Case Study

Think Drink initiative was established in 2015 at NUH. The cause and extent of the problem was identified through audit data of fasting times for patients waiting for surgery and valuable Patient Public Involvement feedback from patients about their experiences. The audit data indicated excessive fasting times for patients across the trust, an average of nine hours; this coupled with some negative feedback from patient, saying they were very thirsty and kept without fluid for long periods prior to their surgery. The overall aim of the initiative is to minimising fasting times for patients across the trust thus improving patient outcomes and experience, reducing dehydration and morbidity.

Think Drink is a very special project, it is not a difficult concept it is about a change in culture that has been longstanding across not only Nottingham University Hospitals but lots of hospitals across the NHS. Such a simple idea has had such a positive and wide spread impact on improving our patients experience; the project has encompassed all wards and departments and really is Trust Wide. Changing the longstanding culture of nil by mouth from midnight has had minimal cost implications for us as a Trust and makes such an immense difference to our patients experience and outcomes.

In terms of contributing to the project’s success, it would not have been made possible without increasing awareness of the benefits of shorter periods of fasting to both staff and patients. Improving communication between theatres and ward staff with the development of specific guidelines and algorithms to simplify the process of fasting.

The project is a simple but innovative project which aims to minimise fasting times for our patients to improve patient experience and outcomes. Complications of excessive fasting are a patient safety issue; minimising fasting times reduces dehydration, hypoglycaemia and potentially reduces the incidence of electrolyte imbalance and acute kidney injury.

Implementation has been made possible by the inclusivity of all staff, students and patients through education and training. This has been achieved by developing and adopting specific eating and drinking guidelines and an approved drinks list and incorporating ‘Think Drink’ moments in theatre briefings in order to enhance decision making and communication.

Education and training of staff, students and patients has been undertaken across the whole of the organisation by credible and enthusiastic champions to promote engagement. The success has been measured by improved feedback and audit data; fasting times have reduced from 9 hrs to 3.5 hrs.

More importantly for sustainability, there appears to have been a cultural shift. Wards are more aware of prolonged fasting, and theatres are more comfortable with shorter periods of fasting.

Other organisations across the NHS have shown interest in the project, challenging long held perceptions is not easy and requires persistence and credible champions.

A Project Group was formed which was made up of various members of the multi-disciplinary team including nurses, dieticians, anaesthetists who analysed the feedback from patients and the audit data which was then disseminated to theatre and ward staff at team meetings along with an action plan. The reasons for excessive fasting were explored from both process (theatre list planning, clarity of information given to patients), cultural (the ritual of nil by mouth from midnight) and educational (what are the recommended fasting times) paradigms.

Innovative solutions were generated by on the ground staff aiming to improve both patient outcomes and experience. The interventions targeted staff and patient understanding of the rationale for limited fasting, and ways to facilitate safe fasting times within changing theatre schedules. Small scale rapid pilots were used to refine the guidelines before wider roll out.

Theatre briefings now include a Think Drink moment where a named member of the team clarifies with the anaesthetist and surgeon which patients can drink and until what time, based on the expected duration of cases. This is done for all patients on the theatre list and repeated during the day, this is communicated to the ward and admission areas. Ward and admission areas are then able to offer patients drinks up to two hours prior to their procedure. Patients are able to choose from a specially formulated drinks list to further improve their experience this includes: tea and coffee with no more than one fifth of skimmed, semi or soya milk, dilute squash, still energy drinks or drinks part of the enhanced recovery after surgery. The project guidelines incorporate adult and paediatric patients and include elective and emergency patients.

In terms of delivering and embedding the project, a Project Lead was employed to work closely with theatre and ward areas throughout the hospital, disseminating the guidelines and providing education and training to all staff and patients in order to promote understanding and engagement.

The Projects efficacy has been measured by improved patient feedback; this has been collated in a number of ways. One of the ways in which this has been collated is in the form of PPI feedback, the feedback received thus far has been exceptionally positive. Another measure used to assess the impact of the project is audit data of fasting times for patients across the Trust. This has reduced from 9 hours to just 3.5 hours which is a huge improvement especially given the size of NUH and the enormous culture change required.

We continue to gather feedback and have seen a reduction in negative comments regarding excessive waits; however on-going comments have enabled us to focus on continuous improvement. As a Trust we have made huge inroads in changing the culture and ritualistic practice of nil by mouth from midnight. This has only been made possible by improving knowledge and communication and cohesion between staff and different specialities.

Moving forwards in order to sustain the fantastic success of the project, we aim to continue to carry out regular teaching sessions for staff by developing a video; this can be shown to students and staff at Trust induction days and mandatory training.

With the implementation of specific eating and drinking guidelines, think drink moments and algorithms we have made a sustained change in culture. New staff coming into the Trust perhaps unaware of the Project and guidelines will see it being championed and learn from the example set by other staff.

Nutrition link professionals continue to champion the project in individual ward areas. Furthermore, patient information will be made available on the intranet to reinforce the importance of remaining hydrated prior to surgery, not only in terms of patient experience but examining and explaining some of the complications which are attributable to dehydration and pre-operative fasting.

The initiative is extremely relevant to other trusts in the Country, the project has enabled us to greatly increase patient experience whilst at the same time improve patient outcomes. Using the most up to date evidence for fasting showing that long periods of fasting are no longer beneficial and that shorter period of fasting have better outcomes for patients. NUH have recently been shortlisted for a Nursing Times Award for the Project and the Project has received positive recognition in NUHs recent CQC report.

•  – Challenging the long-held dogma (nil by mouth from midnight) is not easy and requires persistence and credible champions.
•  – When there are competing pressures (reducing starvation versus perceived risk of list delays/cancellations) these need to be discussed openly.
•  – Focussing the project on the patient rather than the process allows staff to speak up as the patients advocate.
•  – Small things, such as clarifying what fluids are allowed until what time can make a huge difference to our patients.

Watch the Think Drink Presentation Here!