Use .FAST to Sip Til Send: A Quality Improvement Initiative Using Digital Solutions to Facilitate Best Practice Preoperative Fasting Protocols in Emergency General Surgery

ABSTRACT

Background

Reduced preoperative fasting times are beneficial for patients, have negligible aspiration risk and minimise intravenous fluid (IVF) use. For over 15 years the national anaesthetic guidelines in Australia have recommended solid food until 6 h prior to surgery and unlimited clear fluids until 2 h prior to surgery. In 2024 an additional recommendation was added: sips of clear fluids (typically water) up to 200 mL/h until sent to theatres. Nonetheless, ‘fast from midnight’ (FFM) and ‘nil by mouth’ (NBM) are commonly used.

Methods

This study was conducted on patients in a single, tertiary, metropolitan hospital. Baseline preoperative fasting data were retrospectively collected from 21/08/2024 to 18/09/2024. A staff education campaign and an EMR smart phrase (“.FAST”) were then introduced. Post implementation data were prospectively collected from 28/10/2025 to 20/01/2025. Data were analysed for fasting protocol type, total fasting time (TFT), and preoperative IVF use. Data modelling was used to calculate the projected impact of the .FAST protocol.

Results

Uptake of best practice fasting guidelines increased from 1% to 47% (p < 0.001). This was associated with a marked IVF use reduction—from 41% to 17% of patients (p < 0.001)—and a decrease in median fasting time from 9 to 2 h (p < 0.001). Median total time on IVF reduced from 8 to 0 h (p < 0.001). Projected annual savings in EGS with 100% uptake of the .FAST protocol were projected to be 23 doctor workdays and 46 nurse workdays (assuming an 8 h workday), and $2460 in IVF cost.

Conclusions

Implementation of a simple to use, contemporary preoperative fasting protocol in EGS through staff education and an EMR smart phrase led to decreased time fasted for patients and IVF use. No patients fasted with .FAST had surgery cancelled due to inadequate fasting.

1. Introduction

Reduced preoperative fasting times not only enhance patient comfort, but improve haemodynamic stability, reduce metabolic stress and minimise intravenous fluid (IVF) use when compared to the prolonged fasting times associated with protocols such as ‘nil by mouth’ (NBM) and ‘fast from midnight’ (FFM) [1]. Nonetheless, FFM and NBM remain widely used despite contemporary evidence‐based guidelines from the Australian and New Zealand College of Anaesthetists (ANZCA) advocating significantly shorter fasting durations [2]. ANZCA recommend usual oral intake continue until 6 h before surgery, and unlimited clear fluids continue until 2 h prior to surgery. Patients can safely continue sips of clear fluids (typically water), up to 200 mL per hour, until sent from the ward to theatre; reducing the time a patient spends fasted [3]. Furthermore, patients do not routinely require IVF prior to surgery if fasted according to these guidelines, which is of particular significance during the current global IVF shortage [3, 4].

Whilst some degree of fasting is necessary to prevent complications with general anaesthesia, the benefits of limiting fasting are clear. Fasting from solids for at least 6 h prior to procedures mitigates potentially harmful complications such as regurgitation and gastric content aspiration [5]. Continuing preoperative oral fluids at a rate of less than 200 mL per hour until sent for theatre (“Sip Til Send”) has been shown to be beneficial in terms of improving intravenous access, reducing postoperative nausea and vomiting, and enhanced recovery after surgery, notably without increased risk of aspiration or regurgitation [2].

Despite this evidence and the existence of easily accessible fasting guidelines, clinical practice implementation has lagged, resulting in an evidence–practice gap. Audits and surveys consistently show that most patients continue to experience prolonged and unnecessary fasting times due to poor adherence to established guidelines [6, 7, 8]. Patients awaiting emergency general surgery (EGS) are especially vulnerable to excessive fasting due to unpredictable theatre access times. A UK multicentre audit found EGS patients fasted significantly longer than elective cases (13 h vs. 4.9 h, p < 0.0001) [7]. Furthermore, a retrospective study showed only 6.1% of fasted emergency patients underwent surgery, with < 1% in low‐acuity triage groups; highlighting routine overuse of fasting without confirmed surgical need [6].

