A sip of coffee and a bite of rye toast. That's all the man in the photo wants before he rides to the surgery center for his knee arthroscopy. But you've sentenced him to a long and uncomfortable fast, giving him strict instructions not to eat or drink anything after midnight, even though his surgery's not until 11 a.m., and even though evidence points to the dangers of prolonged fasting and the benefits of pre-operative nutrition.

He's not the only one facing the major stress of surgery while hungry, thirsty, anxious, nauseated and generally uncomfortable. Surgical facility leaders across the nation are generally slow to abandon outdated pre-op fasting policies, according to last month's Outpatient Surgery Magazine online survey of 153 surgical facility leaders.

• NPO by midnight. More than half (54.8%) of our survey respondents still follow the overly rigid fasting instructions of NPO-by-midnight totally or in some form. "No one will die from not eating for one morning," says Brett Swain, RN, an OR nurse at the Alta Bates Summit Medical Center in Oakland, Calif. "People who aspirate are at markedly higher risk of pneumonia and death. It isn't worth the risk-benefit ratio. You don't know the entire picture of the patient. Is he on narcotics that will slow gastric emptying? Is he borderline diabetic but not on meds yet?"

• Clear liquids. Even though decades of research support the safety and health benefits of consuming clear liquids until a few hours before surgery, surgical facility leaders routinely instruct patients to fast for excessively long pre-op periods. Only about one-third (31.1%) of our survey respondents tell patients they can drink 2 hours before their procedures, while 43% instruct patients not to drink anything after midnight.

When the American Society of Anesthesiologists published its first practice guidelines for pre-operative fasting for healthy patients undergoing elective surgical procedures 17 years ago, it declared it safe for such patients to "have clear liquids up to 2 hours prior to surgery."

"We give our patients a specific time to stop clear liquids. Generally it is 2 to 2 ? hours before their arrival at our center," says the director of an ENT surgery center. "If the patient is to arrive at 0830, we would tell her to stop the clear liquids at 0600. It works out to be about 3 hours before her start time."

What's so magical about midnight?
Nothing to eat or drink after midnight. Though the risk of death or disability from the aspiration of stomach contents is extremely low, healthy outpatients who are having elective procedures are still subjected to the unpleasant consequences of a pre-op fast that may last for 12 to 16 hours, depending on the actual start times of their procedures.

Perhaps it's because the simple, strict instructions of a complete fast are easy to remember and — unless you allow a sip of water the morning of surgery to wash down designated medications — leave nothing open to interpretation. "We tell everyone midnight, but I will let healthy patients have clear liquids up until 6 hours before the procedure if it is a later-in-the-day procedure," says Mr. Swain.

Besides being easy to remember, there's not much magical about fasting from midnight for healthy patients undergoing elective procedures. At the very least, for many patients, it is perpetuating a miserable pre-operative experience. "Are we so pro-midnight because midnight is the way we have always done it or is it because it is just easier to tell everyone midnight?" asks Beverly Kirchner, RN, BSN, CNOR, CASC, president and CEO of Genesee Associates in Southlake, Texas.

Bend but don't break
Despite evidence and recommendations to the contrary, nurses and anesthetists have long been telling patients to strictly fast once the clock strikes 12 on the day of their procedures, but some facilities are bending the rules just a bit, our survey found.

The Pend Oreille Surgery Center in Ponderay, Idaho, bases fasting instructions on the schedule. "We tailor the instructions to the patients and the time of their arrival," says Kris Sabo, RN, the executive director. "We instruct that they discontinue solids 8 hours prior to arrival to our center and they may consume clear liquids up until 3 hours prior to arrival. This gives us a little cushion. Should they need to be moved up in the schedule, they will still meet the 6-hour solid and 2-hour clear liquid NPO guidelines."

It's not uncommon for patients that are scheduled later in the day to get individualized cutoff times for clear liquids based on their start times. "It depends on the case and if the patient calls ahead of time," says Patti Glassey, BSN, RN, CAPA, administrator of the Turk's Head Surgery Center in West Chester, Pa. "RNs do the pre-op phone call the day prior for what to eat and drink and cutoff times."

Another facility lets patients scheduled after 11 a.m. have 6 ounces of clear liquids before 6 a.m. on the day of surgery. Another puts the cutoff time at 12 noon, saying patients can have clear liquids up until 8 a.m. if surgery is after 12 p.m. We also heard from someone who considers the patient's likelihood of following instructions. "If I feel the patient will not be compliant or confuse the times, I will go straight with NPO after midnight," she says. OSM