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Investigators from Vanderbilt University, Nashville, TN, conducted an analysis of a quality improvement (QI) initiative designed to reduce the time that children were made to fast via NPO order prior to sedation and/or anesthesia for a procedure. The study was conducted at a university-affiliated children’s hospital, and the quality improvement initiative was specifically designed for patients admitted to the pediatric hospital medicine service. A multidisciplinary team developed the intervention, which included multiple iterations. The goal was to develop processes that would result in NPO times being more consistent with guidelines from the American Society of Anesthesiologists (ASA) suggesting solid food be discontinued 6 hours, breast milk 4 hours, and clear liquids 2 hours prior to administration of sedation/anesthesia. Based on an estimate that the earliest start time for a non-emergent inpatient sedated procedure at the hospital was 7 am, providers were encouraged to specify that clear liquids be ordered to be discontinued at 5 am, beginning in September 2019.
In December 2019, a “SmartPhrase” was created for order entry to simplify the process of specifying stop for solid foods, breast milk, and clear liquids, 6, 4, and 2 hours, respectively, prior to sedation/anesthesia, and in November 2020, a “NPO for Future Anesthesia/Sedation” order option was added to the order entry system, with default times for stopping solids, breast milk, and clear liquids of 1 am, 3 am, and 5 am, respectively, based on the earliest start time of 7 am. Information from multiple hospital records were abstracted for data dashboards that documented average NPO time (defined as the difference between stopping time for clear liquids and anesthesia start time) on a weekly basis, and percentage of orders with a clear liquids stop time specified. For the analysis, the investigators evaluated dashboard data prior to the initiation of the QI project (November 2, 2017 to September 19, 2019) and after the initiation of the interventions (September 20, 2019 to September 16, 2021). As balancing measures, aspiration events related to anesthesia and procedure delays related to NPO violations were assessed.
Data were analyzed on 579 NPO/anesthesia events during the baseline period and 586 events following initiation of the QI project. During the baseline period, the average NPO time was 10 hours, 13 minutes; following the start of the QI project, average NPO time fell to 6 hours, 37 minutes by January 2020. By March 2021, NPO times averaged 6 hours, 7 minutes until the end of the study period. Similarly, prior to initiation of the project, 2% of NPO orders specified a clear liquids stop time, rising to 64% following introduction of the SmartPhrase and 84% after the NPO order option with defaults was added. No aspiration events have occurred; 4 procedure delays related to NPO violations have been documented.
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