The benefits of a perioperative fasting protocol are numerous; however, widespread adoption has been limited by emergency workflow uncertainty, persistent fear of aspiration, and cultural and institutional inertia [6, 7, 9]. To address these issues, a 2021 Australian pilot study conducted at The Royal Melbourne Hospital demonstrated that leveraging the smart phrase feature of the Electronic Medical Record (EMR) system combined with a staff education campaign could reduce unnecessary fasting times and IVF use in EGS [10].

Building on this 2021 pilot study and the release of the Sip Til Send ANZCA policy in 2024, The Canberra Hospital (TCH) implemented a preoperative fasting protocol for EGS, named ‘.FAST’ after its EMR smart‐phase. A follow‐up audit of protocol uptake was conducted, with time and cost savings modelled. This study aimed to implement a simple and accessible method to help clinicians implement best‐practice evidence‐based fasting guidelines in EGS and evaluate its impact.

2. Methods

2.1. Context

The .FAST study was a quality improvement project conducted from 21 August 2024 to 20 January 2025 in The Canberra Hospital, a tertiary metropolitan Australian hospital. It was based on the ANZCA “guideline on pre‐anaesthesia consultation and patient preparation 2024” that outlines a patient can eat until 6 h and drink clear fluids until 2 h prior to surgery, then have sips of clear fluids (typically water) < 200 mL per hour until sent from the ward to theatre [3].

The study inclusion criteria were adults over 18 years old with a procedure booked under the EGS department between 21 August 2024 to 18 September 2024 (pre‐interventional, retrospective audit) and 28 October 24 to 20 January 2025 (post‐interventional, prospective audit). Patients were excluded if they were fasted for other clinical indications (i.e., bowel obstruction, risk of aspiration, documented clinical judgement) or went directly to theatre after admission.

This study was conducted in three parts; an initial audit of fasting protocols, the intervention (implementation of the .FAST protocol), and a final audit of protocol uptake.

The initial audit was conducted from 21 August 2024 to 18 September 2024 to establish what fasting protocols were used in EGS at TCH and determine what—if any—intervention was required. The audit was conducted by two junior medical officers under the supervision of a consultant General Surgeon, who manually analysed patient notes for fasting protocol (FFM, NBM, other), total fasting time (TFT), and if IVF was ordered (ON‐IVF). This revealed 98 operations, 17 of which were excluded for being either NBM for “direct to theatre” or had a clinical indication precluding .FAST such as bowel obstruction or high aspiration risk.

2.2. Intervention

The intervention was conducted from 19 September 24 to 28 October 24, following analysis of preliminary data. Staff education sessions were delivered to EGS nursing staff, doctors and anaesthetists, and a power point presentation was delivered at the regular departmental education meeting (Annex A). These sessions emphasised the safety, efficiency, and alignment of .FAST with ANZCA preoperative fasting guidelines and Canberra Health Service's fasting policy, available on the hospital intranet site [11]. Once consensus and support for the protocol were built, posters and pamphlets were printed for display on EGS wards (Figure 3).

FIGURE 3.

Poster used to educate staff on the benefits of the updated fasting protocol and how to use .FAST on the EMR.

A central component of the intervention was development of the .FAST smart phrase, created to standardise fasting instructions within the EHR system. This tool enabled clinicians to enter a single command—“.FAST”—which automatically populated detailed, protocol‐compliant fasting instructions into patient notes. The generated text read: “Patient can eat until 2 a.m., have clear fluids until 6 a.m., then sips of water < 200 mL/h until sent to theatre from the ward. (Note: IVF not routinely required using this protocol. Clear fluids include water, black tea, black coffee and no pulp apple juice).” This function was designed to make implementation of the best practice fasting protocol easy, efficient, accessible and accurate for all users.

2.3. Study of Intervention

A prospective audit was conducted from 28 October 2024 to 20 January 2025 repeating the initial audit methodology. Out of 160 operations, 21 operations were excluded as per the exclusion criteria. In collaboration with the team who conducted the EU2WU6 study, data was modelled using the same data modelling techniques to estimate projected annual savings in terms of workhours for nurses and doctors, as well as costs saved from IVF use [10]. This study is distinguishable from the EU2WU6 study due to the inclusion of a pre‐intervention audit prior to protocol implementation, which enabled direct comparison of IVF use before and after the intervention—rather than relying on projected estimates. This study also incorporated the recently released ANZCA policy of Sip Til Send.

