Background:
Ultrasound-guided thoracentesis and paracentesis are frequently performed for both diagnostic and therapeutic indications. While the risk of aspiration is low, our institution has historically required patients to be fasting for 4 hours prior to the procedure. In the hospital setting, unnecessary fasting requirements could contribute to missed patient meals and procedure delays. Here, we report data obtained as part of an internal quality improvement initiative designed to reduce unnecessary NPO orders prior to thoracentesis and paracentesis.
Methods:
In partnership with Gastroenterology, Pulmonary and Interventional Radiology, the requirement for patients to be fasting prior to thoracentesis and paracentesis procedures was reviewed and felt to be clinically unnecessary. The appropriate procedural policy statements were updated. Rather than rely on high-effort, often low yield provider education interventions to disseminate this practice change, the project was designed to promote a sustained change in provider ordering behavior by customizing the electronic orderset used to request these procedures. With the assistance of IT, the orderset was revised to include the statement “Fasting not required unless sedation anticipated” (implemented June 2016).
Results:
For paracentesis, pre-intervention data obtained from September 2015 showed 21/59 (36%) of patients undergoing paracentesis were unnecessarily fasting at the time of the procedure. Mean time to procedure completion was 345 mins (IQR 109 mins – 403 mins). Post-intervention (September 2016), the rate of unnecessary fasting dropped to 6/39 (18%), p = 0.03. Mean time to procedure remained similar at 401 mins (IQR 128 – 395). For thoracentesis, pre-intervention data obtained from September 2015 showed 9/21 (43%) of patients undergoing paracentesis were unnecessarily fasting at the time of the procedure. Mean time to procedure was 305 mins (IQR 98 – 395). Post-intervention (September 2016), the rate of unnecessary fasting orders was not significantly decreased at 8/22 (36%), p = 0.66. Mean time to procedure remained similar at 329 mins (IQR 118 – 365). There was no significant difference between the time to procedure for patients with fasting orders and those without fasting orders for either paracentesis or thoracentesis (p = 0.15 and 0.09, respectively). No aspiration events were noted in either group pre- or post-intervention.
Conclusions:
The intervention prompted a sustained decrease in unnecessary NPO orders prior to paracentesis, but did not significantly affect unnecessary NPO orders prior to thoracentesis. Potentially, providers may consider thoracentesis a “higher risk” procedure than paracentesis, making them more likely to continue placing unnecessary NPO orders despite the intervention. Our findings did not support our initial hypothesis that unnecessary NPO orders delay procedures, suggesting that other factors serve as rate-limiting steps in scheduling process.