We usually issue “NPO” (nothing by mouth) orders to protect patients. For example, in appropriate care of the stroke patient we keep them “NPO” until we have done a swallowing assessment and are reasonably sure the patient will not aspirate when we begin food or liquids by mouth. Similarly, patients are often kept “NPO” prior to a surgical procedure to reduce the risk of aspiration. But the UK National Patient Safety Agency recently issued a “signal” about patients being harmed while “NPO”.
They found over 100 occurrences in their incident databases of patients being inadvertently kept “NPO” for prolonged periods and being potentially vulnerable to dehydration, malnutrition or delayed or missed medications. During these delays there is often inattention to several of these patient needs. As in most significant adverse events with harm, communication issues are prominent. For example, when a scheduled surgery is cancelled there may be inadequate communication between services or or sites such that an order to resume feeding never takes place.
The NPSA suggests that each organization consider that appropriate documentation for an “NPO” order include the date, time and staff who will be responsible for review of that order and that such orders be accompanied by a plan for alternative methods of hydration, nutrition and medication administration. They also recommend that there be clear communication about the patient status among all members of the healthcare team, including dietary and housekeeping staffs.
We recommend you do a simple audit on several units to see (a) how many patients are on “NPO” status and (b) why are they “NPO” and (c) are their nutritional, hydration, and medication needs being met. You may identify gaps and identify communication barriers. You may also identify other related issues. For example, you may find a patient has a central line in place for hydration or parenteral alimentation that is no longer necessary (because they are capable of feeding) yet puts them at risk for nosocomial bacteremia (CLABSI).
So, while the “NPO” order sounds like a protective or at least harmless order in most circumstances, you can see its potential to lead to harm.
National Patient Safety Agency (UK). Risk of harm to patients who are nil by mouth. February 14, 2011