2.4. Measures

Data were collected from all eligible participants as per the inclusion criteria outlined above. Demographic data including age, primary procedure type and surgery date were recorded to contextualise fasting protocols and indication for fasting. Data were categorised based on fasting protocol used (‘FFM’, ‘NBM’, ‘other’ and ‘.FAST’ for the post intervention audit), TFT preoperatively (hours), and if IVF was ordered (yes = ON‐IVF). These parameters were selected to align with the EU2WU6 protocol for ease of comparison and data projection.

TFT was calculated based on the specific fasting protocol used: either from midnight for FFM, or from the timestamp of the progress note ordering NBM or alternative fasting instruction, which varied depending on clinical practice. In cases where patients were fasted multiple times before ultimately proceeding to theatre, the most recent fasting instruction and corresponding fasting start time were used for calculation.

ON‐IVF time was calculated as the interval between the documented IVF commencement and the time the patient proceeded to theatre, as recorded in the operation note. For data modelling using the EU2WU6 methodology, IVF use was also recorded as a binary “yes/no”—indicating whether IVF was ordered at all during the fasting period. This simplification assumed that the outcome measure of interest—doctor time to order IVF, nurse time to prepare and administer it, and cost per bag—would remain consistent regardless of the duration for which fluids were charted.

Changes in fasting protocol use were analysed by comparing the percentage distribution of each protocol type before and after the intervention. TFT and ON‐IVF use were also examined as percentages pre‐ and post‐intervention, as well as within each intervention group.

Data modelling was based on the EU2WU6 pilot study methodology, using the assumption of comparable patient loads between the EGS systems at TCH and RMH [10]. This included assumption of 100% .FAST protocol uptake with an average of 20 patients per day on the EGS booking system. Modelling assumed that if patients received IVF overnight, this would equate to 1 bag of fluid, requiring approximately 5 min of a physician's time to chart and 10 min of a nurse's time to administer, at a cost of A$1.12 per bag [10]. Workdays saved were calculated as 8 h shifts (projected hours saved divided by eight).

2.5. Analysis

Microsoft Excel (Microsoft Corp., Redmond, Washington) was used to record data, which was analysed using Jamovi version 2.6. Data were modelled using SPSS (Corp I. IBM SPSS Statistics for Windows. 28.0 edition, Armonk, New York). Categorical data were compared using Chi squared or Fisher's exact tests, while continuous data were compared using Mann‐Whiteney U Tests. The significance threshold was set using Bonferonni corrected p value of p < 0.017.

2.6. Ethical Considerations

The ACT Human Research Ethics Committee deemed this project met the definition of a quality assurance/improvement activity with negligible risk to participants (2025.QAI.00119), thereby permitting completion without formal ethics application. This manuscript was written in accordance with the SQUIRE reporting guidelines.

3. Results

3.1. Protocol Uptake

Between 21 August 2024 to 18 September 2024, 81 fasting episodes were included; 36% (n = 29) were NBM, 36% (n = 29) were FFM, and 27% (n = 22) had ‘other’ instructions that did not completely align with ANZCA policy (Figure 1). Only one patient was appropriately fasted, with instructions that followed ANZCA policy, which is annotated as .FAST in Figure 1 for simplicity of analysis—however they did not use the .FAST smart phrase as it had not yet been created. This audit justified the need for .FAST protocol implementation.

FIGURE 1.

The percentage of protocols used in EGS at TCH before (blue) and after (orange) implementation of the .FAST protocol. FFM = fast from midnight (36% to 16%, p < 0.001), NBM = nil by mouth (36% to 23%, p = 0.006), other = any other fasting protocol (27% to 14%, p = 0.02), FAST = .FAST fasting protocol (1% to 47%, p < 0.001). Note that prior to the establishment of the .FAST smart phrase, one patient was fasted in accordance with the same fasting guidelines as .FAST, and is included here for completeness of comparison.

The prospective audit after .FAST protocol implementation from 28 October 2024 to 20 January 2025 included 139 fasting episodes, whereby the majority used .FAST (47%, n = 65). 23% (n = 32) were NBM, 16% (n = 22) were FFM, and 14% (n = 20) were ‘other’. Comparison before and after .FAST implementation is illustrated in Figure 1.

