New research calls on the doctors running emergency rooms, surgical departments, and other hospital programs to let patients eat more regularly and sleep more soundly.
In a commentary published online in the journal BMJ Quality & Safety, the researchers urge an end to needlessly long pre-operative fasts and call for improved sleep quality for those recovering from surgical procedures.
“Avoidable starvation and induced sleep deprivation are ubiquitous in health care. It’s no surprise that these factors influence patient outcomes,” says coauthor and surgeon Martin Makary of Johns Hopkins University.
“We should view hospitals as healing environments rather than isolated clinical spaces and design patient care accordingly.”
Days without food
The commentary lays out a typical case: a 65-year-old woman with pneumonia who feels too sick to eat or drink much for several days. She goes to an emergency room, where food is withheld in case she needs invasive tests or surgery. She might go for days more without food and with little sleep, between continuous monitoring and noise in and outside her hospital room.
“Surgery takes a huge physiologic toll on the body,” Makary says. “Forcing sick people, especially the elderly, who are already in a frail state, to fast for eight to 12 hours, or even days, before surgery, only amplifies that stress on the body.”
When subjected to the same levels of sleep deprivation and lack of nutrition, healthy people can develop weakened immune systems, dangerous fatigue, and impaired judgment within 24 hours, the authors note.
“Subject sick or elderly individuals to those same conditions, and each next medical intervention becomes more dangerous as their illness takes a turn for the worse,” Makary says.
Healing may be delayed, he says, and discharged patients may need to return to the hospital, a scenario so common it has been dubbed post-hospital syndrome.
The problems have increased as hospitals get busier and as the population ages, say Makary and colleagues Elizabeth Wick, a surgeon, and Tim Xu, a medical student and public policy expert. With medical care now highly specialized, breakdowns in communication among medical staff often adds to delays in definitive care, extending periods of malnutrition and sleeplessness.
Makary says most pre-operative patients are told not to eat or drink anything after midnight the day before surgery to avoid problems with stomach contents entering the lungs and blocking airflow. For patients with early OR slots, that fasting may not be a serious issue, but surgeries take place all day and can run late.
More important, the midnight cutoff is woefully out of date, the authors note. They cite research showing that food should be curtailed only six to eight hours before surgery and drinks just two hours before.
At the Johns Hopkins Hospital, many surgical patients now receive a carbohydrate-rich sports drink two hours before their procedures to mitigate fasting stress. The protocol also limits the use of intravenous feeding and calls for a faster return to normal feeding.
A recent study led by Wick demonstrates that the new protocol can reduce the average length of stay for colorectal patients by two days. The average cost of treatment was cut from nearly $11,000 to $9,000 per patient.
Reducing sleep deprivation, however, may require more dramatic changes in hospital routine. Hospitals are noisy, stressful environments, with loud conversations, phones ringing, repeat overhead pages, and shared rooms, the authors write. Many lights are on all the time, particularly in the emergency department, and draws of blood for tests occur at all hours.
Drawing blood during the day, eliminating overhead paging, and private rooms could be helpful. In addition, smaller interventions, such as providing eye masks, gentle music, and art in hospital rooms can also encourage relaxation and sleep, the authors write.
Source: Johns Hopkins University