Objective: Asymptomatic bacteriuria (ASB) denotes asymptomatic carriage of bacteria within the urinary tract and does not require treatment in most patient populations. Unnecessary antimicrobial treatment has several consequences, including promotion of antimicrobial resistance, potential for medication adverse effects, and risk for Clostridiodes difficile infection. The aim of this quality improvement effort was to decrease both the unnecessary ordering of urine culture studies and unnecessary treatment of ASB.
Methods: This is a single-center study of patients who received care on 3 internal medicine units at a large, academic medical center. We sought to determine the impact of information technology and educational interventions to decrease both inappropriate urine culture ordering and treatment of ASB. Data from included patients were collected over 3 1-month time periods: baseline, post-information technology intervention, and post-educational intervention.
Results: There was a reduction in the percentage of patients who received antibiotics for ASB in the post-education intervention period as compared to baseline (35% vs 42%). The proportion of total urine cultures ordered by internal medicine clinicians did not change after an information technology intervention to redesign the computerized physician order entry screen for urine cultures.
Conclusion: Educational interventions are effective ways to reduce rates of inappropriate treatment of ASB in patients admitted to internal medicine services.
Keywords: asymptomatic bacteriuria, UTI, information technology, education, quality.
Asymptomatic bacteriuria (ASB) is a common condition in which bacteria are recovered from a urine culture (UC) in patients without symptoms suggestive of urinary tract infection (UTI), with no pathologic consequences to most patients who are not treated.1,2 Patients with ASB do not exhibit symptoms of a UTI such as dysuria, increased frequency of urination, increased urgency, suprapubic tenderness, or costovertebral pain. Treatment with antibiotics is not indicated for most patients with ASB.1,3 According to the Infectious Diseases Society of America (IDSA), screening for bacteriuria and treatment for positive results is only indicated during pregnancy and prior to urologic procedures with anticipated breach of the mucosal lining.1
An estimated 20% to 52% of patients in hospital settings receive inappropriate treatment with antibiotics for ASB.4 Unnecessary prescribing of antibiotics has several negative consequences, including increased rates of antibiotic resistance, Clostridioides difficile infection, and medication adverse events, as well as increased health care costs.2,5 Antimicrobial stewardship programs to improve judicious use of antimicrobials are paramount to reducing these consequences, and their importance is heightened with recent requirements for antimicrobial stewardship put forth by The Joint Commission and the Centers for Medicare & Medicaid Services.6,7
A previous review of UC and antimicrobial use in patients for purposes of quality improvement at our institution over a 2-month period showed that of 59 patients with positive UCs, 47 patients (80%) did not have documented symptoms of a UTI. Of these 47 patients with ASB, 29 (61.7%) received antimicrobial treatment unnecessarily (unpublished data). We convened a group of clinicians and nonclinicians representing the areas of infectious disease, pharmacy, microbiology, statistics, and hospital internal medicine (IM) to examine the unnecessary treatment of ASB in our institution. Our objective was to address 2 antimicrobial stewardship issues: inappropriate UC ordering and unnecessary use of antibiotics to treat ASB. Our aim was to reduce the inappropriate ordering of UCs and to reduce treatment of ASB.
Methods
Setting
The study was conducted on 3 IM nursing units with a total of 83 beds at a large tertiary care academic medical center in the midwestern United States, and was approved by the organization’s Institutional Review Board.
Participants
We included all non-pregnant patients aged 18 years or older who received care from an IM primary service. These patients were admitted directly to an IM team through the emergency department (ED) or transferred to an IM team after an initial stay in the intensive care unit.
Data Source
Microbiology laboratory reports generated from the electronic health record were used to identify all patients with a collected UC sample who received care from an IM service prior to discharge. Urine samples were collected by midstream catch or catheterization. Data on urine Gram stain and urine dipstick were not included. Henceforth, the phrase “urine culture order” indicates that a UC was both ordered and performed. Data reports were generated for the month of August 2016 to determine the baseline number of UCs ordered. Charts of patients with positive UCs were reviewed to determine if antibiotics were started for the positive UC and whether the patient had signs or symptoms consistent with a UTI. If antibiotics were started in the absence of signs or symptoms to support a UTI, the patient was determined to have been unnecessarily treated for ASB. Reports were then generated for the month after each intervention was implemented, with the same chart review undertaken for positive UCs. Bacteriuria was defined in our study as the presence of microbial growth greater than 10,000 CFU/mL in UC.
Interventions
Initial analysis by our study group determined that lack of electronic clinical decision support (CDS) at the point of care and provider knowledge gaps in interpreting positive UCs were the 2 main contributors to unnecessary UC orders and unnecessary treatment of positive UCs, respectively. We reviewed the work of other groups who reported interventions to decrease treatment of ASB, ranging from educational presentations to pocket cards and treatment algorithms.8-13 We hypothesized that there would be a decrease in UC orders with CDS embedded in the computerized order entry screen, and that we would decrease unnecessary treatment of positive UCs by educating clinicians on indications for appropriate antibiotic prescribing in the setting of a positive UC.
Information technology intervention. The first intervention implemented involved redesign of the UC ordering screen in the computerized physician order entry (CPOE) system. This intervention went live hospital-wide, including the IM floors, intensive care units, and all other areas except the ED, on February 1, 2017 (Figure 1). The ordering screen required the prescriber to select from a list of appropriate indications for ordering a UC, including urine frequency, urgency, or dysuria; unexplained suprapubic or flank pain; fever in patients without another recognized cause; screening obtained prior to urologic procedure; or screening during pregnancy. An additional message advised prescribers to avoid ordering the culture if the patient had malodorous or cloudy urine, pyuria without urinary symptoms, or had an alternative cause of fever. Before we implemented the information technology (IT) intervention, there had been no specific point-of-care guidance on UC ordering.
Educational intervention.The second intervention, driven by clinical pharmacists, involved active and passive education of prescribers specifically designed to address unnecessary treatment of ASB. The IT intervention with CDS for UC ordering remained live. Presentations designed by the study group summarizing the appropriate indications for ordering a UC, distinguishing ASB from UTI, and discouraging treatment of ASB were delivered via a variety of routes by clinical pharmacists to nurses, nurse practitioners, physician assistants, pharmacists, medical residents, and staff physicians providing care to patients on the 3 IM units over a 1-month period in March 2017. The presentations contained the same basic content, but the information was delivered to target each specific audience group.
Medical residents received a 10-minute live presentation during a conference. Nurse practitioners, physician assistants, and staff physicians received a presentation via email, and highlights of the presentation were delivered by clinical pharmacists at their respective monthly group meetings. A handout was presented to nursing staff at nursing huddles, and presentation slides were distributed by email. Educational posters were posted in the medical resident workrooms, nursing breakrooms, and staff bathrooms on the units.
Outcome Measurements
The endpoints of interest were the percentage of patients with positive UCs unnecessarily treated for ASB before and after each intervention and the number of UCs ordered at baseline and after implementation of each intervention. Counterbalance measures assessed included the incidence of UTI, pyelonephritis, or urosepsis within 7 days of positive UC for patients who did not receive antibiotic treatment for ASB.
Results
Data from a total of 270 cultures were examined from IM nursing units. A total of 117 UCs were ordered during the baseline period before interventions were implemented. For a period of 1 month following activation of the IT intervention, 73 UCs were ordered. For a period of 1 month following the educational interventions, 80 UCs were ordered. Of these, 61 (52%) UCs were positive at baseline, 37 (51%) after the IT intervention, and 41 (51%) after the educational intervention. Patient characteristics were similar between the 3 groups (Table); 64.7% of patients were female in their early to mid-seventies. The majority of UCs were ordered by providers in the ED in all 3 periods examined (51%-70%). The percentage of patients who received antibiotics prior to UC for another indication (including bacteriuria) in the baseline, post-IT intervention, and post-education intervention groups were 30%, 27%, and 45%, respectively.
The study outcomes are summarized in Figure 2. Among patients with positive cultures, there was not a reduction in inappropriate treatment of ASB compared to baseline after the IT intervention (48% vs 42%). Following the education intervention, there was a reduction in unnecessary ASB treatment as compared both to baseline (35% vs 42%) and to post-IT intervention (35% vs 48%). There was no difference between the 3 study periods in the percentage of total UCs ordered by IM clinicians. The counterbalance measure showed that 1 patient who did not receive antibiotics within 7 days of a positive UC developed pyelonephritis, UTI, or sepsis due to a UTI in each intervention group.
Discussion
The results of this study demonstrate the role of multimodal interventions in antimicrobial stewardship and add to the growing body of evidence supporting the work of antimicrobial stewardship programs. Our multidisciplinary study group and multipronged intervention follow recent guideline recommendations for antimicrobial stewardship program interventions against unnecessary treatment of ASB.14 Initial analysis by our study group determined lack of CDS at the point of care and provider knowledge gaps in interpreting positive UCs as the 2 main contributors to unnecessary UC orders and unnecessary treatment of positive UCs in our local practice culture. The IT component of our intervention was intended to provide CDS for ordering UCs, and the education component focused on informing clinicians’ treatment decisions for positive UCs.
It has been suggested that the type of stewardship intervention that is most effective fits the specific needs and resources of an institution.14,15 And although the IDSA does not recommend education as a stand-alone intervention,16 we found it to be an effective intervention for our clinicians in our work environment. However, since the CPOE guidance was in place during the educational study periods, it is possible that the effect was due to a combination of these 2 approaches. Our pre-intervention ASB treatment rates were consistent with a recent meta-analysis in which the rate of inappropriate treatment of ASB was 45%.17 This meta-analysis found educational and organizational interventions led to a mean absolute risk reduction of 33%. After the education intervention, we saw a 7% decrease in unnecessary treatment of ASB compared to baseline, and a 13% decrease compared to the month just prior to the educational intervention.
Lessons learned from our work included how clear review of local processes can inform quality improvement interventions. For instance, we initially hypothesized that IM clinicians would benefit from point-of-care CDS guidance, but such guidance used alone without educational interventions was not supported by the results. We also determined that the majority of UCs from patients on general medicine units were ordered by ED providers. This revealed an opportunity to implement similar interventions in the ED, as this was the initial point of contact for many of these patients.
