Back to accessibility links

Fed up: improving nutritional care for emergency and orthopaedic trauma surgery patients

Project Added:
2 August 2016
Last updated:
19 August 2016

Fed up: improving nutritional care for emergency and orthopaedic trauma surgery patients

Summary

This project implemented a new process for measuring and managing preoperative fasting in emergency and orthopaedic trauma patients, with education provided to staff and patients on preoperative fasting best practice.

View a poster from the Centre for Healthcare Redesign graduation, August 2016.

Fed up poster

Aim

To ensure no emergency or orthopaedic trauma surgery patient at Gosford Hospital fasts for longer than 12 hours without review, reducing preoperative fasting to a minimum of six hours without solids and two hours without clear fluids.

Benefits

  • Improves quality of care and clinical outcomes for emergency and orthopaedic trauma patients undergoing surgery.
  • Reduces unnecessary and lengthy episodes of preoperative fasting.
  • Reduces the risk of surgical delays and cancellations.
  • Reduces the risk of complications associated with preoperative fasting, including malnutrition, dehydration, biochemical imbalances and hypoglycaemia.
  • Improves patient satisfaction and reduces the number of complaints about preoperative fasting.
  • Maximises the skills of nursing staff by empowering them with responsibility for preoperative fasting care.
  • Supports the CCLHD organisational strategy ‘Every Patient, Every Time’ and the Agency for Clinical Innovation’s Minimum Standards for the Management of Hip Fractures in the Older Person1.

Background

The Australian and New Zealand College of Anaesthetists (ANZCA) guidelines state that patients undergoing surgery with no risk of aspiration should avoid solid foods for a minimum of six hours before surgery and clear fluids for a minimum of two hours before surgery.2

Extended preoperative fasting, or repeated fasting due to surgery delays or cancellations, is not only distressing for patients and their families, but can increase the risk of malnutrition, dehydration, biochemical imbalances and hypoglycaemia. ANZCA guidelines suggest that fasting from midnight is unnecessary in most cases and that reducing lengthy episodes of preoperative fasting can improve clinical outcomes.

A Quality System Assessment (QSA) review conducted in August 2014 found that many emergency and orthopaedic trauma patients at Gosford Hospital were fasting for up to 12 hours. At the time, the only guideline in place regarding preoperative fasting was that all patients were required to fast from 2am to 6am, regardless of whether there was a confirmed plan for surgery. The QSA identified three areas of preoperative fasting that required attention:

  • 63% of the time, there were no clear guidelines outlining specific minimum and maximum fasting times required, including when fasting was not required
  • 13% of the time, there was no monitoring of compliance with fasting times
  • 69% of the time, staff and patients had access to food and fluids outside normal meal times.

Surveys of 60 nursing staff conducted in March 2016 found that staff were dissatisfied with the preoperative fasting process and expressed the need for clear guidelines in this area.

Patient stories collected in March 2016 showed that patients didn’t understand why they were required to fast for such long periods of time. Fasting for long periods of time made them feel nauseated and irritable, with half of all patients interviewed stating the “lack of communication between staff and patients regarding the plan for surgery was very frustrating and caused them anxiety”. Many patients stated they would be happy with fluids alone if they could not eat and that a better preoperative fasting system was required.

The results from the QSA, staff surveys and patient stories suggested there was an issue with unnecessary and lengthy episodes of preoperative fasting at Gosford Hospital. This was frustrating for staff and negatively impacted the patient journey.

Implementation

  • Nurses were empowered to provide food and fluids to patients, in consultation with their anaesthetist and surgical team, once they had reached 12 hours of fasting with no definite surgery time allocated.
  • Patients were provided with clear fluids on arrival to the emergency department.
  • A clear, documented fasting plan was developed for all emergency and orthopaedic trauma surgery patients. These were added to the patient’s progress notes and stated whether they should be fasted or fed.
  • A process was developed each evening where the surgical team would identify the first four cases to be operated on the next morning, allowing patients with later surgeries to have solid foods or clear fluids at appropriate times.
  • An education program for patients and carers outlining the reasons for preoperative fasting will be developed in collaboration with the Nutrition Department, Carers Retreat, nursing staff and medical officers. This is expected to commence in September 2016.
  • An education program for nursing, kitchen, nutrition and medical staff will be developed and is expected to commence in September 2016. It will include face-to-face training with change champions and steering committee members, posters displayed in the hospital wards, stories in the CCLHD staff newsletter and advertising banners on the CCLHD intranet homepage.
  • Fasting clocks were incorporated into patient journey boards, so clinical staff could accurately determine fasting periods for each patient. The fasting clocks flash red when a patient reaches eight hours of fasting, which prompts staff to review the patient’s fasting status and determine a plan of care. This may include continuing to fast, administering clear fluids or feeding the patient.
  • ‘Break Your Fast’ packs were developed by kitchen staff and available for nursing staff to collect outside of kitchen opening times or when food/fluids were required immediately.

Project status

Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

June 2015 – November 2016.

Implementation sites

Surgical Inpatient Units, Gosford Hospital, CCLHD

Partnership

Centre for Healthcare Redesign

Evaluation

A full evaluation will take place in November 2016, to measure:

  • the number of patients who fast for eight hours
  • the number of patients who fast longer than 12 hours
  • the number of patients who receive food within 30 minutes of surgery
  • the number of patients who receive clear fluids in the emergency department  
  • the number of emergency and orthopaedic trauma surgical patients with a documented fasting plan.

Lessons learnt

  • Good planning, communication and organisation are essential to making sure the project stays on track and goals are achieved.
  • Allocating a redesign leader and networking with local health districts that have implemented similar projects is invaluable. It allows the project team to learn from their mistakes and save considerable time.
  • The tools and processes available to manage and implement change are vast, so it is often challenging to determine which ones best suit the needs of the project. The project team learned by trial and error, often going back to the drawing board to redesign a new solution when something wasn’t working.
  • The project team had many challenges along the way, including changes to executive sponsorship, finding time to implement the project, waiting for decisions to be made and issues to be resolved, a lack of project management experience and struggling with the terminology and tools used in the project. Addressing these risks early in the project may reduce delays and improve results.

References

  1. ACI. Minimum Standards for the Management of Hip Fractures in the Older Person. 2014.
  2. Australian and New Zealand College of Anaesthetists (ANZCA).  Guidelines on Pre-Anaesthesia Consultation and Patient Preparation. 2016.

Further reading

Contacts

Lisa Moran
Clinical Nurse Educator
Gosford Hospital
Central Coast Local Health District
Phone: 02 4320 3569
lisa.moran@health.nsw.gov.au

Ian James
Clinical Nurse Educator
Gosford Hospital
Central Coast Local Health District
Phone: 02 4320 2411
ian.james@health.nsw.gov.au

Search Projects

Browse Projects

Submit your local innovation
and improvement project