In a commentary published ahead of print Sept. 8 in BMJ Quality & Safety, Martin Makary, M.D., M.P.H., and his co-authors urge the wide adoption of protocols to end the practice of imposing needlessly long fasts on patients preparing for operations and to improve sleep quality in those recovering from such procedures.
“Surgery takes a huge physiologic toll on the body, and 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,” Makary says.
In their commentary, the authors describe what they say is a typical case of a 65-year-old woman who develops pneumonia at home and feels too sick to eat or drink much for several days. She then goes to the emergency room, where food is withheld by medical personnel in case she needs certain invasive tests or actual surgery. If needed, surgery might add more days without food and little sleep, owing to continuous monitoring and noise in and outside her hospital room.
The authors point out that when subjected to the same level of sleep deprivation and lack of nutrition, healthy people can develop weakened immune systems, dangerous fatigue and impaired judgment within 24 hours.
“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 often such individuals are readmitted after discharged home — a scenario so common it has been dubbed post-hospital syndrome.
Makary and his colleagues argue that acute malnutrition and sleep deprivation, the latter already endemic in hospitalized patients, have increased as hospitals get busier, and as the population ages. Moreover, Makary and his co-authors say, 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.
Currently, says Makary, most pre-operative patients are told not to eat or drink anything past midnight on the day before a scheduled surgery to prevent stomach contents from entering the lungs and blocking airflow. For patients who operations are scheduled early in the morning, that may not be a serious issue, but surgeries take place all day and are often delayed.
More importantly, Makary and his co-authors note, such limitations are woefully out of date, and they cite research showing that food needs to be curtailed only six to eight hours before surgery and drinks just two hours before. Under a protocol dubbed the Enhanced Recovery After Surgery (ERAS) and already used at The Johns Hopkins Hospital for many, but not all, patients scheduled for surgery are prescribed a carbohydrate-rich sports drink, two hours before the procedure, to mitigate the stress of fasting. The approach also includes limiting the use of intravenous feeding and a faster return to normal feeding.
A recent study led by Johns Hopkins surgeon Elizabeth Wick, M.D., a co-author on the commentary, demonstrated that the ERAS approach can reduce the average length of stay by two days among colorectal patients, among other complications. The average cost of treatment also decreased from nearly $11,000 to $9,000 per patient.
Reducing sleep deprivation, however, may require more dramatic changes in hospital routine, the authors say. Currently, hospitals are noisy, stressful environments, with loud conversations outside the room, phones ringing, repeat overhead pages and shared rooms, the authors write.
While the World Health Organization recommends keeping hospital noise levels below 35 decibels at night and 40 decibels during the day, most hospitals exceed those levels, occasionally by several orders of magnitude, according to a 2012 study described in Intensive and Critical Care Nursing. Adding to sleep problems, many lights remain on, particularly in the emergency department, and lab draws of blood occur at all times of day and night.
Johns Hopkins changed practices so that lab draws now occur only during the day. The hospital has also eliminated overhead paging on clinical units to reduce sleep disturbance, and most patients stay in private rooms.
The authors suggest that hospitals should conduct noise studies and encourage patient feedback on the most disruptive sources of noise. Smaller interventions, such as providing eye masks, gentle music and art in hospital rooms can also encourage relaxation and sleep, the authors write.
“Avoidable starvation and induced sleep deprivation are ubiquitous in health care. It’s no surprise that these factors influence patient outcomes,” Makary says. “We should view hospitals as healing environments rather than isolated clinical spaces and design patient care accordingly.”
Tim Xu, M.P.P., a public policy expert and a student at the Johns Hopkins University School of Medicine, is the third co-author on the commentary.