Background: Traditional inpatient procedural fasting practices lead to excessive periods of patient fasting. Patients are unnecessarily ordered to be nil per os (NPO) at midnight, independent of current recommendations and evidence specific to the type of procedure being performed or expected time for the procedure to occur. This approach is based largely on the assumption that longer NPO duration decreases aspiration risk, though published data has demonstrated this not to be the case. Rather, current evidence supports graduated dietary restriction as well as shorter NPO durations to maximize nutrition, healing, and recovery as well as patient experience. Some studies suggest more rapid gastric emptying with clear liquid diet which may actually lead to decreased aspiration risk. Others demonstrate safety of strategies for strict NPO for just 2 hours with clear liquids up to 6 hours prior to the planned procedure. Furthermore, studies involving invasive gastric procedures with similar modifications demonstrated increased patient satisfaction, decreased length of stay, and decreased cost without increased aspiration pneumonias, pain, or delayed healing.
Purpose: We hypothesized that implementing a graduated approach to inpatient procedural fasting will result in a decreased overall NPO duration.
Description: We reviewed data from inpatient medicine teams at the Lexington VA Medical Center detailing average duration of NPO and discovered excessive fasting times. First, we engaged the dietary, nursing, and proceduralist communities to discuss barriers and logistics with changing diet orders. Next, we used design-based rapid protocol development to build an ideal order menu to facilitate practices reflective of current evidence. This was then constructed and tested by the information technology team via the CPRS electronic health record and Computrition foodservice software. Providers performing heart catheterization or bronchoscopy agreed to participate after literature review. Education of nursing, catheterization lab, endoscopy suite, dietary, and providers preceded implementation of the new order set. With the new order set, when entering an NPO order, providers are prompted for the procedure (cardiac catheterization, bronchoscopy, or other) which directs them to the appropriate order. Those undergoing the catheterization or bronchoscopy are given a clear liquid diet from midnight to 8AM followed by NPO; all other procedures are NPO at midnight. Feasibility was monitored daily and initial data was extracted six weeks after implementation.
Conclusions: Baseline data from June to August 2017 demonstrated inpatient medicine team NPO times to average 14.03 hours (n=450) and those undergoing the cardiac catheterization or bronchoscopy averaged 11.67 hours (n=35). Following our intervention, overall average NPO duration decreased to 13.03 hours (n=173) regardless of reason for NPO, while average NPO time for the selected procedures decreased to 8.38 hours (n=21) when using the new order. No adverse events related to dietary changes/aspirations were reported. This represents a successful decrease in procedural NPO duration with a modest impact on overall NPO. We anticipate phased implementation of this to include all procedures, in accordance with national anesthesia guidelines, will result in a dramatic lowering of fasting times for our patients and enhance their satisfaction and overall experience.