‘Hangry’ no more: Overnight fasting no longer required for two common HHS cardiac procedures

HN Summary

• No more routine overnight fasting: Hamilton Health Sciences found that most patients undergoing coronary angiograms or PCIs can safely eat a light meal up to two hours beforehand and drink clear liquids until their procedure. 

• Better patient experience without added safety concerns: Patients following the shorter fasting protocol reported less hunger, greater comfort and less nausea, with no serious complications such as aspiration reported in either study group. 

• Quality improvement driving broader change: The five-month HHS project contributed evidence supporting shorter fasting protocols, has been published in the Journal of Patient Safety, and has already helped prompt another Ontario hospital to change its fasting practices.

Anyone who has fasted overnight before a medical procedure knows how uncomfortable it is to grow increasingly hungry and thirsty as they wait. And if their procedure is delayed, that discomfort can turn into feeling “hangry”—the familiar mix of hunger and anger, or irritability.

Close to 6,000 patients undergo coronary angiograms and percutaneous coronary interventions (PCIs) each year at Hamilton Health Sciences’ (HHS) Heart Investigation Unit, located at Hamilton General Hospital (HGH). A coronary angiogram checks for narrowing or blockages in the heart’s arteries, while a PCI is used to open them. Both procedures are performed using sedation, where patients are awake, relaxed and breathing on their own, and typically take less than an hour. Many patients visit the hospital for these procedures and return home afterwards.

It has long been standard practice for patients having a coronary angiogram or PCI to follow the same rigorous fasting rules as patients undergoing major surgeries with general anesthesia, where they’re unconscious and require breathing support. The `no food or drinks after midnight’ rule is an important safety precaution for preventing aspiration — a dangerous complication where stomach contents are inhaled into the lungs.

Driving change through Quality Improvement projects

But several studies, and an HHS quality improvement (QI) patient safety project at the Heart Investigation Unit, all found that hours-long fasting is excessive and unnecessary for most coronary angiograms and PCIs. Instead, patients can safely eat a light meal up to two hours before their procedure. And they can drink clear liquids until the time of their procedure.

The project’s goal was to improve patients’ experience by demonstrating that the fasting window for coronary angiograms and PCIs could be safely shortened to two hours.

“Our sole motivation for this project was to improve the patient experience,” says Laura Sheehan, manager of the Heart Investigation Unit during the project. She has since changed to a different role at HHS.

Dr. Madhu Natarajan, an HHS interventional cardiologist at the Heart Investigation Unit, led the project. He was inspired after taking a QI patient safety course led by his HHS colleague, anesthesiologist Dr. Ekta Khemani.

Khemani is a co-director for the HHS Knowledge Centre and a QI expert. She develops and runs QI patient safety courses especially for physicians and other health-care providers who work directly with patients. Courses are offered through the Knowledge Centre’s Quality Improvement and Education Program.

“QI projects are a way for physicians to gather and use evidence in decision making around best practices and patient care,” says Khemani, adding that the Knowledge Centre recently started offering a very affordable two-day introductory course in QI and patient safety and will also offer a 12-week certification course.

Studying HHS heart patients

Natarajan drew on previously published meta analyses that combined results from several smaller trials at other hospitals examining shortened fasting windows. A meta analysis pulls together data from earlier studies to identify broader patterns and outcomes.

His five-month QI project, launched in April 2024 at the Heart Investigation Unit, included outpatients and inpatients having coronary angiograms and PCIs. Outpatients visit the hospital for tests and return home afterwards, while inpatients stay overnight in hospital.

The project, managed by Knowledge Centre research coordinator Marija Corovic, compared outcomes before and after the new two-hour fasting window.

The “before” patients had followed the longstanding practice of nothing to eat or drink after midnight, while the “after” patients could have a light meal, such as toast or cereal, up to two hours before their procedure, and drink clear liquids like water, black tea or coffee, right up until their procedure.

The project team partnered with the hospital’s Patient and Family Advisory Council to develop clear, easy-to-follow instructions for patients around eating and drinking. This council is made up of HHS patients and family members who share their hospital experiences and give feedback to help make care better. They play an important role in improving how HHS delivers health care across the region.

Study participants filled out a survey afterwards about their experience. While both groups gave high marks for their care, people with the two-hour fasting window reported feeling more comfortable and less hungry. They also experienced less nausea. No one from either group had serious complications, like aspiration.

Sharing knowledge

While some other hospitals, provincially and nationally, have moved to shorter fasting windows for coronary angiograms and PCIs, many still require overnight fasting. Natarajan stresses that patients should still follow exact instructions provided by their hospital for their particular procedure.

But QI projects like the one led by Natarajan could help move the needle. For example, a Toronto hospital changed to a two-hour window after hearing the results of Natarajan and team’s project.

A paper on the HHS project’s findings has been recently published by the Journal of Patient Safety. 

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