Reducing the use of nil per os past midnight for inpatient diagnostic and therapeutic procedures: A quality improvement initiative.

Abstract

Pre-procedural fasting (nil per os[NPO]) is a commonly implemented protocol to prevent aspiration during certain diagnostic and therapeutic procedures. However, evidence suggests aspiration risk is quite low. Current guidelines support a reduced fasting duration before procedures necessitating anesthesia or sedation, but many health systems persist in the use of NPO past midnight. We aimed to reduce the use of NPO p MN before inpatient diagnostic and therapeutic procedures necessitating anesthesia or sedation by 50% within 6 months. We performed a quality improvement initiative at a single academic health system in Southeast Texas. We include the experience of patients of all ages across 4 affiliated hospitals (one main academic hospital and three community satellite hospitals). An interprofessional team was convened to review best practices and oversee this quality improvement initiative. Diagnostic imaging protocols previously requiring NPO were amended to reflect evidence-based fasting requirements. A pre-procedure clear liquid diet was also implemented. We describe the steps to implementation, feasibility of implementation as described through key process measures, and the safety of implementation (balancing measures). NPO requirements were removed from 70% of existing diagnostic imaging and therapeutic orders. After these amended protocols and the implementation of a pre-procedure clear liquid diet, we displayed an immediate 50% reduction in NPO past midnight usage. Further stakeholder engagement/education and targeted interventions reduced NPO past midnight usage to only 33% of pre-procedural diet orders. Surgery remains the most common indication for continued use of NPO. Aspiration events and procedural delays were rare.