Ending the misery of ‘nil by mouth’

Theatre staff at Nottingham University Hospitals NHS Trust have exploded the myth of long-standing practices around fasting patients before their operations. 

Although there is national and international guidance that reassures clinicians that it is safe to eat closer to the time of an operation and safe to drink certain drinks up to two hours before, that isn’t how things are generally done across the NHS.

The unwritten rules around a perceived need more severe fasting over longer periods are widely accepted and have remained unchallenged for decades.  You might say they had become something of a “sacred cow”, untouchable.

Not only many staff but also patients and the parents of child patients still think that starvation from midnight prior to surgery is necessary and that it decreases the risk of the operation being cancelled.

With times of surgeries sometimes slipping back through the day as emergency patients are slotted in among those who have a pre-planned appointment, this can often leave people without food and drink for very long periods. The effect in these situations, as an anaesthetist explained to me, is that it is much harder for their bodies to stay strong against the unavoidable onslaught of invasive procedures, anaesthetics and other drugs.

It was patient feedback that finally led the trust, the fourth largest acute teaching trust in England, to review their practices. They were consistently hearing that patients were dehydrated, uncomfortable and unhappy about it and that forced them to take a look at whether they could do things differently.

A project team made up of anaesthetists, surgeons, theatre and ward nurses, safety leads and dieticians reviewed the whole thing and found there wasn’t actually any need for conflict between the patient safety goals and those around improving patient experience.

As is very often the case, they go hand in glove. It was actually okay for people to have not just a glass of water but a cup of tea or coffee – with up to one-fifth milk – a diluted cordial or a non-carbonated energy drink just a couple of hours before going into theatre.

Sometimes that’s all it takes to make a patient comfortable and more relaxed during a tense wait for an operation.

The trust’s Think Drink project has overturned the old ways of thinking and reduced fasting times, which were typically between nine to 12 hours, down to just over three hours.  They aim to get it down to two hours for most patients over the next few months and to hold it there through ongoing staff training and continued use of their new processes and flow-charts for both planned and emergency operations.

In an initiative that cost them very little financially and was driven through by dogged theatre staff, they have succeeded in delivering both cultural and procedural change.

Their evaluation already shows that patients are much happier.  Not only that, but staff are seeing faster recovery from the anaesthetic, with less nausea.  The next step is to undertake some longer-term research around the clinical and recovery outcomes and the impact on how long patients need to remain in hospital.

Think Drink is a simple idea but it is having an enormous impact.  Even better news is that it’s fully replicable across other theatres.

The team responsible won the Insight for Improvement category at the Patient Experience Network National Awards in March.  The award was supported by NHS England, who have just co-hosted with the Patient Experience Network a series of good practice events around the country, giving other providers and commissioners an opportunity to learn more about some of the innovative projects that are using feedback to drive healthcare improvements.

A short video about the project has been published on our YouTube channel.

The next round of PEN awards – again with an Insight for Improvement category – were launched last week and I can’t help wondering how many more NHS “sacred cows” are already being eyed up by innovative and determined frontline healthcare staff.

Gillian Radcliffe

Gillian Radcliffe leads communications and engagement work within the Insight and Feedback Team at NHS England, supporting work primarily on the Friends and Family Test but also around national surveys and related projects.

Gillian has been a senior communications professional in the public sector for almost 30 years, with experience in the health, education and criminal justice sectors.