Physician or anesthetists knowledge or perception and nurses’ knowledge or perception regarding preoperative fasting.

127The Journal of Continuing Education in Nursing · Vol 49, No 3, 2018

Knowledge of Nurses About Preoperative Fasting in a Corporate Hospital Shivegowda Mohan, DA, DNB; Murali Chakravarthy, MD, DA, DNB, FIACTA; Antony George, MD, DM; Ashokanand Devanahalli, DA, DNB; and Jeevan Kumar, MBBS

Preoperative fasting is defined as fasting for a pre-scribed period prior to any procedure (American Society of Anesthesiologists, 2011; “Practice Guide- lines,” 2017). Although patients are advised by the doc- tors, the opinion and knowledge of the nurses are relevant because they are the first point of contact with patients. Therefore, nurses need to be knowledgeable about nil per os (NPO) guidelines so that they would be able to imple-

ment them appropriately and educate patients (Liddle, 2014). It has been revealed that adequate preoperative in- structions alleviate anxiety, increase patient participation in their own care and patient satisfaction and minimize the development of perioperative complications (Lee & Lee, 2000).

Many professional societies have issued their guidelines on preoperative fasting. The American Society of Anesthe- siologists (2011), Association of Paediatric Anaesthetists of Great Britain and Ireland (2007), Royal College of Nurs- ing (2005), and European Society of Anaesthesia (“Preop- erative fasting,” 2005; Smith et al., 2011) have all recom- mended preoperative fasting of 2 hours for clear fluids, 4 hours for breast milk, and 6 hours for solids, nonhuman, and formula milk in children (De Aguilar-Nascimento & Dock-Nascimento, 2010).

The guideline development group recommends that up to 30 mL of clear fluid could be taken at any time preop- eratively to help adult patients take their medications and up to 0.5 mL/kg of water orally in children (Royal College of Nursing, 2005).

Adherence to NPO guidelines enhances safety by pre- venting aspiration of gastric contents while administering

Background: Preoperative fasting is a requirement to be made by anesthesiologists, but they generally depend on nurses to ensure it is carried out by patients. Lack of updated knowledge among nurses may cause complica- tions.

Method: The objective of this study was to understand the knowledge of nurses about preoperative fasting. The multi-unit study was conducted in the units of our hospi- tals using an Internet-based survey. The responders were anonymous to the authors.

Results: The survey was sent to approximately 5,000 nurses, with more than 600 responding to the survey. Most of the respondents were aware of the preoperative fasting guidelines. The understanding regarding preop- erative fasting appeared to be insufficient among nurses. The nurses appreciated the concern of the anesthesiolo- gists about fasting. The nurses opined that additional training regarding preoperative fasting might benefit them.

Conclusion: This survey conveyed to the authors that the nurses of our hospitals were knowledgeable but re- quired further training to update them. J Contin Educ Nurs. 2018;49(3):127-131.

abstract

Dr. Mohan is Consultant Anesthesiologist, Dr. Chakravarthy is Chief Consultant, Department of Anesthesia, Critical Care and Pain Relief, Dr. George is Consultant Anesthesiologist, Dr. Devanahalli is Consultant An- esthesiologist, and Mr. Kumar is Resident in Anesthesia, Fortis Hospitals, Bangalore, India.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Murali Chakravarthy, MD, DA, DNB, FIACTA, Chief Consultant, Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, 154/9, Opposite IIM Bangalore, Bannerghatta Road, Bangalore, Karnataka 560076, India; e-mail: mailchakravarthy@ gmail.com.

Received: June 1, 2017; Accepted: December 20, 2017 doi:10.3928/00220124-20180219-07

128 Copyright © SLACK Incorporated

anesthesia (Ljungqvist & Søreide, 2003). It may be valu- able to teach-back (i.e., a communication method to con- firm whether a patient understands what is being explained to them) to evaluate patient and family understanding (Agency for Healthcare Research and Quality, 2015).

Studies have estimated that about 2% to 3.5% of pa- tients admitted for surgery are noncompliant to fasting instructions (Laffey, Carroll, Donnelly, & Boylan, 1998; Walker, Thorn, & Omundsen, 2006). This may result in surgeries getting rescheduled, causing inconvenience to all concerned. Hence, it becomes the responsibility of anes- thesiologists, surgeons, and the nurses to educate patients about the importance of preoperative fasting. They ought to mention the number of hours of fasting prior to any surgery or procedure and the complications resulting from inadequate fasting. In the study by Laffey et al. (1998), it was found that 4% of patients lied about the fasting duration to avoid rescheduling of surgery. Poor commu- nication between the patient and health care staff were some of the reasons for the above findings. The syllabus of nursing education consists of chapters on the importance of preoperative fasting (Royal College of Nursing, 2005). Despite this, there may be paucity of knowledge and a lack of application in practice. The intention of conduct- ing this survey was to assess the knowledge of preoperative fasting among nurses.

