18 avril 2023

Lutter contre des habitudes inutiles mobilise beaucoup d’énergie

Average pre-operative fasting times for clear liquids are many times longer than those specified in national and international guidelines. We sought to decrease fasting times by applying a quality management tool aimed at continuous improvement. Through the application of iterative 'plan-do-study-act' cycles, tools to reduce pre-operative liquid fasting times were developed and applied, the effects measured, analysed and interpreted and the conclusions used to inform the next plan-do-study-act cycle. The first step was the introduction of unrestricted drinking until the patient was called to the operating theatre, with training of anaesthetic staff, adaption of local standard procedures and verbal information for patients. This did not result in short liquid fasting times, median (IQR [range]) 12.0 (9.5-14.0 [0.8-23.5]) h. In the second cycle, fasting cards were introduced as a subliminal written training tool for staff, patients and their relatives. This enabled short liquid fasting times to be achieved for outpatients (2.6 (0.8-5.1 [0.3-16]) h) and pre-admission patients (3.4 (1.8-9.4 [0.2-17.2]) h), but not for inpatients (6.5 (2.0-11.7 [0.2-16.2]) h). The third cycle included lectures for ward staff, putting up information posters throughout the hospital, revision of all written materials and provision of screencasts on the homepage for staff and patients. This decreased median liquid fasting time to 2.1 (1.2-3.8 [0.4-18.8]; p<0.0001) h, with inpatients having the shortest fasting time of 1.4 (1.1-3.8 [0.4-18.8]) h. Repeated quality improvement cycles, adapted to local context, can support sustained reductions in pre-operative liquid fasting times.

Commentaire du Dr Marius Laurent (PAQS)

  • J’avoue mon plaisir à inclure cet article qui souligne l’utilisation d’une méthodologie rigoureuse de cycles d’amélioration pour s’attaquer à un problème à la fois assez futile et extraordinairement difficile à résoudre : faire appliquer l’abolition de mesures de restriction d’apports de boissons avant la chirurgie que l’EBM juge inutile et qui ont disparu de la plupart des recommandations scientifiques, alors qu’elles entravent le confort du patient et parfois sa sécurité même. La force de l’habitude est bien plus pesante que celle des éléments probants… La persistance de durées de privation de liquide de plus de 18 heures chez certains patients après plusieurs cycles de formation en atteste, même si les moyennes ont diminué « significativement ».

Ruggeberg A, Nickel EA. Unrestricted drinking before surgery : an iterative quality improvement study. Anaesthesia 2022;77(12):1386-1394. Doi : 10.1111/anae.15855.