As with any clinical intervention, the anticipated benefits should be weighed against potential harm. Using counterbalance measures, we found there was minimal risk in the occurrence of UTI, pyelonephritis, or sepsis if clinicians avoided treating ASB. This finding is consistent with IDSA guideline recommendations and other studies that suggest that withholding treatment for asymptomatic bacteriuria does not lead to worse outcomes.1
This study has several limitations. Data were obtained through review of the electronic health record and therefore documentation may be incomplete. Also, antimicrobials for empiric coverage or treatment for other infections (eg, pneumonia, sepsis) may have confounded our results, as empirical antimicrobials were given to 27% to 45% of patients prior to UC. This was a quality improvement project carried out over defined time intervals, and thus our sample size was limited and not adequately powered to show statistical significance. Additionally, given the bundling of interventions, it is difficult to determine the impact of each intervention independently. Although CDS for UC ordering may not have influenced ordering, it is possible that the IT intervention raised awareness of ASB and influenced treatment practices.
Conclusion
Our work supports the principles of antibiotic stewardship as brought forth by IDSA.16 This work was the effort of a multidisciplinary team, which aligns with recommendations by Daniel and colleagues, published after our study had ended, for reducing overtreatment of ASB.14 Additionally, our study results provided valuable information for our institution. Although improvements in management of ASB were modest, the success of provider education and identification of other work areas and clinicians to target for future intervention were helpful in consideration of further studies. This work will also aid us in developing an expected effect size for future studies. We plan to provide ongoing education for IM providers as well as education in the ED to target providers who make first contact with patients admitted to inpatient services. In addition, the CPOE UC ordering screen message will continue to be used hospital-wide and will be expanded to the ED ordering system. Our interventions, experiences, and challenges may be used by other institutions to design effective antimicrobial stewardship interventions directed towards reducing rates of inappropriate ASB treatment.
Corresponding author: Prasanna P. Narayanan, PharmD, 200 First Street SW, Rochester, MN 55905; narayanan.prasanna@mayo.edu.
Financial disclosures: None.
References
1. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68:e83–75.
2. Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an antimicrobial stewardship approach for urinary catheter-associated asymptomatic bacteriuria. JAMA Intern Med. 2015;175:1120-1127.
3. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36:309-332.
4. Trautner BW. Asymptomatic bacteriuria: when the treatment is worse than the disease. Nat Rev Urol. 2011;9:85-93.
5. Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010;340:c2096.
7. Federal Register. Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care.Centers for Medicare & Medicaid Services. June 16, 2016. CMS-3295-P
8. Hartley SE, Kuhn L, Valley S, et al. Evaluating a hospitalist-based intervention to decrease unnecessary antimicrobial use in patients with asymptomatic bacteriuria. Infect Control Hosp Epidemiol. 2016;37:1044-1051.
9. Pavese P, Saurel N, Labarere J, et al. Does an educational session with an infectious diseases physician reduce the use of inappropriate antibiotic therapy for inpatients with positive urine culture results? A controlled before-and-after study. Infect Control Hosp Epidemiol. 2009;30:596-599.
10. Kelley D, Aaronson P, Poon E, et al. Evaluation of an antimicrobial stewardship approach to minimize overuse of antibiotics in patients with asymptomatic bacteriuria. Infect Control Hosp Epidemiol. 2014;35:193-195.
11. Chowdhury F, Sarkar K, Branche A, et al. Preventing the inappropriate treatment of asymptomatic bacteriuria at a community teaching hospital. J Community Hosp Intern Med Perspect. 2012;2.
12. Bonnal C, Baune B, Mion M, et al. Bacteriuria in a geriatric hospital: impact of an antibiotic improvement program. J Am Med Dir Assoc. 2008;9:605-609.
13. Linares LA, Thornton DJ, Strymish J, et al. Electronic memorandum decreases unnecessary antimicrobial use for asymptomatic bacteriuria and culture-negative pyuria. Infect Control Hosp Epidemiol. 2011;32:644-648.
14. Daniel M, Keller S, Mozafarihashjin M, et al. An implementation guide to reducing overtreatment of asymptomatic bacteriuria. JAMA Intern Med. 2018;178:271-276.
15. Redwood R, Knobloch MJ, Pellegrini DC, et al. Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings. Antimicrob Resist Infect Control. 2018;7:4.
16. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62:e51–e7.
17. Flokas ME, Andreatos N, Alevizakos M, et al. Inappropriate management of asymptomatic patients with positive urine cultures: a systematic review and meta-analysis. Open Forum Infect Dis. 2017;4:1-10.
Objective: Asymptomatic bacteriuria (ASB) denotes asymptomatic carriage of bacteria within the urinary tract and does not require treatment in most patient populations. Unnecessary antimicrobial treatment has several consequences, including promotion of antimicrobial resistance, potential for medication adverse effects, and risk for Clostridiodes difficile infection. The aim of this quality improvement effort was to decrease both the unnecessary ordering of urine culture studies and unnecessary treatment of ASB.
Methods: This is a single-center study of patients who received care on 3 internal medicine units at a large, academic medical center. We sought to determine the impact of information technology and educational interventions to decrease both inappropriate urine culture ordering and treatment of ASB. Data from included patients were collected over 3 1-month time periods: baseline, post-information technology intervention, and post-educational intervention.
Results: There was a reduction in the percentage of patients who received antibiotics for ASB in the post-education intervention period as compared to baseline (35% vs 42%). The proportion of total urine cultures ordered by internal medicine clinicians did not change after an information technology intervention to redesign the computerized physician order entry screen for urine cultures.
Conclusion: Educational interventions are effective ways to reduce rates of inappropriate treatment of ASB in patients admitted to internal medicine services.
Keywords: asymptomatic bacteriuria, UTI, information technology, education, quality.
Asymptomatic bacteriuria (ASB) is a common condition in which bacteria are recovered from a urine culture (UC) in patients without symptoms suggestive of urinary tract infection (UTI), with no pathologic consequences to most patients who are not treated.1,2 Patients with ASB do not exhibit symptoms of a UTI such as dysuria, increased frequency of urination, increased urgency, suprapubic tenderness, or costovertebral pain. Treatment with antibiotics is not indicated for most patients with ASB.1,3 According to the Infectious Diseases Society of America (IDSA), screening for bacteriuria and treatment for positive results is only indicated during pregnancy and prior to urologic procedures with anticipated breach of the mucosal lining.1
An estimated 20% to 52% of patients in hospital settings receive inappropriate treatment with antibiotics for ASB.4 Unnecessary prescribing of antibiotics has several negative consequences, including increased rates of antibiotic resistance, Clostridioides difficile infection, and medication adverse events, as well as increased health care costs.2,5 Antimicrobial stewardship programs to improve judicious use of antimicrobials are paramount to reducing these consequences, and their importance is heightened with recent requirements for antimicrobial stewardship put forth by The Joint Commission and the Centers for Medicare & Medicaid Services.6,7
A previous review of UC and antimicrobial use in patients for purposes of quality improvement at our institution over a 2-month period showed that of 59 patients with positive UCs, 47 patients (80%) did not have documented symptoms of a UTI. Of these 47 patients with ASB, 29 (61.7%) received antimicrobial treatment unnecessarily (unpublished data). We convened a group of clinicians and nonclinicians representing the areas of infectious disease, pharmacy, microbiology, statistics, and hospital internal medicine (IM) to examine the unnecessary treatment of ASB in our institution. Our objective was to address 2 antimicrobial stewardship issues: inappropriate UC ordering and unnecessary use of antibiotics to treat ASB. Our aim was to reduce the inappropriate ordering of UCs and to reduce treatment of ASB.
Methods
Setting
The study was conducted on 3 IM nursing units with a total of 83 beds at a large tertiary care academic medical center in the midwestern United States, and was approved by the organization’s Institutional Review Board.
Participants
We included all non-pregnant patients aged 18 years or older who received care from an IM primary service. These patients were admitted directly to an IM team through the emergency department (ED) or transferred to an IM team after an initial stay in the intensive care unit.
Data Source
Microbiology laboratory reports generated from the electronic health record were used to identify all patients with a collected UC sample who received care from an IM service prior to discharge. Urine samples were collected by midstream catch or catheterization. Data on urine Gram stain and urine dipstick were not included. Henceforth, the phrase “urine culture order” indicates that a UC was both ordered and performed. Data reports were generated for the month of August 2016 to determine the baseline number of UCs ordered. Charts of patients with positive UCs were reviewed to determine if antibiotics were started for the positive UC and whether the patient had signs or symptoms consistent with a UTI. If antibiotics were started in the absence of signs or symptoms to support a UTI, the patient was determined to have been unnecessarily treated for ASB. Reports were then generated for the month after each intervention was implemented, with the same chart review undertaken for positive UCs. Bacteriuria was defined in our study as the presence of microbial growth greater than 10,000 CFU/mL in UC.
Interventions
Initial analysis by our study group determined that lack of electronic clinical decision support (CDS) at the point of care and provider knowledge gaps in interpreting positive UCs were the 2 main contributors to unnecessary UC orders and unnecessary treatment of positive UCs, respectively. We reviewed the work of other groups who reported interventions to decrease treatment of ASB, ranging from educational presentations to pocket cards and treatment algorithms.8-13 We hypothesized that there would be a decrease in UC orders with CDS embedded in the computerized order entry screen, and that we would decrease unnecessary treatment of positive UCs by educating clinicians on indications for appropriate antibiotic prescribing in the setting of a positive UC.
Information technology intervention. The first intervention implemented involved redesign of the UC ordering screen in the computerized physician order entry (CPOE) system. This intervention went live hospital-wide, including the IM floors, intensive care units, and all other areas except the ED, on February 1, 2017 (Figure 1). The ordering screen required the prescriber to select from a list of appropriate indications for ordering a UC, including urine frequency, urgency, or dysuria; unexplained suprapubic or flank pain; fever in patients without another recognized cause; screening obtained prior to urologic procedure; or screening during pregnancy. An additional message advised prescribers to avoid ordering the culture if the patient had malodorous or cloudy urine, pyuria without urinary symptoms, or had an alternative cause of fever. Before we implemented the information technology (IT) intervention, there had been no specific point-of-care guidance on UC ordering.