METHOD The survey was created using SurveyMonkey™ and was

e-mailed to all the nursing staff of all the units of For- tis hospitals of India after testing its viability via a pilot study. The survey consisted of multiple-choice questions. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was used for reporting the results of survey (Eysenbach, 2016). Institutional review board approval was obtained prior to deployment.

This survey consisted of 22 questions; they were sent either via e-mail or as a URL to the mobile telephones

of nurses at 50 branch facilities for Fortis Hospitals. The first survey was sent on August 8, 2016, and the last on September 19, 2016. Three reminders approximately 1 week apart were sent during this duration. Respondent information and identity were not sought, and the sur- vey responses were saved on a password-protected server accessible only to key study personnel. The participation in the survey was voluntary and no incentives were of- fered to respondents. The respondents could not edit the questions; however, they could alter their responses until submission. A possible duplicate submission was prevented by a mechanism called Internet protocol ad- dress check provided by SurveyMonkey. It was expected that nurses may use one or the other guidelines to re- spond. Responses were automatically archived by the SurveyMonkey database and analyzed by the authors. Incomplete responses were not a reason for exclusion. More than one respondent from the same facility was al-lowed. Descriptive analysis was performed based on survey questions, and subgroup analysis was done to de- scribe the salient points. For a population size of 5,800, the 95% confidence interval with 4% margin sample size was calculated to be 545.

RESULTS The survey link was sent via e-mail to approximately

5,000 nurses at Fortis hospitals; 628 responded (via e-mail invitation, n = 535; via web link, n = 93). The response rate was 12.56% (628 of 5,000). In our survey, 38.5% of the respondents were working in the intensive care unit, 26.7% were working on wards, 7.80% in the operation de- partment, 7.1% in the emergency department, and 19.9% in other departments. The nurses’ experience is shown in Table 1; a majority our study participants had up to 6 years of experience. Most (98%) of the respondents were aware of fasting guidelines. Approximately 80% incorrectly re- sponded that clear fluids could be allowed for up to 6 hours, and 13.6% thought fasting for 4 hours prior to surgery was adequate; only 6% correctly knew that clear fluids could be allowed up to 2 hours prior to surgery. Less than half of the

TABLE 1

NURSING EXPERIENCE OF THE SURVEY RESPONDENTS (N = 628)

Nursing Experience of Respondents (Years) %

0 to 2 27

3 to 6 35

7 to 12 20

.12 18

Figure. Response indicating awareness about clear fluids.

129The Journal of Continuing Education in Nursing · Vol 49, No 3, 2018

respondents correctly knew that infants could be breast fed up to 4 hours. Approximately two thirds of the respondents were aware that adults could be allowed milk up to 6 hours prior to surgery. Only one fifth correctly responded that it

was acceptable to allow intake of solid foods, which was up to 6 hours prior to surgery. Two thirds responded that solid food must be stopped 8 hours prior. The majority (91.6%) of the respondents correctly considered water as clear liq-

TABLE 2

RESPONSES REGARDING KNOWLEDGE, ATTITUDE, AND PRACTICE ABOUT PREOPERATIVE FASTING AMONG NURSES

Question Respondents (%)a

Do you instruct patients about nil by mouth (NBM) or wait for the orders by doctor?

We will instruct 41.8

Doctor’s orders 58.2

Do you educate the patient about need for NBM?

Yes 98.1

No 0.6

Not applicable 1.3

Risk due to inadequate fasting during induction of general anesthesia

Hypotension 35.5

Hyperglycemia 1.1

Aspiration of gastric contents 92.5

Hypertension 0.8

Do you educate the patient about potential risk of inadequate fasting?

Yes 96.9

No 3.1

Fasting period for regional anesthesia, compared with general anesthesia

Shorter 44.5

Same 30.2

Longer 19.6

No fasting required 5.7

Fasting period for monitored anesthesia care compared with general anesthesia

Shorter 40.7

Same 32.7

Longer 22.3

No fasting required 4.3

Can the patient take his regular medications when he or she is fasting?

Yes 89.3

No 10.7

If the patients are excessively fasted preoperatively, they may experience:

Dehydration 54.8

Hypotension 39.7

Hypoglycemia 72.3

Adverse metabolic consequences 22 a Percentages may not sum 100 because respondents were given the option to provide more than one response.

