guidelines but did not specify the frequency for these audits. Our study shows that the presence of policy itself does not automatically translate to effective implementation.
Our audit series underscores the challenge of maintaining successful interventions over time, partly due to staff turnover. New staff are likely to arrive from other institutions where the practice is different. To address this, we included Think Drink in the staff induction for all anesthetists. Despite this, we found instances where the locum medical or nursing staff incorrectly instructed patients not to drink water, citing that ‘their surgery could be cancelled and require rescheduling if they had anything to drink.’ This misconception, implying patients were no longer ‘fasted’ if they drank water less than 2 h prior to their procedure, did not reflect our institutional guidelines. Think Drink posters in the staff areas and patient bed spaces helped to reinforce the message that preoperative water intake is safe. We called it the 0-2-6 approach, permitting sips of water up to 0 hr prior to being called to theatre, breast milk up to 4 hr prior to being called and solid foods up to 6 hr prior to being called (Figs. 1 and 2). We introduced Think Drink for adults and pediatric patients.
There was initial anxiety among the staff when Think Drink was introduced in 2018, both regarding potential risk of aspiration and medicolegal implications. To address these concerns, we conducted departmental presentations at meetings to highlight the safety of preoperative water intake, supported by robust evidence from the literature and several examples of similar practices within the UK and abroad. Our institutional fasting guidelines were revised to include the Think Drink approach that was approved by institutional clinical governance committees. There have been no instances of aspiration or regurgitation during the study periods. By ensuring that Think Drink is firmly embedded in the institutional guidelines and providing continuous staff education, we aim to mitigate these concerns further and maintain safe practice.
The audit series also highlights the challenges of implementation. For instance, our 2022 audit showed that only 65% of the patients were offered a ‘welcome drink’ of water. One contributing factor may be that 17% of the staff at that time stated that they were not aware of Think Drink, despite posters being displayed at multiple locations including patient bays, nursing stations, and staff rooms. Informal observations suggested that patients were not happy to rely on posters to inform about their preoperative fluid intake and would decline fluids unless explicitly told by a doctor, nurse, or even their own surgeon that water was permitted. It was also informally noted that many patients rely on their own ‘research,’ often using online resources or advice from relatives and friends that predominantly discourage preoperative fluid intake. As a result, a degree of anxiety persists among patients regarding the perceived risks, leading them to opt out of drinking water preoperatively. This audit series has limitations in that it relies on survey data from a subset of patients. As patients from multiple specialties in different operating theater complexes within the institution were included, it is likely to reflect the broader patient population.
Since the introduction of Think Drink, similar approaches in adults (e.g., Sip till Send) have been introduced in other hospitals in the UK and abroad [14–16]. All these studies have shown improved patient satisfaction and an acceptable safety profile. Although our institution does not include surgical specialties such as thoracic, transplant, or neurosurgery, we believe that the Think Drink approach can be safely extended to the vast majority of these patient groups, given the favorable safety data in the literature. The guideline for the pediatric population was recently revised to reduce the time interval of fasting for clear fluids to 1 h [17]. Whilst this is a positive step forward, it still carries the challenges of monitoring. With emerging evidence about the safety of ingestion of water, it is hoped that the fasting guidelines for adults will be reviewed in the near future.
It took almost 20 years for the fasting duration to be reduced in our institution. A change in approach to address the practical challenges is what led to success. In order to sustain this, regular audit, education, and reinforcement will be necessary. We would suggest that preoperative fasting times be taken as an essential ‘Quality of Service Indicator’ along with others such as postoperative pain, nausea, and vomiting. Institutions should endeavor to conduct periodic audits within a reasonable time frame (e.g., three years) for the above indicators so that patients have good perioperative experience and outcomes.
Acknowledgements
We are grateful to all our colleagues involved in data collection for all the audits since 2004.
Notes
Funding
None.
Conflicts of Interest
No potential conflict of interest relevant to this article was reported.
Data Availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Author Contributions
Katarzyna A. R. MacDougall (Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing – original draft; Writing – review & editing)
Shahnoor E. S. Bushra (Conceptualization; Data curation; Formal analysis; Methodology; Writing – review & editing)
Santhana G. Kannan (Conceptualization; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Supervision; Writing – original draft; Writing – review & editing)