or: “I’ll ask your
doctor if that’s OK”
In the Emergency Department, it is
almost always the case that patients will be required to wait. Patients often
present themselves in waves at certain times of day, overwhelming the Department’s
capacity to attend to them quickly. Critical cases can appear at any time, and
consume the attention of the entirety of the physician and nursing staff in an
area. These things are true, but they do not provide any comfort to a person who is hungry, thirsty or needs to use the
bathroom.
Patients are made to wait in these
miserable states as a result of an abundance of caution related to patient
safety concerns. They are often made, officially or unofficially, NPO until
cleared because of the unknown risk of aspiration, either as a result of
emergent RSI/anesthesia, or spontaneous vomiting. Patients are also sometimes
confined to their beds, unable to get up to go to the restroom, due to a
perceived risk that they will fall by ED staff. This risk is usually formally
assessed at triage, but sometimes gets subjectively upgraded by staff during
the visit.
As a member of the ED staff, having
an unknown patient (or their family members) confront you at random demanding
to know if they can eat, drink, or get up to go to the bathroom can be a
frustrating experience, given your responsibilities to your other patients, and
the significant perceived downside and risk of giving the patient permission and them experiencing an adverse outcome. It would be
helpful to have some objective guidelines or criteria to consider, for both
your own patients as well as for that time when you are on the spot being
confronted. Thankfully, both of these areas have been subjects of at least some objective
consideration.
 |
| KINDER 1 Fall Risk Assessment from Waszinski et al. (1) |
First consider fall risk on the way
to the bathroom. This question has been studied specifically in the emergency
environment by Waszinski et al. (1), who did a retrospective analysis of their own
Level 1 Trauma center population and, after finding existing inpatient
screening inadequate, developed their own Fall Risk Assessment Tool, KINDER1, for their nursing staff. This has been implemented and studied in other
Emergency Departments and found to be at least somewhat successful (2). In the
immediate setting when briefly assessing a patient, it is also easy to
implement because it is quite binary; if a patient meets any of the five
criteria (Age, Fall history, Mobility Impairment, AMS or Judgment) than they are a
high risk and definitely should not be walking by themselves to the bathroom. The
“Judgement” criteria relates basically to dizziness, both symptomatic
vertigo/dizziness/pre-syncope, as well as any medications they might be on that
might induce those symptoms (narcotics, diuretics, anti-hypertensive).
When it comes to ingestion, one is always concerned that a patient might unexpectedly require emergent intubation for airway protection/OR, or procedural sedation in the ED. For the first issue, the American Society of Anesthesiologists released
guidelines in 1999 advising a two hour fast for clear liquids, and a six hour
fast for solids prior to intubation. The recommendation came after many studies
demonstrating no significant different in Residual Gastric Volume in patients
with two hours versus over twelve hours fast from liquids, with intake volumes in some studies of up
to one liter of fluid (5). For the second issue, this has been studied in the
Emergency Department setting itself, with guidelines released by ACEP in 2005
(revised 2014) recommending no delay for fast for procedures in the ED, and
finding no difference in adverse rates between zero hours of fast, and eight
hours of fast prior to said procedures. (3)
By combining these two
recommendations, it becomes clear that if a patient is awake and talking to you,
is not vomiting, declining in mental status and clearly not going to the OR within the
next two hours for some other reason, than there is no reason they should not be able to drink some
water in order to relieve their
thirst. Food, unfortunately, requires a greater degree of decision making data
then might be available briefly at bedside and in fact should be deferred to their
provider.
A
caveat to the above is that trauma and various nervous system pathologies (head
injury, diabetic neuropathy) can delay gastric emptying; but these affect clear
liquid emptying only in their advanced stages. (4) This post is not meant to be a guide on how to
carefully parse the diet orders of the complex patient who’s able to take PO,
or allow one to hand out large meals to patients who have not been evaluated.
It is simply meant to demonstrate that for a certain large subset of patients
in the ED who present stable and may wait a long time for evaluation, a small
drink of water or other clear liquid is by no means inappropriate.
An
emergency department under strain from volume is a very unpleasant place to be,
both for staff and for patients. There are many more difficult problems which
may not have good answers except better staffing that are not addressed here. These include patients who do clearly pose a fall risk but need to use the
restroom, and patients who are very hungry but have not been able to receive an
evaluation yet that satisfactorily clears them of a need for intubation or
surgery. However, for some patients, suffering can easily be reduced and conflict
avoided by any staff member walking by, just by letting them walk to the
bathroom or get a small drink of water when they comfortably meet the criteria
laid out. A little comfort can go a long way towards keeping the peace during your Monday afternoon shift.
4. Allman, Keith. Wilson, Iain. Oxford Handbook of Anestehsia. Oxford University Press. Oxford, July 28, 2011.