Educational intervention.The second intervention, driven by clinical pharmacists, involved active and passive education of prescribers specifically designed to address unnecessary treatment of ASB. The IT intervention with CDS for UC ordering remained live. Presentations designed by the study group summarizing the appropriate indications for ordering a UC, distinguishing ASB from UTI, and discouraging treatment of ASB were delivered via a variety of routes by clinical pharmacists to nurses, nurse practitioners, physician assistants, pharmacists, medical residents, and staff physicians providing care to patients on the 3 IM units over a 1-month period in March 2017. The presentations contained the same basic content, but the information was delivered to target each specific audience group.
Medical residents received a 10-minute live presentation during a conference. Nurse practitioners, physician assistants, and staff physicians received a presentation via email, and highlights of the presentation were delivered by clinical pharmacists at their respective monthly group meetings. A handout was presented to nursing staff at nursing huddles, and presentation slides were distributed by email. Educational posters were posted in the medical resident workrooms, nursing breakrooms, and staff bathrooms on the units.
Outcome Measurements
The endpoints of interest were the percentage of patients with positive UCs unnecessarily treated for ASB before and after each intervention and the number of UCs ordered at baseline and after implementation of each intervention. Counterbalance measures assessed included the incidence of UTI, pyelonephritis, or urosepsis within 7 days of positive UC for patients who did not receive antibiotic treatment for ASB.
Results
Data from a total of 270 cultures were examined from IM nursing units. A total of 117 UCs were ordered during the baseline period before interventions were implemented. For a period of 1 month following activation of the IT intervention, 73 UCs were ordered. For a period of 1 month following the educational interventions, 80 UCs were ordered. Of these, 61 (52%) UCs were positive at baseline, 37 (51%) after the IT intervention, and 41 (51%) after the educational intervention. Patient characteristics were similar between the 3 groups (Table); 64.7% of patients were female in their early to mid-seventies. The majority of UCs were ordered by providers in the ED in all 3 periods examined (51%-70%). The percentage of patients who received antibiotics prior to UC for another indication (including bacteriuria) in the baseline, post-IT intervention, and post-education intervention groups were 30%, 27%, and 45%, respectively.
The study outcomes are summarized in Figure 2. Among patients with positive cultures, there was not a reduction in inappropriate treatment of ASB compared to baseline after the IT intervention (48% vs 42%). Following the education intervention, there was a reduction in unnecessary ASB treatment as compared both to baseline (35% vs 42%) and to post-IT intervention (35% vs 48%). There was no difference between the 3 study periods in the percentage of total UCs ordered by IM clinicians. The counterbalance measure showed that 1 patient who did not receive antibiotics within 7 days of a positive UC developed pyelonephritis, UTI, or sepsis due to a UTI in each intervention group.
Discussion
The results of this study demonstrate the role of multimodal interventions in antimicrobial stewardship and add to the growing body of evidence supporting the work of antimicrobial stewardship programs. Our multidisciplinary study group and multipronged intervention follow recent guideline recommendations for antimicrobial stewardship program interventions against unnecessary treatment of ASB.14 Initial analysis by our study group determined lack of CDS at the point of care and provider knowledge gaps in interpreting positive UCs as the 2 main contributors to unnecessary UC orders and unnecessary treatment of positive UCs in our local practice culture. The IT component of our intervention was intended to provide CDS for ordering UCs, and the education component focused on informing clinicians’ treatment decisions for positive UCs.
It has been suggested that the type of stewardship intervention that is most effective fits the specific needs and resources of an institution.14,15 And although the IDSA does not recommend education as a stand-alone intervention,16 we found it to be an effective intervention for our clinicians in our work environment. However, since the CPOE guidance was in place during the educational study periods, it is possible that the effect was due to a combination of these 2 approaches. Our pre-intervention ASB treatment rates were consistent with a recent meta-analysis in which the rate of inappropriate treatment of ASB was 45%.17 This meta-analysis found educational and organizational interventions led to a mean absolute risk reduction of 33%. After the education intervention, we saw a 7% decrease in unnecessary treatment of ASB compared to baseline, and a 13% decrease compared to the month just prior to the educational intervention.
Lessons learned from our work included how clear review of local processes can inform quality improvement interventions. For instance, we initially hypothesized that IM clinicians would benefit from point-of-care CDS guidance, but such guidance used alone without educational interventions was not supported by the results. We also determined that the majority of UCs from patients on general medicine units were ordered by ED providers. This revealed an opportunity to implement similar interventions in the ED, as this was the initial point of contact for many of these patients.
As with any clinical intervention, the anticipated benefits should be weighed against potential harm. Using counterbalance measures, we found there was minimal risk in the occurrence of UTI, pyelonephritis, or sepsis if clinicians avoided treating ASB. This finding is consistent with IDSA guideline recommendations and other studies that suggest that withholding treatment for asymptomatic bacteriuria does not lead to worse outcomes.1
This study has several limitations. Data were obtained through review of the electronic health record and therefore documentation may be incomplete. Also, antimicrobials for empiric coverage or treatment for other infections (eg, pneumonia, sepsis) may have confounded our results, as empirical antimicrobials were given to 27% to 45% of patients prior to UC. This was a quality improvement project carried out over defined time intervals, and thus our sample size was limited and not adequately powered to show statistical significance. Additionally, given the bundling of interventions, it is difficult to determine the impact of each intervention independently. Although CDS for UC ordering may not have influenced ordering, it is possible that the IT intervention raised awareness of ASB and influenced treatment practices.
Conclusion
Our work supports the principles of antibiotic stewardship as brought forth by IDSA.16 This work was the effort of a multidisciplinary team, which aligns with recommendations by Daniel and colleagues, published after our study had ended, for reducing overtreatment of ASB.14 Additionally, our study results provided valuable information for our institution. Although improvements in management of ASB were modest, the success of provider education and identification of other work areas and clinicians to target for future intervention were helpful in consideration of further studies. This work will also aid us in developing an expected effect size for future studies. We plan to provide ongoing education for IM providers as well as education in the ED to target providers who make first contact with patients admitted to inpatient services. In addition, the CPOE UC ordering screen message will continue to be used hospital-wide and will be expanded to the ED ordering system. Our interventions, experiences, and challenges may be used by other institutions to design effective antimicrobial stewardship interventions directed towards reducing rates of inappropriate ASB treatment.
Corresponding author: Prasanna P. Narayanan, PharmD, 200 First Street SW, Rochester, MN 55905; narayanan.prasanna@mayo.edu.
Financial disclosures: None.
From the Mayo Clinic, Rochester, MN.
Abstract
Objective: Asymptomatic bacteriuria (ASB) denotes asymptomatic carriage of bacteria within the urinary tract and does not require treatment in most patient populations. Unnecessary antimicrobial treatment has several consequences, including promotion of antimicrobial resistance, potential for medication adverse effects, and risk for Clostridiodes difficile infection. The aim of this quality improvement effort was to decrease both the unnecessary ordering of urine culture studies and unnecessary treatment of ASB.
Methods: This is a single-center study of patients who received care on 3 internal medicine units at a large, academic medical center. We sought to determine the impact of information technology and educational interventions to decrease both inappropriate urine culture ordering and treatment of ASB. Data from included patients were collected over 3 1-month time periods: baseline, post-information technology intervention, and post-educational intervention.
Results: There was a reduction in the percentage of patients who received antibiotics for ASB in the post-education intervention period as compared to baseline (35% vs 42%). The proportion of total urine cultures ordered by internal medicine clinicians did not change after an information technology intervention to redesign the computerized physician order entry screen for urine cultures.
Conclusion: Educational interventions are effective ways to reduce rates of inappropriate treatment of ASB in patients admitted to internal medicine services.
Keywords: asymptomatic bacteriuria, UTI, information technology, education, quality.
Asymptomatic bacteriuria (ASB) is a common condition in which bacteria are recovered from a urine culture (UC) in patients without symptoms suggestive of urinary tract infection (UTI), with no pathologic consequences to most patients who are not treated.1,2 Patients with ASB do not exhibit symptoms of a UTI such as dysuria, increased frequency of urination, increased urgency, suprapubic tenderness, or costovertebral pain. Treatment with antibiotics is not indicated for most patients with ASB.1,3 According to the Infectious Diseases Society of America (IDSA), screening for bacteriuria and treatment for positive results is only indicated during pregnancy and prior to urologic procedures with anticipated breach of the mucosal lining.1
An estimated 20% to 52% of patients in hospital settings receive inappropriate treatment with antibiotics for ASB.4 Unnecessary prescribing of antibiotics has several negative consequences, including increased rates of antibiotic resistance, Clostridioides difficile infection, and medication adverse events, as well as increased health care costs.2,5 Antimicrobial stewardship programs to improve judicious use of antimicrobials are paramount to reducing these consequences, and their importance is heightened with recent requirements for antimicrobial stewardship put forth by The Joint Commission and the Centers for Medicare & Medicaid Services.6,7
A previous review of UC and antimicrobial use in patients for purposes of quality improvement at our institution over a 2-month period showed that of 59 patients with positive UCs, 47 patients (80%) did not have documented symptoms of a UTI. Of these 47 patients with ASB, 29 (61.7%) received antimicrobial treatment unnecessarily (unpublished data). We convened a group of clinicians and nonclinicians representing the areas of infectious disease, pharmacy, microbiology, statistics, and hospital internal medicine (IM) to examine the unnecessary treatment of ASB in our institution. Our objective was to address 2 antimicrobial stewardship issues: inappropriate UC ordering and unnecessary use of antibiotics to treat ASB. Our aim was to reduce the inappropriate ordering of UCs and to reduce treatment of ASB.
Methods
Setting
The study was conducted on 3 IM nursing units with a total of 83 beds at a large tertiary care academic medical center in the midwestern United States, and was approved by the organization’s Institutional Review Board.
Participants
We included all non-pregnant patients aged 18 years or older who received care from an IM primary service. These patients were admitted directly to an IM team through the emergency department (ED) or transferred to an IM team after an initial stay in the intensive care unit.