130 Copyright © SLACK Incorporated

uid, whereas a varying percentage of them considered fruit juice with or without pulp, black tea or coffee, carbonated aerated drinks, and milk as clear liquids (Figure). Confu- sion existed among the respondents (Table 2).

Respondents’ knowledge was inconsistent regarding the amount of water that could be allowed to facilitate swal- lowing of regular medications (among adult and pediatric patients) (Tables 3-4). Most of the nurses understood the insistence of the anesthesiologists about preoperative fast- ing by patients. Responsible individuals were described in descending order: nurses, anesthesiologist, surgeons, and hospital administration. Most (73.7%) of the nurses agreed that they required additional training regarding fasting, the hazards of aspiration pneumonitis, and the nurses’ role in preventing it. The correct duration of fasting shown in Ta- ble 5 was used by the authors (“Practice Guidelines,” 2017).

DISCUSSION This survey assessed the knowledge of nurses who are

either graduates or diploma holders in nursing. Adequate knowledge of nurses about fasting ensures quality nursing care during the preoperative period. This is a reassurance to anesthesiologists to whom the matter of preoperative fast- ing matters.

These results show that although the nurses received training on various topics during nursing education, addi- tional training about preoperative fasting must be provid- ed, especially if the guidelines change. The anesthesiolo- gists may teach their nursing colleagues because this issue actually concerns their patient safety, quality, and reputa- tion. In general, nurses follow guidelines and mandatory requirements well; it is easier to inculcate good habits in them. In this survey, the responding nurses were aware of issues concerning preoperative fasting, and the adverse effects of nonadherence, but only a minority knew the guidelines accurately. It is necessary that nurses involved in pediatric surgical care must be thorough about not only the duration of fasting but also other requirements, such as changing fasting duration for various types of feeds and the amount of water allowed while consuming their regular oral medications. A nurse may voice a concern should duration of fasting be more than necessary (e.g., in diabetic patients with autonomic dysfunction, inter- nal obstruction and congestive heart failure), to prevent hypovolemia and its related complications in a pediatric subsect. The hospital administration must spend resource and manpower to encourage teaching in this regard. It appeared from our study that a majority of the nursing colleagues educated the patients about the requirement of preoperative fasting, but they did not elaborate on the consequences of aspiration pneumonitis. The teach-back method of explaining may confirm that the patient has indeed understood (Agency for Healthcare Research and Quality, 2015). It may be expected that by explaining the consequences, one might encourage the patients to com- ply with the instructions. It may be wise to inform the patients that despite adhering to the advice, aspiration of gastric contents might still occur because of various factors such as electrolyte abnormality, pregnancy, old age, diabe- tes mellitus, and alcohol consumption. It is also necessary to mentor young anesthesiologists to inform the nurses that other forms of mild anesthesia, such as monitored

TABLE 3

KNOWLEDGE ABOUT ALLOWED WATER TO CONSUME REGULAR MEDICINES IN ADULTSa

Amount of Allowed Water With Medications (mL) Response (%)

10 30

20 36

30 23

40 11 a Correct answer is 30 mL.

TABLE 4

KNOWLEDGE ABOUT ALLOWED WATER TO CONSUME REGULAR MEDICINES IN PEDIATRICSa

Amount of Allowed Water With Medications (mL/kg) Response (%)

0.5 29

1 27

2 26

4 18 a Correct volume of water allowed is 0.5 mL/kg.

TABLE 5

CORRECT DURATION OF FASTING FOR VARIOUS TYPES OF FLUIDS AND SOLIDS

Ingested Material Minimum Fasting

Period (Hours)

Clear liquids 2

Breast milk 4

Infant formula 6

Nonhuman milk 6

Light meal 6

131The Journal of Continuing Education in Nursing · Vol 49, No 3, 2018

anesthesia care, spinal anesthesia, and regional blocks, also require stringent fasting precautions. The nurses in our survey appear to be varied in their knowledge about this.

Yet another survey concluded there is a need for nurses to coordinate instructional practices to involve patients more in their own care with consistent information and comprehensive education and assist them in reducing fasting on clear fluids after hospital admission (Ingadottir et al., 2016; Lee & Lee, 2000). This survey serves as our baseline benchmark. We wish to provide further educa- tion about preoperative fasting in our nursing conferences and reassess at a later date.

CONCLUSION This survey revealed that nurses were aware of several facts

of preoperative fasting, but their knowledge was deficient.

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