How to slay a vampire: When some ideas just won’t die part 2
Myron Yaster MD and Lynn Martin MD
As discussed in “How to slay a vampire part 1” (PAAD November 14, 2022), Jay Deshpande, Justin Lockman and I described how certain ideas, like vampires, simply cannot be killed, even when exposed to vampire killing sunlight (evidence). In that PAAD, we discussed the vampire idea of administering sodium bicarbonate to treat acidosis during cardio-pulmonary resuscitation even though substantial evidence has demonstrated that bicarb makes a bad situation worse and giving it is more harmful than good. We would like to tackle another vampire idea, the 6-4-2 fasting guidelines to prevent or limit pulmonary aspiration of gastric contents during surgery. There is a substantial amount of evidence showning that prolonged fasting for clear liquids prior to anesthesia is unnecessary and may even be harmful. Today’s PAAD by Ong and Walker1 is a quality improvement project using Kotter's 8 steps of change2 to implement revised fasting guidelines to reduce the duration of the preoperative fast at the Alder Hey Children's Hospital in Liverpool, UK. This is not only a perfect opportunity to review this article, but also serves as a companion to the recent symposium on this topic presented at the 36th Annual Meeting of the Society for Pediatric Anesthesia held in New Orleans last October. The symposium can still be viewed on the SPA website for registered attendees.(https://www2.pedsanesthesia.org/meetings/2022annual/guide/program/index.iphtml)Finally, I’ve asked frequent PAAD contributor Dr. Lynn Martin to assist. Myron Yaster MD
Original article
Ong, SY, Walker, A. Using Kotter's 8 steps of change to tackle over-fasting of children attending day surgery. Pediatr Anesth. 2022; 32: 1238- 1245. doi: 10.1111/pan.14499
The Case for Change in Clear Fluid Fasting Policy - Panel Discussion Society for Pediatric Anesthesia 36th Annual meeting. Mark Thomas, BSc MBBChir FRCA; Alexander Schmidt, MD; Sulpicio G. Soriano, III, MD, FAAP https://www2.pedsanesthesia.org/meetings/2022annual/guide/program/index.iphtml
The conservative 6-4-2 fasting rules to prevent or limit pulmonary aspiration of gastric contents often results in prolonged fasting times.3 The European Society of Anaesthesiology and Intensive Care, the Society for Paediatric Anaesthesia of New Zealand and Australia (SPANZA), as well as many other national societies and now several large academic departments of anesthesiology in the United States have liberalized their clear fluid fasting time to 1 hour.4, 5 Indeed, Dr. Mark Thomas of the Great Ormand Street Hospital, London, and president of the Association of Pediatric Anesthetists of Great Britain and Ireland, in his SPA lecture reported that clear fluids are given to all pediatric patients on arrival to the preop area of the hospital during check-in! Why our practice in the United States hasn’t changed despite this growing evidence that the prolonged clear liquid fast is unnecessary once again is a testimony to the power of vampire ideas.
OK, let’s assume that you, a reader of today’s PAAD, are convinced that the evidence is overwhelming, these fasting rules need to be changed, and you are going to be the change champion…how do you do it? Ong and Walker used Kotter’s well known 8 step for change (figure) and provide us with a detailed step by step description of how they did it.2 What are some of the elements? First, they started in the most powerful way possible, using a patient story in video to show the need for change. Second, they formed a multi-disciplinary fasting improvement team (powerful coalition) consisting of a food, fluid and nutrition nurse, dietitian, day surgery nurses, preassessment nurses, anesthetic registrars, surgical registrar, and consultant anesthetists to study the problem and third created a shared vision for change (what would success look like). Further, “by sharing patients' and parents' feedback with our staff and asking their opinions and suggestions for change, patients/parents made it known to the team that they are a vital part of this change process. The team gave staff ownership over various tasks such as offering drinks to the patients. Then, the team took a step back to allow staff to perform their tasks ably without micromanagement.”1 Next, they created short term wins, using feedback from staff, children, and their parents to continuously make changes and further improvements. Finally, they celebrated their success and put processes in place to sustain their changes.
The intended primary goals, 90% day surgery patients achieving fluid fasting time of <2 h and 90% of afternoon day surgery patients having breakfast, were not reached. Why? First they are starting with a median performance of 5%, so logically it will take time to change first staff behaviors following by the culture and patient/parental expectations. Their improvement efforts started August 2018 and ended in May 2019, a very short period of time to change these cultural expectations. “The author learned from their valuable patient/family feedback that there are children who actively refused a drink or breakfast. Perhaps better communications with parents earlier and offering the child’s favorite drink or breakfast food could have improved these measures further. We also have parents who are still worried about cancellations and adverse effects of giving their child a drink despite clear written information. Secondly, despite our best effort to spread the word and educate new staff, there are still some who are unaware of our initiative or new guidelines and therefore inadvertently over-fasting the children. We addressed this by including this in our induction program (during a presentation and in written information), where new anesthetic registrars rotate every 2 months.”1 Thus, the authors made great strides reducing preoperative fasting times, but vampires are still hard to kill.
As a Kotter frequent flier (LDM), I learned that these 8 steps frequently work, but require some enhancements. (1) Seek volunteers to work on the team, (2) set initial goals lower to allow the quick wins (such as 25% initial target in this fasting project) and (3) build in the feedback system to assure the team is getting the true picture of the new problems as they arise. This way the team can celebrate early success and stays engaged with a positive experience and mindset as improvement efforts continue. If the authors continued their project, they would need to better understand and address why some patients did not eat or drink. In Seattle we encourage preoperative liquids, but we learned that parents frequently do not want to wake a sleeping child to drink or eat. We learned that the messages from the surgeon’s office and surgery center must be coordinated and consistent to allay historical fears of cancellations and communicate why liquids are important. Lastly the communications must be repetitive and via multiple forums. Patients receive paper in their pre-operative surgical clinic visit, get online reinforcement 2 weeks prior to surgery, verbal confirmation and reminder in the pre-operative phone nurse call 3 days prior to surgery, and finally receive verbal post-operative care instructions during surgery that is delivered in print upon discharge.
Why are US centers so slow to adopt this new evidence? There is one additional element making it difficult to change fasting guideline changes, namely, fear of litigation and bucking the official fasting guidelines of the American Society of Anesthesiologists. Hopefully the ASA and/or SPA will provide the updated guidelines needed soon. What are you doing in your practice? Let Myron know and he’ll post in a reader’s response.
References
1. Ong SY, Walker A. Using Kotter's 8 steps of change to tackle over-fasting of children attending day surgery. Pediatric Anesthesia. 2022;32(11):1238-1245. doi:https://doi.org/10.1111/pan.14499
2. Kotter JP. Leading Change. Harvard Business School Press; 1996.
3. Al-Robeye AM, Barnard AN, Bew S. Thirsty work: Exploring children's experiences of preoperative fasting. Paediatric anaesthesia. Jan 2020;30(1):43-49. doi:10.1111/pan.13759
4. Frykholm P, Disma N, Andersson H, et al. Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. European journal of anaesthesiology. Jan 1 2022;39(1):4-25. doi:10.1097/eja.0000000000001599
5. Linscott D. SPANZA endorses 1-hour clear fluid fasting consensus statement. Paediatric anaesthesia. Mar 2019;29(3):292. doi:10.1111/pan.13585