Data Source
Microbiology laboratory reports generated from the electronic health record were used to identify all patients with a collected UC sample who received care from an IM service prior to discharge. Urine samples were collected by midstream catch or catheterization. Data on urine Gram stain and urine dipstick were not included. Henceforth, the phrase “urine culture order” indicates that a UC was both ordered and performed. Data reports were generated for the month of August 2016 to determine the baseline number of UCs ordered. Charts of patients with positive UCs were reviewed to determine if antibiotics were started for the positive UC and whether the patient had signs or symptoms consistent with a UTI. If antibiotics were started in the absence of signs or symptoms to support a UTI, the patient was determined to have been unnecessarily treated for ASB. Reports were then generated for the month after each intervention was implemented, with the same chart review undertaken for positive UCs. Bacteriuria was defined in our study as the presence of microbial growth greater than 10,000 CFU/mL in UC.
Interventions
Initial analysis by our study group determined that lack of electronic clinical decision support (CDS) at the point of care and provider knowledge gaps in interpreting positive UCs were the 2 main contributors to unnecessary UC orders and unnecessary treatment of positive UCs, respectively. We reviewed the work of other groups who reported interventions to decrease treatment of ASB, ranging from educational presentations to pocket cards and treatment algorithms.8-13 We hypothesized that there would be a decrease in UC orders with CDS embedded in the computerized order entry screen, and that we would decrease unnecessary treatment of positive UCs by educating clinicians on indications for appropriate antibiotic prescribing in the setting of a positive UC.
Information technology intervention. The first intervention implemented involved redesign of the UC ordering screen in the computerized physician order entry (CPOE) system. This intervention went live hospital-wide, including the IM floors, intensive care units, and all other areas except the ED, on February 1, 2017 (Figure 1). The ordering screen required the prescriber to select from a list of appropriate indications for ordering a UC, including urine frequency, urgency, or dysuria; unexplained suprapubic or flank pain; fever in patients without another recognized cause; screening obtained prior to urologic procedure; or screening during pregnancy. An additional message advised prescribers to avoid ordering the culture if the patient had malodorous or cloudy urine, pyuria without urinary symptoms, or had an alternative cause of fever. Before we implemented the information technology (IT) intervention, there had been no specific point-of-care guidance on UC ordering.
Educational intervention.The second intervention, driven by clinical pharmacists, involved active and passive education of prescribers specifically designed to address unnecessary treatment of ASB. The IT intervention with CDS for UC ordering remained live. Presentations designed by the study group summarizing the appropriate indications for ordering a UC, distinguishing ASB from UTI, and discouraging treatment of ASB were delivered via a variety of routes by clinical pharmacists to nurses, nurse practitioners, physician assistants, pharmacists, medical residents, and staff physicians providing care to patients on the 3 IM units over a 1-month period in March 2017. The presentations contained the same basic content, but the information was delivered to target each specific audience group.
Medical residents received a 10-minute live presentation during a conference. Nurse practitioners, physician assistants, and staff physicians received a presentation via email, and highlights of the presentation were delivered by clinical pharmacists at their respective monthly group meetings. A handout was presented to nursing staff at nursing huddles, and presentation slides were distributed by email. Educational posters were posted in the medical resident workrooms, nursing breakrooms, and staff bathrooms on the units.
Outcome Measurements
The endpoints of interest were the percentage of patients with positive UCs unnecessarily treated for ASB before and after each intervention and the number of UCs ordered at baseline and after implementation of each intervention. Counterbalance measures assessed included the incidence of UTI, pyelonephritis, or urosepsis within 7 days of positive UC for patients who did not receive antibiotic treatment for ASB.
Results
Data from a total of 270 cultures were examined from IM nursing units. A total of 117 UCs were ordered during the baseline period before interventions were implemented. For a period of 1 month following activation of the IT intervention, 73 UCs were ordered. For a period of 1 month following the educational interventions, 80 UCs were ordered. Of these, 61 (52%) UCs were positive at baseline, 37 (51%) after the IT intervention, and 41 (51%) after the educational intervention. Patient characteristics were similar between the 3 groups (Table); 64.7% of patients were female in their early to mid-seventies. The majority of UCs were ordered by providers in the ED in all 3 periods examined (51%-70%). The percentage of patients who received antibiotics prior to UC for another indication (including bacteriuria) in the baseline, post-IT intervention, and post-education intervention groups were 30%, 27%, and 45%, respectively.
The study outcomes are summarized in Figure 2. Among patients with positive cultures, there was not a reduction in inappropriate treatment of ASB compared to baseline after the IT intervention (48% vs 42%). Following the education intervention, there was a reduction in unnecessary ASB treatment as compared both to baseline (35% vs 42%) and to post-IT intervention (35% vs 48%). There was no difference between the 3 study periods in the percentage of total UCs ordered by IM clinicians. The counterbalance measure showed that 1 patient who did not receive antibiotics within 7 days of a positive UC developed pyelonephritis, UTI, or sepsis due to a UTI in each intervention group.
Discussion
The results of this study demonstrate the role of multimodal interventions in antimicrobial stewardship and add to the growing body of evidence supporting the work of antimicrobial stewardship programs. Our multidisciplinary study group and multipronged intervention follow recent guideline recommendations for antimicrobial stewardship program interventions against unnecessary treatment of ASB.14 Initial analysis by our study group determined lack of CDS at the point of care and provider knowledge gaps in interpreting positive UCs as the 2 main contributors to unnecessary UC orders and unnecessary treatment of positive UCs in our local practice culture. The IT component of our intervention was intended to provide CDS for ordering UCs, and the education component focused on informing clinicians’ treatment decisions for positive UCs.
It has been suggested that the type of stewardship intervention that is most effective fits the specific needs and resources of an institution.14,15 And although the IDSA does not recommend education as a stand-alone intervention,16 we found it to be an effective intervention for our clinicians in our work environment. However, since the CPOE guidance was in place during the educational study periods, it is possible that the effect was due to a combination of these 2 approaches. Our pre-intervention ASB treatment rates were consistent with a recent meta-analysis in which the rate of inappropriate treatment of ASB was 45%.17 This meta-analysis found educational and organizational interventions led to a mean absolute risk reduction of 33%. After the education intervention, we saw a 7% decrease in unnecessary treatment of ASB compared to baseline, and a 13% decrease compared to the month just prior to the educational intervention.
Lessons learned from our work included how clear review of local processes can inform quality improvement interventions. For instance, we initially hypothesized that IM clinicians would benefit from point-of-care CDS guidance, but such guidance used alone without educational interventions was not supported by the results. We also determined that the majority of UCs from patients on general medicine units were ordered by ED providers. This revealed an opportunity to implement similar interventions in the ED, as this was the initial point of contact for many of these patients.
As with any clinical intervention, the anticipated benefits should be weighed against potential harm. Using counterbalance measures, we found there was minimal risk in the occurrence of UTI, pyelonephritis, or sepsis if clinicians avoided treating ASB. This finding is consistent with IDSA guideline recommendations and other studies that suggest that withholding treatment for asymptomatic bacteriuria does not lead to worse outcomes.1
This study has several limitations. Data were obtained through review of the electronic health record and therefore documentation may be incomplete. Also, antimicrobials for empiric coverage or treatment for other infections (eg, pneumonia, sepsis) may have confounded our results, as empirical antimicrobials were given to 27% to 45% of patients prior to UC. This was a quality improvement project carried out over defined time intervals, and thus our sample size was limited and not adequately powered to show statistical significance. Additionally, given the bundling of interventions, it is difficult to determine the impact of each intervention independently. Although CDS for UC ordering may not have influenced ordering, it is possible that the IT intervention raised awareness of ASB and influenced treatment practices.
Conclusion
Our work supports the principles of antibiotic stewardship as brought forth by IDSA.16 This work was the effort of a multidisciplinary team, which aligns with recommendations by Daniel and colleagues, published after our study had ended, for reducing overtreatment of ASB.14 Additionally, our study results provided valuable information for our institution. Although improvements in management of ASB were modest, the success of provider education and identification of other work areas and clinicians to target for future intervention were helpful in consideration of further studies. This work will also aid us in developing an expected effect size for future studies. We plan to provide ongoing education for IM providers as well as education in the ED to target providers who make first contact with patients admitted to inpatient services. In addition, the CPOE UC ordering screen message will continue to be used hospital-wide and will be expanded to the ED ordering system. Our interventions, experiences, and challenges may be used by other institutions to design effective antimicrobial stewardship interventions directed towards reducing rates of inappropriate ASB treatment.
Corresponding author: Prasanna P. Narayanan, PharmD, 200 First Street SW, Rochester, MN 55905; narayanan.prasanna@mayo.edu.
Financial disclosures: None.
References
1. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68:e83–75.
2. Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an antimicrobial stewardship approach for urinary catheter-associated asymptomatic bacteriuria. JAMA Intern Med. 2015;175:1120-1127.
3. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36:309-332.
4. Trautner BW. Asymptomatic bacteriuria: when the treatment is worse than the disease. Nat Rev Urol. 2011;9:85-93.
5. Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010;340:c2096.
7. Federal Register. Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care.Centers for Medicare & Medicaid Services. June 16, 2016. CMS-3295-P
8. Hartley SE, Kuhn L, Valley S, et al. Evaluating a hospitalist-based intervention to decrease unnecessary antimicrobial use in patients with asymptomatic bacteriuria. Infect Control Hosp Epidemiol. 2016;37:1044-1051.
9. Pavese P, Saurel N, Labarere J, et al. Does an educational session with an infectious diseases physician reduce the use of inappropriate antibiotic therapy for inpatients with positive urine culture results? A controlled before-and-after study. Infect Control Hosp Epidemiol. 2009;30:596-599.
10. Kelley D, Aaronson P, Poon E, et al. Evaluation of an antimicrobial stewardship approach to minimize overuse of antibiotics in patients with asymptomatic bacteriuria. Infect Control Hosp Epidemiol. 2014;35:193-195.
11. Chowdhury F, Sarkar K, Branche A, et al. Preventing the inappropriate treatment of asymptomatic bacteriuria at a community teaching hospital. J Community Hosp Intern Med Perspect. 2012;2.
