Fourteen Hours Without Food, Eleven Without Water: Defining the Problem of Prolonged Preoperative Fasting in a Same-Day Surgery Center From an Audit of 120 Patients
[Student Name]
University of Phoenix
DNP/710: Evidence-Based Practice Measurement and Clinical Inquiry
Week 1 Assignment
[Instructor Name]
[Date]
The hospital and audit figures are composites written for a model paper.
I am a clinical nurse specialist for perioperative services at a 250-bed community hospital with a same-day surgery center that performs about 6,000 elective procedures a year. Patients arriving for afternoon surgery often tell our preoperative nurses they are dizzy, thirsty and have a headache. Our written instructions still say "nothing to eat or drink after midnight." I suspected our patients were fasting far longer than necessary. This paper describes the audit I conducted, the gap it revealed and my problem statement.
The National Standard
The American Society of Anesthesiologists (2017) practice guidelines for healthy patients undergoing elective procedures allow clear liquids up to 2 hours before anesthesia, a light meal up to 6 hours before and fatty or fried food up to 8 hours before. These guidelines have been in place, in similar form, for nearly two decades. Nothing after midnight is not a guideline recommendation but a tradition.
Evidence That Shorter Fluid Fasts Are Safe
Brady et al. (2003), in a Cochrane review of 22 trials, found no evidence that a shortened preoperative fluid fast increased gastric volume or acidity compared with a standard fast in adults not at increased risk of aspiration, and patients given water preoperatively had slightly lower gastric volumes. Few trials reported aspiration directly, but the review found no indication of harm from shorter fluid fasts.
Audit Method
Over four weeks, preoperative nurses asked 120 consecutive adult elective patients, excluding those with diabetes, gastroparesis, obesity with a body mass index over 40 or bowel obstruction, when they last ate solid food and when they last drank any liquid. Times were recorded against the time of anesthesia induction from the record. Nurses also asked what instructions patients had received and rated their thirst and hunger on a 0-to-10 scale.
Audit Results
Median fasting from solids was 14.2 hours, with an interquartile range of 12.1 to 16.8 hours. Median fasting from liquids was 11.4 hours, with an interquartile range of 9.3 to 14.0 hours. Only 7 of 120 patients, or 6%, had drunk any clear liquid within 4 hours of induction. Patients scheduled after noon fasted longest, with a median of 16.5 hours from solids. Eighty-two percent reported being told nothing after midnight. Forty-four percent rated thirst at 7 or higher, and 31% rated hunger at 7 or higher.
The guideline allowed water two hours before surgery; our median patient's last sip was eleven hours before.
A Published Comparison
Falconer et al. (2014) surveyed 292 surgical patients in a Scottish teaching hospital and found a median fast from solids of 13.5 hours and from fluids of 9.4 hours for elective patients, far longer than recommended, and noted that universal fasting instructions and patient choice prolonged fasting. They concluded that clinical practice is slow to change. Our results are similar or worse, suggesting that our instructions, not our patients, are the main cause.
Who Fasts Longest
Breaking the results down showed where the problem concentrates. Patients on afternoon lists fasted about five hours longer than morning patients from liquids. Patients over 70 were less likely to drink anything after midnight even when told they could, often out of caution. Patients whose surgery was delayed by more than an hour fasted longest of all, since no one told them they could drink while they waited. These patterns show where a change would matter most.
What Patients Said
Nurses recorded patients' comments during the audit. One woman scheduled at 3 p.m. said she had not had water since 9 p.m. the night before because she "didn't want to be canceled." A man said he had a headache since morning and felt faint when he stood. Several patients said they would have drunk water if anyone had told them it was allowed. Their words make the numbers concrete.
Consequences
Prolonged fasting causes thirst, hunger, headache, anxiety and discomfort. It may contribute to dehydration, hypotension on induction and postoperative nausea. For afternoon patients, fasting approaches a full day. Our nurses report that dehydrated patients take longer to cannulate and that some patients arrive lightheaded. These consequences affect comfort, safety and efficiency.