Figure 1 also highlights the marked reduction in inappropriate fasting protocols NBM and FFM after .FAST introduction. Post‐intervention, .FAST was used in almost half of cases, demonstrating a significant increase in uptake from 1% to 47% (1/81 vs. 65/139, p < 0.001). Conversely FFM use significantly reduced from 36% to 16% (29/81 vs. 22/139, p < 0.001). NBM use decreased from 36% to 23% (29/81 vs. 32/139, p = 0.006) and other protocols decreased from 27% to 14% (22/81 vs. 20/139, p = 0.02).

3.2. IVF Usage

Overall IVF use was significantly reduced after .FAST implementation, from 41% to 17% (33/81 vs. 23/139, p < 0.001). Figure 2 outlines the decrease in use of IVF by fasting protocol, with less than a quarter of all patients fasted using .FAST given IVF. Total time on IVF was reduced from a median of 8 h prior to .FAST, to 0 h median after (p < 0.001).

FIGURE 2.

The percentages of IVF use before (blue) and after (orange) implementation of the .FAST protocol in EGS at TCH. FFM = fast from midnight (36% to 19%, p = 0.201), NBM = nil by mouth (57% to 33%, p = 0.098), other = any other fasting protocol (7% to 24%, p = 0.099), FAST = .FAST fasting protocol (0% to 8%). Overall IVF use was significantly reduced after .FAST implementation, from (41% to 17%, p < 0.001).

NBM and FFM demonstrated a reduction in IVF use percentage after the education campaign but this was not significantly different. NBM decreased from 57% to 33% (16/28 vs. 7/21, p = 0.098), while FFM decreased from 36% to 19% (10/28 vs. 4/21, p = 0.201). ‘Other’ fasting protocols saw increased percentage IVF use from 7% to 24% (2/28 vs. 5/21, p = 0.099). After .FAST implementation at TCH EGS, only 8% of patients fasted with .FAST had IVF charted, representing the least IVF use of all protocols (Table 1).

TABLE 1.

IVF use after implementation of .FAST protocol in EGS at TCH.

Fasting protocol	n	Proportion of all fasting protocols (%)	IVF used (n) a	IVF use as a proportion of fasting protocol (%)
.FAST	65	47	5	8
NBM	32	23	10	31
FFM	22	16	4	18
Other b	20	14	4	20
Total	139		23	17

^a ON‐IVF: IVF charted preoperatively.

^b Fasting protocol such as eat until 2 a.m. or sips til send, but not using .FAST protocol specifically or no clear fasting protocol documented.

3.3. Total Fasting Time

TFT was reduced from a median of 9 h to 2 h after .FAST implementation (p ≤ 0.001).

3.4. Data Modelling for Projected Savings

Projected annual savings in doctor and nurse time as well as cost of IVF bags are presented in Table 2 [10]. With full .FAST adoption, Table 2 suggests an annual savings of approximately 23 doctor workdays and 46 nurse workdays, along with a reduction in intravenous fluid costs by approximately A$2460 per annum.

TABLE 2.

Projected annual savings in doctor time, nurse time and cost of IVF bags based on pre and post .FAST protocol implementation data in EGS at TCH.

	IVF (minutes)	Doctor (minutes)	Nurse (minutes)	Cost of IVF bags ($)
Before .FAST	3514.56	17572.80	35145.60	3936.31
After .FAST	1317.96	6589.80	13179.60	1476.12
Savings per annum	2196.60	10983.00	21966.00	2460.19

3.5. Comparison to EU2WU6

The uptake of .FAST was 47% over the period from 28 October 2024 to 20 January 2025, and the final uptake of EU2WU6 was 80% over the period 1 September 2021 to 31 December 2021. A total of 40% of patients had IVF charted overnight with median total time on IVF of 3 h (p < 0.001) for the EU2WU6 study, while 17% of patients had IVF charted with median total time on IVF of 0 h (p < 0.001) in the .FAST study. Median TFT was reduced from 13 to 7 h (p < 0.001) in EU2WU6 and 9 to 2 h (p < 0.001) for .FAST. Projected savings for EU2WU6 were ~17 doctor workdays, ~34 nurse workdays and A$2296 saved, compared to ~23 doctor workdays, ~46 nurse workdays and A$2460 saved. No surgeries were cancelled in either study. Comparison of the two studies is outlined in Table 3.

TABLE 3.

Comparison of .FAST and .EU2WU6 protocols.

