019 Nil by mouth and peri-operative medicines administration in trauma and emergency surgery patients

Published Date: 10th January 2023

Publication Authors: Dunn J

Background
An 88-year-old woman attends theatre for dynamic hip screw (DHS) 2 days after a trip and fall, delayed due to clinical pressures. BP, usually well controlled, is through the roof and her atrial fibrillation (AF) is no longer rate controlled; her anaesthetic risk is now considerably greater than prior to admission. Why? The drug chart shows omission of all regular medications since admission as she is ‘nil by mouth’ (NBM). Readers have undoubtedly seen similar cases in their practice. Poor peri-operative drug administration risks increasing peri-operative morbidity and contributing to poorer outcomes in an already vulnerable patient group. Aims of this quality-improvement project (QIP) are to increase peri-operative administration of prescribed regular proton pump inhibitors (PPIs) in Confidential Enquiry into Perioperative Deaths (CEPOD)/trauma patients by 50%. PPIs being used as an indicator of regular drug administration practice in this group.

Methods
A retrospective audit was undertaken of the notes of trauma patients attending theatre over a 1-month period, including drugs given/omitted and reason. A staff questionnaire was administered assessing understanding of ‘peri-operative NBM’ and a real-time audit was undertaken of patients brought to trauma/CEPOD theatres over 7 days. Staff education, poster deployment and improvement of guideline accessibility were undertaken and re-audit for each QIP cycle was undertaken.

Results
Seventy-one per cent of patients in the retrospective audit had their regular medicines omitted inappropriately and 73% in the real-time audit, with 36% receiving their prescribed PPIs. Thirty per cent of staff questioned knew the correct guidance regarding NBM and oral medications: 60% would contact anaesthetics if unsure and 70% were aware of intranet guidelines. Cycles 1, 2 and 3 led to 86%/71%/64% of patients receiving their prescribed PPIs.

Discussion
Poor peri-operative medicines administration in these patients seems to be driven by misunderstanding of peri-operative NBM guidelines. Trust guidelines on the topic are easily navigated and thorough, but can be difficult to locate. Simple interventions in this area have potential to improve patient safety significantly. Cycle 1 (education) showed the greatest improvement; something we focused on at the endpoint of this QIP. Analysing the problem as a multidisciplinary team led to significant interest from pharmacy to develop a collaborative programme of education with guideline update and quick access quick response (QR) posters. In the long-term, empowering staff through regular education and removing barriers to guideline access are important.

 

Dunn, J; Thornton, T; Lyons, M. (2023). 019 Nil by mouth and peri-operative medicines administration in trauma and emergency surgery patients. Anaesthesia. 78(Suppl 1), p.15. [Online]. Available at: https://dx.doi.org/10.1111/anae.15924 [Accessed 23 February 2023]

 

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