What’s New in the Patient Safety World

November 2015

Starving Our Patients?



Two of our most popular columns were our April 2011 What’s New in the Patient Safety World column “Harm from NPO Orders” and our August 6, 2013 Patient Safety Tip of the Week “Let Me Sleep!”). In the former we discussed how NPO orders often remain in effect for inappropriate periods, as noted in a study from the National Patient Safety Agency in the UK (NPSA 2011). In the latter we discussed how so many factors in the hospital interfere with patients getting a night’s sleep.


Apparently we’re not the only ones concerned about these “under the radar” issues. Martin Makary and colleagues just published a viewpoint paper on how sleep deprivation and starvation are happening to our hospitalized patients (Xu 2015). They begin by describing an elderly woman with pneumonia who had poor oral intake for several days prior to admission and then gets made NPO during a prolonged period between arrival in the ED and ultimate arrival to the hospital floor. She is then kept NPO for an anticipated procedure, which gets delayed in scheduling. Ultimately she is not fed for 3 days in the hospital plus the 3 days prior to arrival for a total of 6 days with suboptimal intake and then she just got jello and soup!


They go on to describe how we underappreciate malnourishment in the hospital setting and how malnutrition has an impact on morbidity and mortality, adverse events like falls, and hospital length of stay. They cite important trends such as reducing the period of fasting prior to anesthesia and limiting fasting as part of the ERAS (Enhanced Recovery after Surgery) protocols in vogue for gastrointestinal surgery.


They have practical recommendations such as using multimodal analgesia in order to reduce opioid use that might delay the return of bowel function post-op (or cause nausea and vomiting that might impair oral intake). Importantly they note all staff should be educated and empowered to question NPO status frequently.


In our April 2011 What’s New in the Patient Safety World column “Harm from NPO Orders we recommended 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).


And in our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we discussed how many inpatients who are transported for diagnostic imaging or other studies may be made NPO prior to transport and then no one remembers to restart their oral intake and oral medications upon return from that procedure. Having those items addressed in your “Ticket to Ride” (intrahospital transport checklist) should help prevent unnecessary delays in your patients resuming oral intake and oral medications.


We’re also intrigued about the possibility of using tools from another recent study to alert us to inadequate feeding in some patients. Hooper and colleagues tested several osmolality equations to identify patients who were dehydrated (Hooper 2015). Though their patients were not hospital inpatients, the clinical lab variables used in the study are readily available on almost all hospital inpatients. It would be easy to set up a script to be run in the background that would trigger an alert in the EMR that a patient was likely dehydrated. Conceivably that might be one way to remind us that we forgot to rescind the “NPO” order on our patient.


Xu and colleagues then go on to describe all the things that prevent inpatients from getting a good night’s sleep. We discussed those in detail in our August 6, 2013 Patient Safety Tip of the Week “Let Me Sleep!”. Waking patients at night for vital signs that may not be important in some patients, lack of coordinating nursing and phlebotomy visits, and others are important remediable factors in addition to those that reduce ambient noise. Avoiding waking patients for vital signs if their risk is low (eg. if they have a low MEWS score) should be a logical consideration. We also described the Somerville Protocol (Bartick 2010) which resulted in a 38% reduction in patients noting sleep disruption due to hospital staff and a 49% reduction in patients receiving prn sedatives (actually a 62% reduction for patients aged 65 and older). That protocol consisted of 10 components:

  1. “Quiet Time” designated as 10PM to 6AM
  2. Timing of “routine” vital signs changed to 6AM, 2PM and 10PM
  3. Getting physicians to understand the difference between daily, BID, TID, QID vs. q24 hours, q12 hours, q8 hours, q6 hours
  4. Avoid standing diuretic doses after 4PM
  5. Avoid blood transfusions during Quiet Time where possible
  6. Use of a noise detection device in the nursing station
  7. Lullaby over the PA system at 10PM to alert patients, staff, visitors, etc. to Quiet Time
  8. Timer to dim hallway lights automatically at 10PM
  9. Nurses perform a bedtime routine before Quiet Time (vital signs, bedtime meds, toilet patient, ensure IV bag won’t empty at night, close patient door, etc.)
  10. Avoid antecubital IV catheter site where possible (easier to occlude flow here and set off alarm at night) and even avoid nighttime IV fluids if possible


It’s been just over 2 years since Harlan Krumholz described the “Post-hospital syndrome—an acquired, transient condition of generalized risk” (Krumholz 2013). He described that recently hospitalized patients experience a period of generalized risk for a range of adverse health events and called this a post-hospital syndrome, “an acquired, transient period of vulnerability”. He suggested that the “the risks in the critical 30-day period after discharge might derive as much from the allostatic and physiological stress that patients experience in the hospital as they do from the lingering effects of the original acute illness”. This state leaves patients vulnerable to readmission, often for conditions different from that of the index hospitalization. He went on to describe some of the likely factors contributing to this reduction of functional reserve, including metabolic derangements, disturbed sleep patterns, nutritional factors, cognitive factors, pain and other discomforts, etc.


Sometimes we get so busy addressing complex clinical issues that we forget to attend to the simplest necessities of life – eating and sleeping. Attending to those can improve both medical outcomes and patient satisfaction.






Xu T, Wick EC, Makary MA. Sleep deprivation and starvation in hospitalised patients: how medical care can harm patients. BMJ Qual Saf 2015; doi:10.1136/bmjqs-2015-004395 Published online 8 September 2015




NPSA. National Patient Safety Agency (UK). Risk of harm to patients who are nil by mouth. February 14, 2011




Hooper L, Abdelhamid A, Ali A, et al. Diagnostic accuracy of calculated serum osmolarity to predict dehydration in older people: adding value to pathology laboratory reports. BMJ Open 2015; October 22, 2015




Bartick MC, Thai X, Schmidt T, et al. Decrease in As-needed Sedative Use by Limiting Nighttime Sleep Disruptions from Hospital Staff. Journal of Hospital Medicine 2010; 5(3): E20–E24




Krumholz HM. Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med 2013; 368(2): 100-102







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