Medication management in general surgical patients made nil by mouth perioperatively: A quality improvement study.

Perioperative medication management in patients who are nil by mouth for surgery or endoscopy is often suboptimal. Inappropriate medication management can prolong postoperative recovery and increase morbidity and mortality. This quality improvement study, carried out in general surgical patients at an 800-bed general hospital, aimed to improve perioperative medication management in accordance with the recommendations of the UK Clinical Pharmacy Association Handbook of Perioperative Medicine. Increasing awareness and educating general surgical team members, including doctors and non-medical prescribers, about perioperative medication management led to a non-significant improvement in medication management. However, a statistically significant improvement was achieved when nursing staff were also included. This study highlights the importance of involving different members of the multidisciplinary team in perioperative medication management.

Healthcare Professionals' Perceptions of Stabilized Edible Foam with Adults with Severe Dysphagia; an exploratory study: Use of stabilized edible foam with adults with dysphagia: Use of stabilized edible foam with adults with dysphagia.

BACKGROUND: Improving the quality of life for individuals with severe dysphagia is a priority when considering new areas of dysphagia management, especially if this increases opportunities to participate in social activities associated with eating and drinking. Edible foam is widely researched and available in the food industry; however, the use of edible foam within the field of dysphagia remains unexplored. Despite no research published on effectiveness and safety, a commercial product currently on the market is widely distributed across both Europe and the UK, including 28 NHS Trusts, suggesting that it is increasingly being used in clinical practice. AIMS: To explore the perceptions and experiences of healthcare professionals on the use of stabilized edible foam (SEF) with adults with severe dysphagia in order to inform areas for future research in this novel dysphagia intervention. METHODS & PROCEDURES: Healthcare professionals were recruited using purposeful sampling and snowballing technique. A total of 56 healthcare professionals were initially approached, of which 10 completed the semi-structured interviews. Interview questions were developed from a topic guide and a pilot questionnaire. OUTCOMES & RESULTS: Thematic analysis was used to identify three themes: potential impact, consideration of risk and perceived experiences. Overarching each of these themes was the element of the unknown. CONCLUSIONS & IMPLICATIONS: Use of SEF with adults with dysphagia is in its infancy. Whilst results indicate that some clinicians are embracing this novel approach, others express concerns. Therefore, further research is needed, particularly in relation of direct experience of individuals and contra-indications. WHAT THIS PAPER ADDS: What is already known on the subject The use of SEF with individuals with swallowing problems is a relatively novel area of dysphagia intervention in the UK. There are currently no published studies on its effectiveness and safety profile. What this paper adds to existing knowledge This study provides valuable preliminary work into the area of SEF and adults with severe dysphagia, capturing the experience and perceptions of healthcare professions who have an awareness of SEF. What are the potential or actual clinical implications of this work? Increasing clinicians and researcher's awareness of this novel area of dysphagia management.

A Quality Improvement Project to Assess if Preoperative Trauma Patients Are Receiving Their Prescribed Medications Preoperatively.

Introduction All preoperative trauma patients should receive their preoperative medications regardless of being nil per os (NPO). Anticoagulants, angiotensin-converting enzyme inhibitors (ACE-I), and angiotensin II receptor blockers (ARBs) should be omitted. This is according to both local and national guidelines. We noticed that some preoperative patients have not been receiving their morning medications prior to having their operations. This has led to pre and perioperative complications. The aim of this study, therefore, was to conduct a quality improvement project to assess if preoperative trauma patients are receiving their prescribed medications preoperatively when placed NPO. We then aimed to determine the adverse outcome associated with omission and to furthermore devise a robust system to prevent recurrence. Methods Data were collected from the relevant patients' drug charts on the day of the operation. These cases were available on the daily trauma list. We evaluated if there was any clear reason documented for not providing the medications. Following the first round, we implemented our action plan for posters to be taped to drug trolleys on the orthopedic wards and informed the nursing staff of the need to give preoperative medications. We deemed the following to be important medication classes: calcium channel blockers, neuromodulators, beta-blockers, anti-epileptics, digoxin, bronchodilators, anti-anginals, anti-epileptics, and benzodiazepines. This was re-audited after one month to assess compliance and monitor for improvement. Results Forty patients were included in the first round and 41 in the re-audit. In the first round, 16/41 (39%) patients received their medications correctly. In patients who did not receive their medications (n=25), 22 had important medication classes omitted. Post implementation of the posters, 25/41 (61%) patients received their medications correctly. In patients who did not receive their medications (n=16), 10 had important medication classes omitted. The main reason why medications were incorrectly not given was that patients were NPO. Conclusion This quality improvement audit shows that our interventions between audit cycles have made a significant improvement in patients receiving their medications and therefore this has a direct positive impact on patient safety and outcomes. We should continue to have a close rapport with the nursing staff to maintain standards of correct practice, and these audit findings should be escalated to the emergency theatre thereafter.

