Characteristics and Outcomes of Fasting Orders Among Medical Inpatients

Abstract

While many hospitalized patients have orders to fast in preparation for interventions, the extent to which these orders are necessary or adhere to evidence-based durations is unknown. In this study, we analyzed the length, indication, and associated outcomes of nil per os (NPO) orders for general medicine patients at an academic institution in the United States, and compared them to the best available evidence for recommended length of NPO. Of 924 NPO orders assessed, the indicated intervention was not performed for 183 (19.8%) orders, largely due to a change in plan (75/183, 41.0%) or scheduling barriers (43/183, 23.5%). When analyzed by indication, the median duration of NPO orders ranged from 8.3 hours for kidney ultrasound to 13.9 hours for upper endoscopy. For some indications, the literature suggested NPO orders may be unnecessary. Furthermore, in indications for which NPO was deemed necessary in the literature, the duration of most NPO orders was much longer than minimally required. These results suggest the need for establishing more robust practice guidelines or institutional protocols for NPO orders. Frequent and prolonged fasting can lead to patient dissatisfaction and distress. 1 It may also cause malnutrition and negatively affect outcomes in high-risk populations such as the elderly. 2 Evidence suggests that patients are commonly kept fasting longer than necessary. 3,4 However, the extent to which nil per os (NPO) orders are necessary or adhere to evidence-based duration is unknown.Our study showed half of patients admitted to the general medicine services experienced a period of fasting, and 1 in 4 NPO orders may be avoidable. 5 In this study, we aimed to provide action-oriented recommendations by 1) assessing why some interventions did not occur after NPO orders were placed and 2) analyzing NPO orders by indication and comparing them with the best available evidence. METHODSThis retrospective study was conducted at an academic medical center in the United States. The study protocol was approved by the Mayo Clinic Institutional Review Board.Detailed data handling and NPO order review processes have been described elsewhere. 5 Briefly, we identified 1200 NPO orders of 120 or more minutes' duration that were written for patients on the general medicine services at our institution in 2013. After blinded duplicate review, we excluded 70 orders written in the intensive care unit or on other services, 24 with unknown indications, 101 primarily indicated for clinical reasons, and 81 that had multiple indications. Consequently, 924 orders indicated for a single intervention (eg, imaging study, procedure, or operation) were included in the main analysis.We assessed if the indicated intervention was performed. If performed, we recorded the time when the intervention was started. If not performed, we assessed reasons why it was not performed. We also performed exploratory analyses to investigate factors associated with performing the indicated intervention. The variables were 1) NPO starting at midnight, 2) ...

Impact of gaps in care for malnourished patients on length of stay and hospital readmission

“…[22] Better education of the clinical team on pre-procedure fasting guidelines may help mitigate prolonged nil per os. [13,[22][23][24] Due to the unique nature of our study, there is limited ability to compare our findings with previous studies. Additionally, due to limited resources, our study had a small sample size and therefore lack of association between readmission and gaps in care may be due to type 2 error.…”

Fasting-Evoked En Route Hypoglycemia in Diabetes (FEEHD): An Overlooked Form of Hypoglycemia in Clinical Practice

“…Of note, our study showed that only 36% of patients received proper instructions about preparing for fasting for labs. We have not found literature addressing if patients with diabetes are educated or informed when fasting labs are ordered, except for sporadic reports [ 21 – 23 ]. A small study by Kackov and associates has found that the majority of outpatients are not well informed about how to fast for lab tests [ 21 ].…”

“…Only 15% and 19% of patients reported that they were properly informed by a doctor or a nurse, respectively, about preparation for fasting for labs. Furthermore, few other investigators addressed inpatient fasting orders (for various indications) and raised concerns about the appropriateness of these orders [ 22 ], as well as the potential risk of hypoglycemia in patients with diabetes [ 23 ].…”

Evaluating Gaps in Care of Malnourished Patients on General Medicine Floors in an Acute Care Setting

“…In a different meta‐analysis, it was shown that about 50% of the meals held for patients could have been served . Such prolonged perioperative/periprocedure fasting has been shown to increase the risk for complications and is often unnecessary …”

“…18 Such prolonged perioperative/periprocedure fasting has been shown to increase the risk for complications and is often unnecessary. 19,20 In an effort to improve excessive time spent NPO for procedures or testing, we are proposing that physicians be required to document the purpose for NPO status within the patient's order. This would give staff more clarity as to when food could be served postprocedurally.…”