12. Bonnal C, Baune B, Mion M, et al. Bacteriuria in a geriatric hospital: impact of an antibiotic improvement program. J Am Med Dir Assoc. 2008;9:605-609.
13. Linares LA, Thornton DJ, Strymish J, et al. Electronic memorandum decreases unnecessary antimicrobial use for asymptomatic bacteriuria and culture-negative pyuria. Infect Control Hosp Epidemiol. 2011;32:644-648.
14. Daniel M, Keller S, Mozafarihashjin M, et al. An implementation guide to reducing overtreatment of asymptomatic bacteriuria. JAMA Intern Med. 2018;178:271-276.
15. Redwood R, Knobloch MJ, Pellegrini DC, et al. Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings. Antimicrob Resist Infect Control. 2018;7:4.
16. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62:e51–e7.
17. Flokas ME, Andreatos N, Alevizakos M, et al. Inappropriate management of asymptomatic patients with positive urine cultures: a systematic review and meta-analysis. Open Forum Infect Dis. 2017;4:1-10.
References
1. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68:e83–75.
2. Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an antimicrobial stewardship approach for urinary catheter-associated asymptomatic bacteriuria. JAMA Intern Med. 2015;175:1120-1127.
3. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36:309-332.
4. Trautner BW. Asymptomatic bacteriuria: when the treatment is worse than the disease. Nat Rev Urol. 2011;9:85-93.
5. Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010;340:c2096.
7. Federal Register. Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care.Centers for Medicare & Medicaid Services. June 16, 2016. CMS-3295-P
8. Hartley SE, Kuhn L, Valley S, et al. Evaluating a hospitalist-based intervention to decrease unnecessary antimicrobial use in patients with asymptomatic bacteriuria. Infect Control Hosp Epidemiol. 2016;37:1044-1051.
9. Pavese P, Saurel N, Labarere J, et al. Does an educational session with an infectious diseases physician reduce the use of inappropriate antibiotic therapy for inpatients with positive urine culture results? A controlled before-and-after study. Infect Control Hosp Epidemiol. 2009;30:596-599.
10. Kelley D, Aaronson P, Poon E, et al. Evaluation of an antimicrobial stewardship approach to minimize overuse of antibiotics in patients with asymptomatic bacteriuria. Infect Control Hosp Epidemiol. 2014;35:193-195.
11. Chowdhury F, Sarkar K, Branche A, et al. Preventing the inappropriate treatment of asymptomatic bacteriuria at a community teaching hospital. J Community Hosp Intern Med Perspect. 2012;2.
12. Bonnal C, Baune B, Mion M, et al. Bacteriuria in a geriatric hospital: impact of an antibiotic improvement program. J Am Med Dir Assoc. 2008;9:605-609.
13. Linares LA, Thornton DJ, Strymish J, et al. Electronic memorandum decreases unnecessary antimicrobial use for asymptomatic bacteriuria and culture-negative pyuria. Infect Control Hosp Epidemiol. 2011;32:644-648.
14. Daniel M, Keller S, Mozafarihashjin M, et al. An implementation guide to reducing overtreatment of asymptomatic bacteriuria. JAMA Intern Med. 2018;178:271-276.
15. Redwood R, Knobloch MJ, Pellegrini DC, et al. Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings. Antimicrob Resist Infect Control. 2018;7:4.
16. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62:e51–e7.
17. Flokas ME, Andreatos N, Alevizakos M, et al. Inappropriate management of asymptomatic patients with positive urine cultures: a systematic review and meta-analysis. Open Forum Infect Dis. 2017;4:1-10.
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.
METHOD
This 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) NPO starting within 12 hours of admission, and 3) indication (eg, imaging study, procedure, or operation). We also conducted sensitivity analyses limited to 1 NPO order per patient (N = 673) to assess independence of the orders.
We then further categorized indications for the orders in detail and identified those with a sample size >10. This resulted in 779 orders that were included in the analysis by indication. We reviewed the literature by indication to determine suggested minimally required fasting durations to compare fasting duration in our patients to current evidence-based recommendations.
For descriptive statistics, we used median with interquartile range (IQR) for continuous variables and percentage for discrete variables; chi-square tests were used for comparison of discrete variables. All P values were two-tailed and P < 0.05 was considered significant.
RESULTS
Median length of 924 orders was 12.7 hours (IQR, 10.1-15.7 hours); 190 (20.1%), 577 (62.4%), and 157 (21.0%) orders were indicated for imaging studies, procedures, and operations, respectively. NPO started at midnight in 662 (71.6%) and within 12 hours of admission in 210 (22.7%) orders.
The indicated interventions were not performed in 183 (19.8%) orders, mostly as a result of a change in plan (75/183, 41.0%) or scheduling barriers (43/183, 23.5%). Plan changes occurred when, for example, input from a consulting service was obtained or the supervising physician decided not to pursue the intervention. Scheduling barriers included slots being unavailable and conflicts with other tasks/tests. Notably, only in 1 of 183 (0.5%) orders, the intervention was cancelled because the patient ate (Table 1).
Table 1
NPO orders starting at midnight were associated with higher likelihood of indicated interventions being performed (546/662, 82.5% vs. 195/262, 74.4%; P = 0.006), as were NPO orders starting more than 12 hours after admission (601/714, 84.2% vs. 140/210, 66.7%; P < 0.001). Imaging studies were more likely to be performed than procedures or operations (170/190, 89.5% vs. 452/577, 78.3% vs. 119/157, 75.8%; P = 0.001). These results were unchanged when the analyses were limited to 1 order per patient.
When analyzed by indication, the median durations of NPO orders ranged from 8.3 hours in kidney ultrasound to 13.9 hours in upper endoscopy. These were slightly shortened, most by 1 to 2 hours, when the duration was calculated from start of the order to initiation of the intervention. The literature review identified, for most indications, that the minimally required length of NPO were 2 to 4 hours, generally 6 to 8 hours shorter than the median NPO length in this study sample. Furthermore, for indications such as computed tomography with intravenous contrast and abdominal ultrasound, the literature suggested NPO may be unnecessary (Table 2).6-9,16-30
Table 2
DISCUSSION
We analyzed a comprehensive set of NPO orders written for interventions in medical inpatients at an academic medical center. NPO started at midnight in 71.6% of the analyzed orders. In 1 in 5 NPO orders, the indicated intervention was not performed largely due to a change in plan or scheduling barriers. In most NPO orders in which the indicated interventions were performed, patients were kept fasting either unnecessarily or much longer than needed. This study is the first of its kind in evaluating NPO-ordering practices across multiple indications and comparing them with the best available evidence.
These results suggest current NPO practice in the hospital is suboptimal, and limited literature measures the magnitude of this issue.6,7 An important aspect of our study findings is that, in a substantial number of NPO orders, the indicated interventions were not performed for seemingly avoidable reasons. These issues may be attributable to clinicians’ preemptive decisions or lack of knowledge, or inefficiency in the healthcare system. Minimizing anticipatory NPO may carry drawbacks such as delays in interventions, and limited evidence links excessive NPO with clinical outcomes (eg, length of stay, readmission, or death). However, from the patients’ perspective, it is important to be kept fasting only for clinical benefit. Hence, this calls for substantial improvement of NPO practices.
Furthermore, results indicated that the duration of most NPO orders was longer than the minimal duration currently suggested in the literature. Whereas strong evidence suggests that no longer than 2 hours of fasting is generally required for preoperative purposes,8 limited studies have evaluated the required length of NPO orders in imaging studies and procedures,9-11 which comprised most of the orders in the study cohort. For example, in upper endoscopy, 2 small studies suggested fasting for 1 or 2 hours may provide as good visualization as with the conventional 6 to 8 hours of fasting.9,10 In coronary angiography, a retrospective study demonstrated fasting may be unnecessary.11 Due to lack of robust evidence, guidelines for these interventions either do not specify the required length of fasting or have not changed the conventional recommendations for fasting, leading to large variations in fasting policies by institution.6,12 Therefore, more studies are needed to define required length of fasting for those indications and to measure the exact magnitude of excessive fasting in the hospital.
One of the limitations of this study is generalizability because NPO practice may considerably vary by institution as suggested in the literature.4,6,12 Conversely, studies have suggested that excessive fasting exists in other institutions.3,4,13 Thus, this study adds further evidence of the prevalence of suboptimal NPO practice to the literature and provides a benchmark that other institutions can refer to when evaluating their own NPO practice. Another limitation is the assumption that the evidence for minimally required NPO duration can be applied to our patient samples. Specifically, the American Society of Anesthesiologists guideline states that preoperative or preprocedural fasting may need to be longer than 2 hours for 1) patients with comorbidities that can affect gastric emptying or fluid volume such as obesity, diabetes, emergency care, and enteral tube feeding, and 2) patients in whom airway management might be difficult.8 We did not consider these possibilities, and as these conditions are prevalent in medical inpatients, we may be overstating the excessiveness of fasting orders. On the other hand, especially in patients with diabetes, prolonged fasting may cause harm by inducing hypoglycemia.14 Further, no study rigorously evaluated safety of shortening the fasting period for these subsets of patients. Therefore, it is necessary to establish optimal duration of NPO and to improve NPO ordering practice even in these patient subsets.
While more research is needed to define optimal duration of NPO for various interventions and specific subsets of patients and to establish linkage of excessive NPO with clinical outcomes, our data provide insights into immediate actions that can be taken by clinicians to improve NPO practices using our data as a benchmark. First, institutions can establish more robust practice guidelines or institutional protocols for NPO orders. Successful interventions have been reported,15 and breaking the habit of ordering NPO after midnight is certainly possible. We recommend each institution does so by indication, potentially through interdepartmental work groups involving appropriate departments such as radiology, surgery, and medicine. Second, institutional guidelines or protocols can be incorporated in the ordering system to enable appropriate NPO ordering. For example, at our institution, we are modifying the order screens for ultrasound-guided paracentesis and thoracentesis to indicate that NPO is not necessary for these procedures unless sedation is anticipated. We conclude that, at any institution, efforts in improving the NPO practice are urgently warranted to minimize unnecessary fasting.
Disclosures
This publication was supported by Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. The authors report no financial conflicts of interest.