Barriers to managing medications appropriately when patients have restrictions on oral intake.

RATIONALE, AIMS, AND OBJECTIVES: Investigation of several serious adverse events in our organization highlighted that medications were managed inappropriately when patients have oral intake restrictions. The aim of this work was to identify the barriers to optimal medication management when patients have restrictions on their oral intake. METHOD: Data were feedback and comments obtained between 2011 and 2014 from a hospital-wide quality assurance project. Data had not been purposefully collected and were in response to a general request for feedback regarding managing oral medications when patients have oral intake restrictions. Data came from a range of clinical staff and from various forums associated with the quality assurance project, including 37 presentations, 34 group meetings, and over 50 one-on-one meetings, as well as emails and other sources. Data were analysed using the thematic analysis approach. Data were coded inductively, and the domains of the Theoretical Domains Framework were used to categorize the data. Subthemes and themes were then developed. RESULTS: Barriers could be broadly grouped into systems-level issues (organizational guidance and work environment) and the individual person-level issues (staff knowledge and beliefs). These barriers highlight the complexity of the medication management task. The lack of standardized guidance and consistent terminology regarding medication administration when patients have restrictions on oral intake, particularly when fasting or nil by mouth, were important systems factors, as were workflow issues and the "culture" of the environment in which staff practiced. Lack of knowledge about medication administration, social influences, and role interpretation were important individual person factors. CONCLUSION: Systems- and individual person-level issues were significant contributors to inappropriate medication management when patients have oral intake restrictions. Many of the barriers may be addressed with systems approaches such as hospital-wide guidance that simplifies and standardize oral medication administration instructions, particularly regarding fasting and nil by mouth terminology.

Developing an innovative online medication calculator for patients with Parkinson's disease who are nil by mouth.

Missed Parkinson's disease (PD) medications when patients are admitted to hospital are associated with increased -morbidity and mortality. Swallowing difficulties in hospitalised PD patients are common and should prompt clinicians to -consider conversion of a patient's PD medications to a non-oral form - this is, however, recognised as a challenging area with potential for error. Northumbria Healthcare NHS Foundation Trust's PD service set out to address this patient safety issue through the development of an innovative online medication -calculator (pdmedcalc.co.uk). This article summarises the development process underpinning the calculator, presents numerical data on the usage of the calculator and presents survey data -relating to user experiences of the calculator. Lastly, we highlight how user feedback has been used to refine subsequent iterations of the calculator and how use of the calculator has rapidly spread beyond our trust because of it being freely accessible online.

Quality of Life in a Randomized Trial of Nasogastric Tube Feeding in Acute Pancreatitis.

