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

Background: 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. Objective: 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. Design, Setting and Participants: 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). Intervention: 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. Main Outcome and Measures: We describe the steps to implementation, feasibility of implementation as described through key process measures, and the safety of implementation (balancing measures). Results: 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.