References
1. Carey SK, Conchin S, Bloomfield-Stone S. A qualitative study into the impact of fasting within a large tertiary hospital in Australia - the patients’ perspective. J Clin Nurs. 2015;24:1946-1954. PubMed
2. Kyriakos G, Calleja-Fernández A, Ávila-Turcios D, Cano-Rodríguez I, Ballesteros Pomar MD, Vidal-Casariego A. Prolonged fasting with fluid therapy is related to poorer outcomes in medical patients. Nutr Hosp. 2013;28:1710-1716. PubMed
3. Rycroft-Malone J, Seers K, Crichton N, et al. A pragmatic cluster randomised trial evaluating three implementation interventions. Implement Sci. 2012;7:80. PubMed
4. Breuer JP, Bosse G, Seifert S, et al. Pre-operative fasting: a nationwide survey of German anaesthesia departments. Acta Anaesthesiol Scand. 2010;54:313-320. PubMed
5. Sorita A, Thongprayoon C, Ahmed A, et al. Frequency and appropriateness of fasting orders in the hospital. Mayo Clin Proc. 2015;90:1225-1232. PubMed
6. Lee BY, Ok JJ, Abdelaziz Elsayed AA, Kim Y, Han DH. Preparative fasting for contrast-enhanced CT: reconsideration. Radiology. 2012;263:444-450. PubMed
7. Manchikanti L, Malla Y, Wargo BW, Fellows B. Preoperative fasting before interventional techniques: is it necessary or evidence-based? Pain Physician. 2011;14:459-467. PubMed
8. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114:495-511. PubMed
9. Koeppe AT, Lubini M, Bonadeo NM, Moraes I Jr, Fornari F. Comfort, safety and quality of upper gastrointestinal endoscopy after 2 hours fasting: a randomized controlled trial. BMC Gastroenterol. 2013;13:158. PubMed
10. De Silva AP, Amarasiri L, Liyanage MN, Kottachchi D, Dassanayake AS, de Silva HJ. One-hour fast for water and six-hour fast for solids prior to endoscopy provides good endoscopic vision and results in minimum patient discomfort. J Gastroenterol Hepatol. 2009;24:1095-1097. PubMed
11. Hamid T, Aleem Q, Lau Y, et al. Pre-procedural fasting for coronary interventions: is it time to change practice? Heart. 2014;100:658-661. PubMed
12. Ahmed SU, Tonidandel W, Trella J, Martin NM, Chang Y. Peri-procedural protocols for interventional pain management techniques: a survey of US pain centers. Pain Physician. 2005;8:181-185. PubMed
13. Franklin GA, McClave SA, Hurt RT, et al. Physician-delivered malnutrition: why do patients receive nothing by mouth or a clear liquid diet in a university hospital setting? JPEN J Parenter Enteral Nutr. 2011;35:337-342. PubMed
14. Aldasouqi S, Sheikh A, Klosterman P, et al. Hypoglycemia in patients with diabetes who are fasting for laboratory blood tests: the Cape Girardeau Hypoglycemia En Route Prevention Program. Postgrad Med. 2013;125:136-143. PubMed
15. Aguilar-Nascimento JE, Salomão AB, Caporossi C, Diniz BN. Clinical benefits after the implementation of a multimodal perioperative protocol in elderly patients. Arq Gastroenterol. 2010;47:178-183. PubMed
16. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr. 2010;23: 1115-1127. PubMed
17. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013;26:921-964. PubMed
18. Sinan T, Leven H, Sheikh M. Is fasting a necessary preparation for abdominal ultrasound? BMC Med Imaging. 2003;3:1. PubMed
19. Garcia DA, Froes TR. Importance of fasting in preparing dogs for abdominal ultrasound examination of specific organs. J Small Anim Pract. 2014;55:630-634. PubMed
20. Kidney ultrasound. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. Health Library, Johns Hopkins Medicine. Available at: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/urology/kidney_ultrasound_92,P07709/. Accessed August 17, 2015.
21. Surasi DS, Bhambhvani P, Baldwin JA, Almodovar SE, O’Malley JP. 18F-FDG PET and PET/CT patient preparation: a review of the literature. J Nucl Med Technol. 2014;42:5-13. PubMed
22. Kang SH, Hyun JJ. Preparation and patient evaluation for safe gastrointestinal endoscopy. Clin Endosc. 2013;46:212-218. PubMed
23. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2011;28:556-569. PubMed
24. ASGE Standards of Practice Committee, Saltzman JR, Cash BD, Pasha SF, et al. Bowel preparation before colonoscopy. Gastrointest Endosc. 2015;81:781-794. PubMed
25. Hassan C, Bretthauer M, Kaminski MF, et al; European Society of Gastrointestinal Endoscopy. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2013;45:142-150. PubMed
26. Du Rand IA, Blaikley J, Booton R, et al; British Thoracic Society Bronchoscopy Guideline Group. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013;68(suppl 1):i1-i44. PubMed
27. Thoracentesis. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. Health Library, Johns Hopkins Medicine. Available at: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/thoracentesis_92,P07761/. Accessed August 18, 2015.
28. Runyon BA. Diagnostic and therapeutic abdominal paracentesis. UpToDate. Available at: http://www.uptodate.com/contents/diagnostic-and-therapeutic-abdominal-paracentesis. Published February 18, 2014. Accessed August 18, 2015.
29. Granata A, Fiorini F, Andrulli S, et al. Doppler ultrasound and renal artery stenosis: An overview. J Ultrasound. 2009;12:133-143. PubMed
30. Gerhard-Herman M, Gardin JM, Jaff M, et al. Guidelines for noninvasive vascular laboratory testing: a report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology. Vasc Med. 2006;11:183-200. PubMed
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.
METHOD
This 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) NPO starting within 12 hours of admission, and 3) indication (eg, imaging study, procedure, or operation). We also conducted sensitivity analyses limited to 1 NPO order per patient (N = 673) to assess independence of the orders.
We then further categorized indications for the orders in detail and identified those with a sample size >10. This resulted in 779 orders that were included in the analysis by indication. We reviewed the literature by indication to determine suggested minimally required fasting durations to compare fasting duration in our patients to current evidence-based recommendations.
For descriptive statistics, we used median with interquartile range (IQR) for continuous variables and percentage for discrete variables; chi-square tests were used for comparison of discrete variables. All P values were two-tailed and P < 0.05 was considered significant.
RESULTS
Median length of 924 orders was 12.7 hours (IQR, 10.1-15.7 hours); 190 (20.1%), 577 (62.4%), and 157 (21.0%) orders were indicated for imaging studies, procedures, and operations, respectively. NPO started at midnight in 662 (71.6%) and within 12 hours of admission in 210 (22.7%) orders.
The indicated interventions were not performed in 183 (19.8%) orders, mostly as a result of a change in plan (75/183, 41.0%) or scheduling barriers (43/183, 23.5%). Plan changes occurred when, for example, input from a consulting service was obtained or the supervising physician decided not to pursue the intervention. Scheduling barriers included slots being unavailable and conflicts with other tasks/tests. Notably, only in 1 of 183 (0.5%) orders, the intervention was cancelled because the patient ate (Table 1).
Table 1
NPO orders starting at midnight were associated with higher likelihood of indicated interventions being performed (546/662, 82.5% vs. 195/262, 74.4%; P = 0.006), as were NPO orders starting more than 12 hours after admission (601/714, 84.2% vs. 140/210, 66.7%; P < 0.001). Imaging studies were more likely to be performed than procedures or operations (170/190, 89.5% vs. 452/577, 78.3% vs. 119/157, 75.8%; P = 0.001). These results were unchanged when the analyses were limited to 1 order per patient.
When analyzed by indication, the median durations of NPO orders ranged from 8.3 hours in kidney ultrasound to 13.9 hours in upper endoscopy. These were slightly shortened, most by 1 to 2 hours, when the duration was calculated from start of the order to initiation of the intervention. The literature review identified, for most indications, that the minimally required length of NPO were 2 to 4 hours, generally 6 to 8 hours shorter than the median NPO length in this study sample. Furthermore, for indications such as computed tomography with intravenous contrast and abdominal ultrasound, the literature suggested NPO may be unnecessary (Table 2).6-9,16-30
Table 2
DISCUSSION
We analyzed a comprehensive set of NPO orders written for interventions in medical inpatients at an academic medical center. NPO started at midnight in 71.6% of the analyzed orders. In 1 in 5 NPO orders, the indicated intervention was not performed largely due to a change in plan or scheduling barriers. In most NPO orders in which the indicated interventions were performed, patients were kept fasting either unnecessarily or much longer than needed. This study is the first of its kind in evaluating NPO-ordering practices across multiple indications and comparing them with the best available evidence.
These results suggest current NPO practice in the hospital is suboptimal, and limited literature measures the magnitude of this issue.6,7 An important aspect of our study findings is that, in a substantial number of NPO orders, the indicated interventions were not performed for seemingly avoidable reasons. These issues may be attributable to clinicians’ preemptive decisions or lack of knowledge, or inefficiency in the healthcare system. Minimizing anticipatory NPO may carry drawbacks such as delays in interventions, and limited evidence links excessive NPO with clinical outcomes (eg, length of stay, readmission, or death). However, from the patients’ perspective, it is important to be kept fasting only for clinical benefit. Hence, this calls for substantial improvement of NPO practices.
Furthermore, results indicated that the duration of most NPO orders was longer than the minimal duration currently suggested in the literature. Whereas strong evidence suggests that no longer than 2 hours of fasting is generally required for preoperative purposes,8 limited studies have evaluated the required length of NPO orders in imaging studies and procedures,9-11 which comprised most of the orders in the study cohort. For example, in upper endoscopy, 2 small studies suggested fasting for 1 or 2 hours may provide as good visualization as with the conventional 6 to 8 hours of fasting.9,10 In coronary angiography, a retrospective study demonstrated fasting may be unnecessary.11 Due to lack of robust evidence, guidelines for these interventions either do not specify the required length of fasting or have not changed the conventional recommendations for fasting, leading to large variations in fasting policies by institution.6,12 Therefore, more studies are needed to define required length of fasting for those indications and to measure the exact magnitude of excessive fasting in the hospital.
