From the 2021 HVPAA National Conference
Karen Chang (University of Texas Medical Branch), Krishna Suthar, Erin Hommel
Preoperative fasting (nothing per os, NPO) is implemented before procedures or diagnostic studies to prevent the risk of aspiration in patients. However, patients frequently remain NPO for prolonged periods of time, which can affect patient comfort and extend length of stay. In addition, prevalence of periprocedural aspiration is low and a pre-procedural clear liquid diet is unlikely to increase aspiration risk. Current practice guidelines from the American Society of Anesthesiologists say that clear liquids can be ingested for up to two hours before elective procedures in most patients requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia.
The University of Texas Medical Branch at Galveston is an academic institution which seeks to decrease unnecessary NPO use prior to elective inpatient radiologic imaging, diagnostic procedures and surgical procedures by 50% over six months.
Interventions established included adapting radiological imaging protocols to remove unnecessary NPO requirements, electronic medical record (EMR) upgrade to include adjusted radiological imaging protocols in order entry and at nursing interface, education of frontline staff about adjustments in radiological imaging changes, EPIC build of pre-procedural clear liquid diet including adjusted order sets where appropriate, adaptation of communication strategies for procedural areas to guide frontline nursing in implementation of pre-procedural clear liquid diet, education of frontline staff about implementation of pre-procedural clear liquid diet, monitoring of ongoing use of NPO past midnight and targeted feedback to providers continuing in use of NPO past midnight orders.
At baseline October 2019, there were 1421 total counts of NPO past midnight diet documented. Top reasons for the NPO orders included surgery (37.58%), cardiac catheterization (15.13%), and Interventional Radiology procedures (14.57%). The pre-procedural clear liquid diet was implemented November 2019. By October 2020, orders reduced to 435 total counts of NPO past midnight diet documented. Top reasons for continued NPO order use included surgery (42.30%), possible surgery (12.41%), GI procedures (10.80%), and Interventional Radiology procedures (10.11%). There was a 69% decrease in use of NPO.
Through this quality improvement project, we have decreased the use of NPO past midnight diet at our institution. Many barriers remain to universal acceptance and implementation of the interventions to reduce the pre-operative fasting period. These include safety concerns, communication barriers, and incomplete education.
Patient satisfaction and procedural outcomes can be adversely impacted by extended periods of NPO before procedures or radiologic tests. We have identified methods to reduce unnecessary NPO utilization and duration of preprocedural fasting. However, success requires a multifaceted educational and communication approach led by a multidisciplinary team with a shared mental model.