	The Royal Melbourne Hospital (EU2WU6)	The Canberra Hospital (.FAST)	Comparison
IVF use	40% had IVF charted overnight, with total time on IVF 3 h vs. 8 h (p < 0.001).	17% had IVF charted overnight (compared to 41% prior) and lower total time on IVF (0 h median vs. 8 h p < 0.001).	.FAST achieved a lower IVF use rate and time on IVF compared to EU2WU6.
TFT	Median TFT reduced from 13 h (FFM) to 7 h (EU2WU6) (p < 0.001).	Median TFT reduced from 9 h to 2 h (p < 0.001).	Both protocols successfully reduced fasting times.
Hospital Resources Savings (Annual)	~17 doctor workdays, ~34 nurse workdays. Cost savings: A$2296.	~23 doctor workdays, ~46 nurse workdays. Cost savings: A$2460.	Both protocols resulted in marked projected time savings for doctors and nurses, comparable cost savings.
Uptake	80% by end of 4‐month pilot program. 95% uptake by end of follow‐up audit 3 months afterwards.	47% average uptake. No follow up audit.	EU2WU6 achieved greater protocol uptake than .FAST and confirmed ongoing uptake with a follow‐up audit. a
Surgery cancellations	No surgeries cancelled due to inadequate fasting.		Both protocols demonstrated safe implementation without increased surgical delays or cancellations.

^a .FAST included all fasting protocols documented, while EU2WU6 only made comparison to FFM and did not include NBM or ‘other’ fasting protocols which may explain why uptake of .FAST appears much less.

3.6. Exportable Package for Use in Other Hospitals

A power point presentation was created for education sessions prior to .FAST implementation at TCH, and is attached as Annex A. A poster was also made for dissemination on the EGS ward as part of the education campaign for staff to easily refer to when charting fluids or caring for patients preoperatively (Figure 3).

4. Discussion

The practice of making patients NBM and FFM to prevent aspiration is not necessary and is associated with numerous poor outcomes including dehydration, increased intraoperative IVF requirements, a catabolic state associated with starvation, general discomfort and emotional distress [12]. Numerous studies highlight the benefits and safety of reduced fasting protocols. A systematic review of 16 studies in acutely unwell patients found no increased aspiration risk with reduced fasting times [8]. Similarly, a quality improvement study in elective surgery, which included over 76 000 patients, reported negligible aspiration rates despite liberalised fluid intake policies [6].

Nonetheless, unnecessarily long fasting protocols continue to be used. One study with 293 patients identified that 89% of patients were fasted for more than 8 h, despite guidelines endorsing significantly shorter durations [13]. Similarly, a prospective UK audit showed that 73% of patients were fasted from solids and 21% from clear fluids for an unnecessary length of time [7]. These findings highlight a systemic tendency to fast patients longer than necessary, reinforcing the need for better staff education, communication, and system‐level changes to support consistent use of evidence‐based protocols.

Implementation of the .FAST protocol in EGS at TCH led to a significant shift toward best‐practice fasting in this cohort, with uptake rising from 1% to 47% (p < 0.001). This was associated with a marked IVF use reduction—from 41% to 17% of patients (p < 0.001)—and a decrease in median fasting time from 9 to 2 h (p < 0.001).

.FAST achieved lower IVF usage and greater projected resource savings than the pilot EGS preoperative fasting protocol EU2WU6, reinforcing the value of integrating education and smart documentation tools into digital health systems. By comparing our intervention to EU2WU6, we contribute to building a multi‐centre evidence base that can guide national or system‐level adoption of more patient‐centred fasting protocols in EGS. These findings support scalable implementation to improve perioperative care, reduce unnecessary fasting, and conserve resources amidst a global IVF shortage.

4.1. High Protocol Uptake

Over the study period, the .FAST protocol achieved an average uptake of 47%, accompanied by a concurrent reduction in the use of all other fasting protocols. This is particularly impressive when compared to the pre‐intervention period, where 99% of patients were not fasted appropriately. The exception was the ‘other’ category, which likely reflects partial or incorrect .FAST application. For instance, some notes fasted patients using most elements of .FAST but omitted the instruction to continue sips of water until sent to theatre.