One of the limitations of this study is generalizability because NPO practice may considerably vary by institution as suggested in the literature.4,6,12 Conversely, studies have suggested that excessive fasting exists in other institutions.3,4,13 Thus, this study adds further evidence of the prevalence of suboptimal NPO practice to the literature and provides a benchmark that other institutions can refer to when evaluating their own NPO practice. Another limitation is the assumption that the evidence for minimally required NPO duration can be applied to our patient samples. Specifically, the American Society of Anesthesiologists guideline states that preoperative or preprocedural fasting may need to be longer than 2 hours for 1) patients with comorbidities that can affect gastric emptying or fluid volume such as obesity, diabetes, emergency care, and enteral tube feeding, and 2) patients in whom airway management might be difficult.8 We did not consider these possibilities, and as these conditions are prevalent in medical inpatients, we may be overstating the excessiveness of fasting orders. On the other hand, especially in patients with diabetes, prolonged fasting may cause harm by inducing hypoglycemia.14 Further, no study rigorously evaluated safety of shortening the fasting period for these subsets of patients. Therefore, it is necessary to establish optimal duration of NPO and to improve NPO ordering practice even in these patient subsets.
While more research is needed to define optimal duration of NPO for various interventions and specific subsets of patients and to establish linkage of excessive NPO with clinical outcomes, our data provide insights into immediate actions that can be taken by clinicians to improve NPO practices using our data as a benchmark. First, institutions can establish more robust practice guidelines or institutional protocols for NPO orders. Successful interventions have been reported,15 and breaking the habit of ordering NPO after midnight is certainly possible. We recommend each institution does so by indication, potentially through interdepartmental work groups involving appropriate departments such as radiology, surgery, and medicine. Second, institutional guidelines or protocols can be incorporated in the ordering system to enable appropriate NPO ordering. For example, at our institution, we are modifying the order screens for ultrasound-guided paracentesis and thoracentesis to indicate that NPO is not necessary for these procedures unless sedation is anticipated. We conclude that, at any institution, efforts in improving the NPO practice are urgently warranted to minimize unnecessary fasting.
Disclosures
This publication was supported by Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. The authors report no financial conflicts of interest.
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.
METHOD
This 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) NPO starting within 12 hours of admission, and 3) indication (eg, imaging study, procedure, or operation). We also conducted sensitivity analyses limited to 1 NPO order per patient (N = 673) to assess independence of the orders.
We then further categorized indications for the orders in detail and identified those with a sample size >10. This resulted in 779 orders that were included in the analysis by indication. We reviewed the literature by indication to determine suggested minimally required fasting durations to compare fasting duration in our patients to current evidence-based recommendations.
For descriptive statistics, we used median with interquartile range (IQR) for continuous variables and percentage for discrete variables; chi-square tests were used for comparison of discrete variables. All P values were two-tailed and P < 0.05 was considered significant.
RESULTS
Median length of 924 orders was 12.7 hours (IQR, 10.1-15.7 hours); 190 (20.1%), 577 (62.4%), and 157 (21.0%) orders were indicated for imaging studies, procedures, and operations, respectively. NPO started at midnight in 662 (71.6%) and within 12 hours of admission in 210 (22.7%) orders.
The indicated interventions were not performed in 183 (19.8%) orders, mostly as a result of a change in plan (75/183, 41.0%) or scheduling barriers (43/183, 23.5%). Plan changes occurred when, for example, input from a consulting service was obtained or the supervising physician decided not to pursue the intervention. Scheduling barriers included slots being unavailable and conflicts with other tasks/tests. Notably, only in 1 of 183 (0.5%) orders, the intervention was cancelled because the patient ate (Table 1).
Table 1
NPO orders starting at midnight were associated with higher likelihood of indicated interventions being performed (546/662, 82.5% vs. 195/262, 74.4%; P = 0.006), as were NPO orders starting more than 12 hours after admission (601/714, 84.2% vs. 140/210, 66.7%; P < 0.001). Imaging studies were more likely to be performed than procedures or operations (170/190, 89.5% vs. 452/577, 78.3% vs. 119/157, 75.8%; P = 0.001). These results were unchanged when the analyses were limited to 1 order per patient.
When analyzed by indication, the median durations of NPO orders ranged from 8.3 hours in kidney ultrasound to 13.9 hours in upper endoscopy. These were slightly shortened, most by 1 to 2 hours, when the duration was calculated from start of the order to initiation of the intervention. The literature review identified, for most indications, that the minimally required length of NPO were 2 to 4 hours, generally 6 to 8 hours shorter than the median NPO length in this study sample. Furthermore, for indications such as computed tomography with intravenous contrast and abdominal ultrasound, the literature suggested NPO may be unnecessary (Table 2).6-9,16-30
Table 2
DISCUSSION
We analyzed a comprehensive set of NPO orders written for interventions in medical inpatients at an academic medical center. NPO started at midnight in 71.6% of the analyzed orders. In 1 in 5 NPO orders, the indicated intervention was not performed largely due to a change in plan or scheduling barriers. In most NPO orders in which the indicated interventions were performed, patients were kept fasting either unnecessarily or much longer than needed. This study is the first of its kind in evaluating NPO-ordering practices across multiple indications and comparing them with the best available evidence.
These results suggest current NPO practice in the hospital is suboptimal, and limited literature measures the magnitude of this issue.6,7 An important aspect of our study findings is that, in a substantial number of NPO orders, the indicated interventions were not performed for seemingly avoidable reasons. These issues may be attributable to clinicians’ preemptive decisions or lack of knowledge, or inefficiency in the healthcare system. Minimizing anticipatory NPO may carry drawbacks such as delays in interventions, and limited evidence links excessive NPO with clinical outcomes (eg, length of stay, readmission, or death). However, from the patients’ perspective, it is important to be kept fasting only for clinical benefit. Hence, this calls for substantial improvement of NPO practices.
Furthermore, results indicated that the duration of most NPO orders was longer than the minimal duration currently suggested in the literature. Whereas strong evidence suggests that no longer than 2 hours of fasting is generally required for preoperative purposes,8 limited studies have evaluated the required length of NPO orders in imaging studies and procedures,9-11 which comprised most of the orders in the study cohort. For example, in upper endoscopy, 2 small studies suggested fasting for 1 or 2 hours may provide as good visualization as with the conventional 6 to 8 hours of fasting.9,10 In coronary angiography, a retrospective study demonstrated fasting may be unnecessary.11 Due to lack of robust evidence, guidelines for these interventions either do not specify the required length of fasting or have not changed the conventional recommendations for fasting, leading to large variations in fasting policies by institution.6,12 Therefore, more studies are needed to define required length of fasting for those indications and to measure the exact magnitude of excessive fasting in the hospital.
One of the limitations of this study is generalizability because NPO practice may considerably vary by institution as suggested in the literature.4,6,12 Conversely, studies have suggested that excessive fasting exists in other institutions.3,4,13 Thus, this study adds further evidence of the prevalence of suboptimal NPO practice to the literature and provides a benchmark that other institutions can refer to when evaluating their own NPO practice. Another limitation is the assumption that the evidence for minimally required NPO duration can be applied to our patient samples. Specifically, the American Society of Anesthesiologists guideline states that preoperative or preprocedural fasting may need to be longer than 2 hours for 1) patients with comorbidities that can affect gastric emptying or fluid volume such as obesity, diabetes, emergency care, and enteral tube feeding, and 2) patients in whom airway management might be difficult.8 We did not consider these possibilities, and as these conditions are prevalent in medical inpatients, we may be overstating the excessiveness of fasting orders. On the other hand, especially in patients with diabetes, prolonged fasting may cause harm by inducing hypoglycemia.14 Further, no study rigorously evaluated safety of shortening the fasting period for these subsets of patients. Therefore, it is necessary to establish optimal duration of NPO and to improve NPO ordering practice even in these patient subsets.
While more research is needed to define optimal duration of NPO for various interventions and specific subsets of patients and to establish linkage of excessive NPO with clinical outcomes, our data provide insights into immediate actions that can be taken by clinicians to improve NPO practices using our data as a benchmark. First, institutions can establish more robust practice guidelines or institutional protocols for NPO orders. Successful interventions have been reported,15 and breaking the habit of ordering NPO after midnight is certainly possible. We recommend each institution does so by indication, potentially through interdepartmental work groups involving appropriate departments such as radiology, surgery, and medicine. Second, institutional guidelines or protocols can be incorporated in the ordering system to enable appropriate NPO ordering. For example, at our institution, we are modifying the order screens for ultrasound-guided paracentesis and thoracentesis to indicate that NPO is not necessary for these procedures unless sedation is anticipated. We conclude that, at any institution, efforts in improving the NPO practice are urgently warranted to minimize unnecessary fasting.
Disclosures
This publication was supported by Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. The authors report no financial conflicts of interest.
