Pre-Procedural Fasting Guideline for the Intensive Care Unit

POSTER

PURPOSE  To standardize the process of Pre-procedural fasting in critically ill patients in the intensive care unit OBJECTIVES  Develop a pre-procedural fasting guideline and flow sheet for use in the ICU  Present pre-procedural guidelines and flow sheet for review by key stakeholders such as medical director, unit management, and content experts  Provide education on current pre-procedural fasting guidelines to medical staff in the ICU  Implement a trial of the guideline  Disseminate information. Prepare findings for poster presentation at an appropriate venue BACKGROUND  In the critically ill patient population, major physiologic stress causes metabolic and physiological changes  greater risk for malnutrition  Frequent interruptions of enteral and oral nutrition are correlated with increased ICU and hospital length of stay (up to 26% of interruptions are avoidable)  Up to 68% of ICU patients have malnutrition  Malnutrition costs an extra 19.3% per patient  Evidence demonstrates no need to stop postpyloric enteral feedings prior to procedures  No guideline currently exists in an ICU of a local tertiary medical center for fasting in critically ill or enterally fed patients METHODS GUIDELINE 1. PO (per os) access 1.1. Patients with no increased risk for aspiration 1.1.1. 2 hours fasting from clear liquids 1.1.2. 6 hours fasting from solid foods 1.1.3. 8 hours fasting from heavy meals or fried foods 1.2. Patients with increased risk for aspiration (i.e. suspected aspiration pneumonia, lethargy, confusion, stroke, hemiparalysis, esophageal dysfunction, recent extubation, other specified physical impairment): 1.2.1. Follow specific attending physician/provider orders 1.3. Procedures requiring fasting for reasons OTHER than aspiration risk (EGD, Colonoscopy, etc.) do not follow standard fasting recommendations. Follow attending physician/provider orders specific to the particular procedure. 1.4. Patients going to surgery: 1.4.1. Follow surgeon orders 2. Feeding Tube and Enteral Nutrition 2.1. Post pyloric tube position 2.1.1. Feedings do not need to be stopped 2.1.2. Continue feeds until time of procedure unless otherwise specified by attending physician/provider 2.1.3. Resume feeds immediately after procedure unless otherwise specified by attending physician/provider 2.2. Gastric tube position 2.2.1. Check with attending physician/provider for instruction 2.2.2. Stop feeds no more than 6 hours prior to procedure 2.3. Patients going to surgery: 2.3.1. Follow attending surgeon orders 2.3.1.1. Post pyloric Tube Position 2.3.1.1.1. Should run feedings until time of procedure 2.3.1.2. Gastric Tube Position 2.3.1.2.1. Should stop feedings no longer than 6 hours prior to surgery 3. General Considerations 3.1. PO access 3.1.1. Clear fluids and ice chips up until procedure can be safe and may help increase patient comfort. Check with attending physician/provider 3.2. Feeding Tube and Enteral Nutrition 3.2.1. Do not stop tube feedings for repositioning or bed baths 3.2.2. Do not stop tube feedings for more than 10 minutes for physical therapy or other activities 3.2.2.1. If activity is expected to exceed ten minutes, make accommodations to allow for continuation of feedings 3.2.3. Gastric residual volumes (GRV) do not need to be routinely monitored 3.2.4. Tube Feedings do not need to be held for a random check GRV < 500 mL in the absence of any other signs of feeding intolerance (nausea, vomiting, abdominal bloating/distension, etc.) 3.2.4.1. Check with attending physician/provider if random GRV is >500 mL      A pre-procedural fasting guideline was developed combining current ASA and A.S.P.E.N. recommendations Guideline was presented to key stakeholders and an educational PowerPoint was given to unit providers Nurses were selected for the initial trial and educated on current recommendations and the objectives of the project They collected data for two weeks on:  Each time the guideline was initiated  Whether or not the NPO order was appropriate for the ordered procedure  If NPO orders were changed when warranted by the guideline A post-trial questionnaire was completed and returned via email by the ICU nurses CONCLUSION/IMPLICATIONS  Trial on a larger scale is necessary  High aspiration risk patients receive the majority of NPO orders in the ICU  Benefits of shortened fasting with enteral feeds outweigh theoretical risks  Further research is needed on enteral feedings and gastric emptying  Nursing staff reported the guideline and education as being informative and helpful to their practice  Nursing staff was not up to date on current fasting recommendations  Education for staff concerning fasting and nutrition recommendations is needed Special thanks to Project Chair, Kristi Kissell, DNP, APRN, A-G ACNP-BC, CCRN; Nancy Allen, PhD, ANP-BC; Program specialty track director, Denise Ward, DNP, ACNP-BC; Assistant Dean, Pamela Hardin, PhD, RN, CNE; Content Experts, Vivian Lee, MD, pulmonary critical care, & Merin Kinikini, MSN-APRN