This Signal is about the risk of harm to patients who are kept unintentionally nil by mouth (NBM) for a prolonged period of time.
An incident involved a patient who was nil by mouth for 10 days while awaiting a formal swallowing function assessment. The outcome was not reported but the incident was graded as severe.
A large number of patients are instructed to be nil by mouth for pre-procedural fasting or while awaiting a swallowing function assessment. A delay in assessment can inadvertently prolong the nil by mouth period and lead to increased vulnerability, dehydration, malnutrition, or complications from omitted or delayed medication.
A search of the National Reporting and Learning System (NRLS) database (for the period November 2003 to February 2010) was undertaken for delays in formal swallowing assessments. It revealed 113 relevant incidents causing moderate and severe harm and a further 12 patients who had died. Another search (for the period 1 July to 31 December 2009) identified that 57 patients were left NBM for more than 24 hours and five for more than 10 days without review. The issues described included:
• inconsistent assessment of patient needs;
• nil by mouth plans were not documented, made or reviewed;
• the administration of alternative nutrition or intravenous medication was delayed;
• poor communication between clinical and ward based teams further prolonged NBM status e.g. when the patient’s surgery was cancelled.
There are currently no national guidelines for meeting patients’ needs while nil by mouth although many hospitals have developed local protocols regarding medication needs following the Rapid Response Report, Reducing harm from omitted and delayed medicines in hospital.
Organisations may wish to consider that:
• each patient who is placed nil by mouth is assessed for alternative methods of hydration, nutrition and medication administration;
• the nil by mouth plan is clearly documented. This should include the date, time and staff role responsible for reviewing the nil by mouth plan;
• clear communication of the patient’s status is carried out to the whole team including to catering/ housekeeping staff (for example with the use of bedside ‘Nil by mouth’ signs).
Please contact us with your initiatives to reduce risks in these areas.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.