Reducing preoperative fasting time for children: A multidisciplinary quality improvement project

Pediatric inpatients undergoing sequential procedures under general anesthesia require repetitive periods of pre-procedure fasting that may be longer than the American Society of Anesthesiologists (ASA) recommendations. The purpose of this quality improvement project was to reduce excessive preoperative fasting times in pediatric inpatients requiring multiple procedures within one month at a single-center tertiary care facility.

A multi-disciplinary group was assembled by the Children's Surgery Verification Program. A root cause analysis identified the nil per os (NPO) after midnight Electronic Medical Record (EMR) order as a modifiable risk factor for excessive fasting duration prior to anesthesia. A pre-procedure diet order was implemented, and its effect on patients with three or more anesthetics in one month was monitored using a process-control chart. NPO times were evaluated monthly for 26 months. Plan-do-study act cycles were used within the Model for Improvement.

Overall, the median percentage of patients with greater than 8 h of NPO time decreased from 74 % [95 % confidence interval (CI) 62.5, 77.8] (n = 311, July 2019-March 2022) to 50.0 % [95 % CI 35.3, 66.7] (n = 249, March 2022-December 2024) p = 0.005. Special cause variation was identified at 15-months post-implementation, after which the percent of patients with prolonged fasting was 34 %. In this population, median NPO duration decreased from 12.6 h [11.8,13.8] to 7.6 h [6.3,8.0] p = 0.0001.

The implementation of a customizable EMR-based pre-procedure diet order was associated with reduced pre-procedure NPO time for pediatric inpatients. Successful operationalization requires multidisciplinary and interprofessional collaboration to adhere to quality improvement best practices.