References
1. Carey SK, Conchin S, Bloomfield-Stone S. A qualitative study into the impact of fasting within a large tertiary hospital in Australia - the patients’ perspective. J Clin Nurs. 2015;24:1946-1954. PubMed
2. Kyriakos G, Calleja-Fernández A, Ávila-Turcios D, Cano-Rodríguez I, Ballesteros Pomar MD, Vidal-Casariego A. Prolonged fasting with fluid therapy is related to poorer outcomes in medical patients. Nutr Hosp. 2013;28:1710-1716. PubMed
3. Rycroft-Malone J, Seers K, Crichton N, et al. A pragmatic cluster randomised trial evaluating three implementation interventions. Implement Sci. 2012;7:80. PubMed
4. Breuer JP, Bosse G, Seifert S, et al. Pre-operative fasting: a nationwide survey of German anaesthesia departments. Acta Anaesthesiol Scand. 2010;54:313-320. PubMed
5. Sorita A, Thongprayoon C, Ahmed A, et al. Frequency and appropriateness of fasting orders in the hospital. Mayo Clin Proc. 2015;90:1225-1232. PubMed
6. Lee BY, Ok JJ, Abdelaziz Elsayed AA, Kim Y, Han DH. Preparative fasting for contrast-enhanced CT: reconsideration. Radiology. 2012;263:444-450. PubMed
7. Manchikanti L, Malla Y, Wargo BW, Fellows B. Preoperative fasting before interventional techniques: is it necessary or evidence-based? Pain Physician. 2011;14:459-467. PubMed
8. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114:495-511. PubMed
9. Koeppe AT, Lubini M, Bonadeo NM, Moraes I Jr, Fornari F. Comfort, safety and quality of upper gastrointestinal endoscopy after 2 hours fasting: a randomized controlled trial. BMC Gastroenterol. 2013;13:158. PubMed
10. De Silva AP, Amarasiri L, Liyanage MN, Kottachchi D, Dassanayake AS, de Silva HJ. One-hour fast for water and six-hour fast for solids prior to endoscopy provides good endoscopic vision and results in minimum patient discomfort. J Gastroenterol Hepatol. 2009;24:1095-1097. PubMed
11. Hamid T, Aleem Q, Lau Y, et al. Pre-procedural fasting for coronary interventions: is it time to change practice? Heart. 2014;100:658-661. PubMed
12. Ahmed SU, Tonidandel W, Trella J, Martin NM, Chang Y. Peri-procedural protocols for interventional pain management techniques: a survey of US pain centers. Pain Physician. 2005;8:181-185. PubMed
13. Franklin GA, McClave SA, Hurt RT, et al. Physician-delivered malnutrition: why do patients receive nothing by mouth or a clear liquid diet in a university hospital setting? JPEN J Parenter Enteral Nutr. 2011;35:337-342. PubMed
14. Aldasouqi S, Sheikh A, Klosterman P, et al. Hypoglycemia in patients with diabetes who are fasting for laboratory blood tests: the Cape Girardeau Hypoglycemia En Route Prevention Program. Postgrad Med. 2013;125:136-143. PubMed
15. Aguilar-Nascimento JE, Salomão AB, Caporossi C, Diniz BN. Clinical benefits after the implementation of a multimodal perioperative protocol in elderly patients. Arq Gastroenterol. 2010;47:178-183. PubMed
16. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr. 2010;23: 1115-1127. PubMed
17. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013;26:921-964. PubMed
18. Sinan T, Leven H, Sheikh M. Is fasting a necessary preparation for abdominal ultrasound? BMC Med Imaging. 2003;3:1. PubMed
19. Garcia DA, Froes TR. Importance of fasting in preparing dogs for abdominal ultrasound examination of specific organs. J Small Anim Pract. 2014;55:630-634. PubMed
20. Kidney ultrasound. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. Health Library, Johns Hopkins Medicine. Available at: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/urology/kidney_ultrasound_92,P07709/. Accessed August 17, 2015.
21. Surasi DS, Bhambhvani P, Baldwin JA, Almodovar SE, O’Malley JP. 18F-FDG PET and PET/CT patient preparation: a review of the literature. J Nucl Med Technol. 2014;42:5-13. PubMed
22. Kang SH, Hyun JJ. Preparation and patient evaluation for safe gastrointestinal endoscopy. Clin Endosc. 2013;46:212-218. PubMed
23. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2011;28:556-569. PubMed
24. ASGE Standards of Practice Committee, Saltzman JR, Cash BD, Pasha SF, et al. Bowel preparation before colonoscopy. Gastrointest Endosc. 2015;81:781-794. PubMed
25. Hassan C, Bretthauer M, Kaminski MF, et al; European Society of Gastrointestinal Endoscopy. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2013;45:142-150. PubMed
26. Du Rand IA, Blaikley J, Booton R, et al; British Thoracic Society Bronchoscopy Guideline Group. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013;68(suppl 1):i1-i44. PubMed
27. Thoracentesis. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. Health Library, Johns Hopkins Medicine. Available at: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/thoracentesis_92,P07761/. Accessed August 18, 2015.
28. Runyon BA. Diagnostic and therapeutic abdominal paracentesis. UpToDate. Available at: http://www.uptodate.com/contents/diagnostic-and-therapeutic-abdominal-paracentesis. Published February 18, 2014. Accessed August 18, 2015.
29. Granata A, Fiorini F, Andrulli S, et al. Doppler ultrasound and renal artery stenosis: An overview. J Ultrasound. 2009;12:133-143. PubMed
30. Gerhard-Herman M, Gardin JM, Jaff M, et al. Guidelines for noninvasive vascular laboratory testing: a report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology. Vasc Med. 2006;11:183-200. PubMed
References
1. Carey SK, Conchin S, Bloomfield-Stone S. A qualitative study into the impact of fasting within a large tertiary hospital in Australia - the patients’ perspective. J Clin Nurs. 2015;24:1946-1954. PubMed
2. Kyriakos G, Calleja-Fernández A, Ávila-Turcios D, Cano-Rodríguez I, Ballesteros Pomar MD, Vidal-Casariego A. Prolonged fasting with fluid therapy is related to poorer outcomes in medical patients. Nutr Hosp. 2013;28:1710-1716. PubMed
3. Rycroft-Malone J, Seers K, Crichton N, et al. A pragmatic cluster randomised trial evaluating three implementation interventions. Implement Sci. 2012;7:80. PubMed
4. Breuer JP, Bosse G, Seifert S, et al. Pre-operative fasting: a nationwide survey of German anaesthesia departments. Acta Anaesthesiol Scand. 2010;54:313-320. PubMed
5. Sorita A, Thongprayoon C, Ahmed A, et al. Frequency and appropriateness of fasting orders in the hospital. Mayo Clin Proc. 2015;90:1225-1232. PubMed
6. Lee BY, Ok JJ, Abdelaziz Elsayed AA, Kim Y, Han DH. Preparative fasting for contrast-enhanced CT: reconsideration. Radiology. 2012;263:444-450. PubMed
7. Manchikanti L, Malla Y, Wargo BW, Fellows B. Preoperative fasting before interventional techniques: is it necessary or evidence-based? Pain Physician. 2011;14:459-467. PubMed
8. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114:495-511. PubMed
9. Koeppe AT, Lubini M, Bonadeo NM, Moraes I Jr, Fornari F. Comfort, safety and quality of upper gastrointestinal endoscopy after 2 hours fasting: a randomized controlled trial. BMC Gastroenterol. 2013;13:158. PubMed
10. De Silva AP, Amarasiri L, Liyanage MN, Kottachchi D, Dassanayake AS, de Silva HJ. One-hour fast for water and six-hour fast for solids prior to endoscopy provides good endoscopic vision and results in minimum patient discomfort. J Gastroenterol Hepatol. 2009;24:1095-1097. PubMed
11. Hamid T, Aleem Q, Lau Y, et al. Pre-procedural fasting for coronary interventions: is it time to change practice? Heart. 2014;100:658-661. PubMed
12. Ahmed SU, Tonidandel W, Trella J, Martin NM, Chang Y. Peri-procedural protocols for interventional pain management techniques: a survey of US pain centers. Pain Physician. 2005;8:181-185. PubMed
13. Franklin GA, McClave SA, Hurt RT, et al. Physician-delivered malnutrition: why do patients receive nothing by mouth or a clear liquid diet in a university hospital setting? JPEN J Parenter Enteral Nutr. 2011;35:337-342. PubMed
14. Aldasouqi S, Sheikh A, Klosterman P, et al. Hypoglycemia in patients with diabetes who are fasting for laboratory blood tests: the Cape Girardeau Hypoglycemia En Route Prevention Program. Postgrad Med. 2013;125:136-143. PubMed
15. Aguilar-Nascimento JE, Salomão AB, Caporossi C, Diniz BN. Clinical benefits after the implementation of a multimodal perioperative protocol in elderly patients. Arq Gastroenterol. 2010;47:178-183. PubMed
16. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr. 2010;23: 1115-1127. PubMed
17. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013;26:921-964. PubMed
18. Sinan T, Leven H, Sheikh M. Is fasting a necessary preparation for abdominal ultrasound? BMC Med Imaging. 2003;3:1. PubMed
19. Garcia DA, Froes TR. Importance of fasting in preparing dogs for abdominal ultrasound examination of specific organs. J Small Anim Pract. 2014;55:630-634. PubMed
20. Kidney ultrasound. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. Health Library, Johns Hopkins Medicine. Available at: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/urology/kidney_ultrasound_92,P07709/. Accessed August 17, 2015.
21. Surasi DS, Bhambhvani P, Baldwin JA, Almodovar SE, O’Malley JP. 18F-FDG PET and PET/CT patient preparation: a review of the literature. J Nucl Med Technol. 2014;42:5-13. PubMed
22. Kang SH, Hyun JJ. Preparation and patient evaluation for safe gastrointestinal endoscopy. Clin Endosc. 2013;46:212-218. PubMed
23. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2011;28:556-569. PubMed
24. ASGE Standards of Practice Committee, Saltzman JR, Cash BD, Pasha SF, et al. Bowel preparation before colonoscopy. Gastrointest Endosc. 2015;81:781-794. PubMed
25. Hassan C, Bretthauer M, Kaminski MF, et al; European Society of Gastrointestinal Endoscopy. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2013;45:142-150. PubMed
26. Du Rand IA, Blaikley J, Booton R, et al; British Thoracic Society Bronchoscopy Guideline Group. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013;68(suppl 1):i1-i44. PubMed
27. Thoracentesis. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. Health Library, Johns Hopkins Medicine. Available at: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/thoracentesis_92,P07761/. Accessed August 18, 2015.
28. Runyon BA. Diagnostic and therapeutic abdominal paracentesis. UpToDate. Available at: http://www.uptodate.com/contents/diagnostic-and-therapeutic-abdominal-paracentesis. Published February 18, 2014. Accessed August 18, 2015.
29. Granata A, Fiorini F, Andrulli S, et al. Doppler ultrasound and renal artery stenosis: An overview. J Ultrasound. 2009;12:133-143. PubMed
30. Gerhard-Herman M, Gardin JM, Jaff M, et al. Guidelines for noninvasive vascular laboratory testing: a report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology. Vasc Med. 2006;11:183-200. PubMed
Address for Correspondence and Reprint Requests: Deanne T. Kashiwagi, MD, Mayo Clinic, Division of Hospital Internal Medicine, 200 First Street SW, Rochester, MN 55905; Telephone: 507-255-8715; Fax: 507-255-9189; Email: kashiwagi.deanne@mayo.edu
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