BACKGROUND: Recent clinical studies have shown that nasogastric tube feeding is safe in the majority of patients with acute pancreatitis. Patient-reported outcomes are important, but the impact of nasogastric tube feeding on the quality of life has not been investigated. This study aims to compare quality of life between nasogastric tube feeding and nil-by-mouth groups during and after hospitalization. METHODS: Patient-reported outcomes were recorded daily in a patient diary during hospitalization. The Abdominal Surgery Impact Scale questionnaire was used to determine patients' quality of life. The patients were then followed up at 1 week and 1, 3, and 6 months after discharge. RESULTS: While 17 patients were randomized to nasogastric tube feeding, 18 were put on nil-by-mouth. The overall quality of life and individual domains did not differ significantly between the groups during hospitalization (P = .500) or follow-up. For the entire cohort, individual quality-of-life domains during hospitalization improved significantly, including functional impairment (P < .001), pain (P < .001), sleep (P = .035), and psychological function (P < .001). Quality of life further improved for all patients from time of hospital discharge to 3 (P = .002) and 6 months follow-up (P < .001) but not to 1 week and 1 month. CONCLUSIONS: The use of nasogastric tube feeding, in comparison with nil-by-mouth, does not impair patients' quality of life. Given the clinical benefits of nasogastric tube feeding, nasogastric feeding should be considered the first-line approach in all acute pancreatitis patients requiring enteral nutrition.

The effect of enteral nutrition on adipokines in patients with acute pancreatitis.

The mechanism behind the beneficial effects of enteral nutrition (EN) for patients with acute pancreatitis (AP) is largely unknown. Adipokines, as mediators of metabolism and inflammation, may be a possible mechanism. The study aimed to investigate the effect of EN on adipokines early in the course of AP. Patients with AP were randomised to EN or nil-by-mouth (NBM). Blood samples were taken on the first 4 d of admission and adipokine concentrations for adiponectin, leptin, omentin, resistin and visfatin were determined by ELISA assays. A linear mixed model analysis was run to determine differences in adipokine concentrations between the two study groups. A total of thirty-two patients were included in the study. Omentin concentrations were significantly higher in patients who received EN compared with NBM across the first 4 d of admission (mean difference: 11·6 (95 % CI 1·0, 22·3) ng/ml; P = 0·033). Leptin concentrations were significantly higher in patients who received EN compared with NBM after adjusting for age, sex and BMI (mean difference: 2·3 (95 % CI 0·1, 4·5) ng/ml; P = 0·037). No significant difference in adiponectin, resistin or visfatin concentrations were observed between the two study groups. EN significantly increases omentin and leptin concentrations in AP. Future research should be directed towards understanding whether these adipokines are responsible for the therapeutic benefits of EN.

A qualitative study into the impact of fasting within a large tertiary hospital in Australia--the patients' perspective.

AIMS AND OBJECTIVES: This qualitative study aims to explore the physical and emotional impact of fasting from the patients' perspective. BACKGROUND: Fasting patients in hospital is common practice and generally viewed as necessary for symptom management or for safety of healthcare provision. Negative impacts of repeated or prolonged fasting on nutritional status have been well researched, but little is documented as to how fasting impacts an individual patient's psyche. DESIGN: Qualitative descriptive design within a tertiary hospital in Sydney, Australia. METHODS: Twelve patients having had prolonged periods of continuous or intermittent fasting were invited to participate in a semi-structured interview between January-September 2012. Questions for interview explored each patient's experience of fasting, including physical and emotional impacts, interpretation of communication regarding fasting and the process of recommencing on fluids or foods. An inductive thematic analysis approach was used. RESULTS: Analyses showed six main themes: physical impacts; emotional impacts; food as structure; nil by mouth as jargon; fear of food re-introduction; and dissatisfaction regarding unnecessary fasting. Overwhelmingly, thirst was reported as the worst physical effect of fasting. In the first few days of fasting, patients became emotionally fixated on food. This quickly dissipated leading to a lack of appetite and fear of starting to eat again. CONCLUSIONS: Discomfort experienced by patients coupled with lack of appetite resulting from prolonged fasting and difficulty with food re-introduction strengthens the argument for reducing fasting times in hospital. When patients are fasted, proper hydration and establishing alternate routes of medication administration should be a priority. RELEVANCE TO CLINICAL PRACTICE: It is well recognised that fasting for prolonged periods is detrimental to health outcomes, but this study also shows the distress that fasting can cause. Inadequate hospital systems and out-dated practices need to be replaced with evidence-based, patient-centred governance, addressing the physical, emotional and psychosocial impact of fasting.