Why the Gap Persists
Informal conversations with anesthesiologists, surgeons, schedulers and nurses suggest several causes: printed instructions that were never updated, concern that surgery times shift and a patient scheduled for 2 p.m. might be moved to 10 a.m., uncertainty about what counts as a clear liquid and a belief among some staff that longer fasting is safer. Understanding these causes will shape any change, and each will need a specific answer rather than a general reminder that guidelines have changed.
Problem Statement
In adult elective surgery patients at our same-day surgery center, the median preoperative fast from liquids is 11.4 hours and from solids is 14.2 hours, far exceeding national guidelines that permit clear liquids until 2 hours and a light meal until 6 hours before anesthesia, and 44% of patients report severe thirst before surgery.
Significance
The problem affects about 6,000 patients a year, has clear evidence-based standards and is within nursing's influence, since preoperative nurses give instructions and call patients the day before surgery. It is also a patient experience issue measured in our surveys.
Cost and Efficiency Signals
The audit also found that 9 of 120 patients needed a second attempt at intravenous access, and nurses attributed most of these to dehydration. Each extra attempt adds minutes, supplies and discomfort. I did not measure hypotension on induction, but anesthesia colleagues report that dehydrated patients often need extra fluid boluses. These signals suggest that shorter fasting could improve efficiency as well as comfort.
Limitations of the Audit
Patients' recall of their last meal and drink may be imprecise. The audit covered four weeks and excluded higher-risk patients, so it may not represent all patients who pass through our center. Thirst and hunger ratings were collected by nurses who knew the audit's purpose. Still, the gap is large enough that measurement error is unlikely to explain it.
Stakeholders in the Problem
The problem involves several groups: patients, preoperative nurses who give instructions, schedulers who set arrival times, anesthesiologists who approve fasting rules and surgeons whose case order changes. Each will need to be part of the solution.
Next Steps
Next week I will turn this problem into a searchable clinical question, which will guide my search for evidence about interventions, including shortened fasting instructions and carbohydrate-containing clear drinks.
Conclusion
An audit of 120 elective patients showed median fasts of 14.2 hours from solids and 11.4 hours from liquids, with nearly half reporting severe thirst, despite guidelines allowing clear liquids until 2 hours before anesthesia. A Cochrane review supports the safety of shorter fluid fasts, and a published audit shows the problem is common. Local data define the gap, its size and the patients most affected.
References
American Society of Anesthesiologists. (2017). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. Anesthesiology, 126(3), 376-393. https://doi.org/10.1097/ALN.0000000000001452
Brady, M., Kinn, S., & Stuart, P. (2003). Preoperative fasting for adults to prevent perioperative complications. Cochrane Database of Systematic Reviews, 2003(4), Article CD004423. https://doi.org/10.1002/14651858.CD004423
Falconer, R., Skouras, C., Carter, T., Greenway, L., & Paisley, A. M. (2014). Preoperative fasting: Current practice and areas for improvement. Updates in Surgery, 66(1), 31-39. https://doi.org/10.1007/s13304-013-0242-z
How this DNP 710 Week 1 example is structured
The DNP/710 Week 1 work usually defines a practice problem using internal data. This paper moves from an observation, to an audit with its method stated, to results, to comparison with guidelines and published data, ending in a problem statement that names the gap, the population and its consequences. Students search this week as DNP 710 Week 1, DNP710 Wk 1 or DNP/710 Wk 1; all three are the same assignment.
DNP/710 Week 1 questions, answered
What does DNP/710 Week 1 usually ask for?
Many sections ask students to identify a practice problem in their setting and define it with internal data, showing the gap between current practice and best evidence.
How long do patients need to fast before elective surgery?
National guidelines for healthy patients undergoing elective procedures allow clear liquids up to 2 hours before anesthesia and a light meal up to 6 hours before, much shorter than the traditional nothing after midnight.
Why use internal data to define a practice problem?
Internal data show whether a problem exists locally, how large it is and whom it affects, which makes the case for change specific and persuasive and provides a baseline for measuring improvement.
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