Nonetheless, a 47% uptake is notable when compared to international benchmarks. For instance, a quality improvement initiative in the Netherlands reported 22% uptake of a liberal fluid policy in elective patients after full implementation while a similar project in Moscow involving cardiothoracic patients achieved a 27% improvement in adherence to clear fluid fasting guidelines [9, 14]. However, when compared to the EU2WU6 study which recorded 80% uptake by the end of the intervention period, it seems low. This is because EU2WU6 reported uptake incrementally and excluded NBM or no protocol documented from its data [10]. Given that NBM accounted for a substantial proportion of fasting events post‐intervention and was associated with the highest IVF usage both before and after .FAST, it is likely that excluding NBM and ‘other’ protocols from the .FAST dataset as per EU2WU6, would result in a comparatively higher reported uptake than 47%.

4.2. Reduced Use of Unnecessary Fasting Protocols

Implementation and education surrounding .FAST not only increased the use of best‐practice fasting guidelines, but reduced the use of other non‐evidence based fasting protocols. Prior to the .FAST intervention, most patients were fasted with a fasting protocol not reflective of ANZCA guidelines and evidence (NBM = 36%, FFM = 36%, other = 27%). Following implementation, there was a 13% reduction in NBM and ‘other’ usage and a 10% reduction in FFM. This reflects a meaningful and sustainable shift toward evidence‐based practice and better patient outcomes, as demonstrated by studies where reduced preoperative fasting protocols led to reduced postoperative nausea and vomiting as well as reduced patient thirst with no significant increase in aspiration [8, 9]. It is noteworthy to affirm that no surgeries were cancelled during the observation period due to the .FAST protocol, reinforcing the safety and practicality of implementing .FAST.

4.3. Reduced IVF Use and TFT

Introduction of the .FAST protocol saw a marked decrease in IVF use across the spectrum of all fasting protocols, suggesting overall benefit of the education campaign. Less than one in five patients received IVF post‐intervention (17%) compared to almost half of patients prior (41%, p < 0.001). .FAST was associated with the greatest reduction in IVF use, with only 8% of .FAST‐fasted patients having IVF charted (Table 1). While changes in IVF use among non‐.FAST protocols did not reach statistical significance, this may be due to small sample sizes. A reduction in IVF use by almost a quarter in NBM patients (24%, p = 0.098), and almost a fifth in FFM patients (17%, p = 0.201) still represents positive progress towards saving IVF, time, money and enhancing patient outcomes.

Overall reduction in IVF use also coincided with a reduction in time patients spent fasting. TFT was reduced by a median of 7 h post‐intervention, likely because patients do not need to fast completely using .FAST as they are still permitted to Sip Til Send. This contrasts with the EU2WU6 study, conducted prior to the release of the Sip Til Send policy. Nonetheless, both EU2WU6 and .FAST led to marked reductions in IVF use and TFT, with similar projected staff time and hospital costs saved, as outlined in Table 3.

4.4. Projected Savings

Modelling the effect of 100% .FAST protocol adoption is outlined in Table 2 and suggests significant resource and cost benefits institution‐wide. Compared to EU2WU6, .FAST achieved slightly greater projected time, cost and IVF savings. The EU2WU6 study projected annual savings of approximately 2050 bags of IVF (A$2296), approximately 21 doctor workdays, and 42 nurse workdays at full adoption of its protocol. By comparison, the .FAST initiative forecasts roughly 23 doctor workdays and 46 nurse workdays saved at 100% implementation, alongside A$2460 in fluid cost savings. Both EU2WU6 and .FAST data modelling illustrate that implementing a best‐practice pre‐operative fasting protocol not only benefits patients but saves precious staff time currently spent charting and preparing IVF. It also saves thousands of dollars in hospital funds that could otherwise be spent to improve patient outcomes, and minimises landfill created by IVF bags hung for patients that could have sips until they are sent to theatre.

4.5. Limitations and Further Directions

Future research and implementation of .FAST should seek to address potential barriers to complete adoption of the fasting protocol. Neither .FAST nor EU2WU6 achieved full adoption by the end of their respective study periods, highlighting the importance of increasing and sustaining protocol use longitudinally. Continued partial reliance on alternative fasting protocols such as FFM and NBM, indicates a persistent gap in best practice adherence, despite clear guidelines. Identifying and addressing specific barriers to full uptake is crucial to improve compliance in future implementation. Challenges to uptake include early resistance and habit inertia, as seen in one study requiring multiple cycles of repeated education and visual cues to engage ward staff and spark cultural change [12]. Once cultural change is achieved, there are staff‐related and patient‐related challenges to sustained adherence to the new protocol.

Patient‐related barriers to adherence are largely to do with psychological and communication barriers. Even when instructed appropriately, some patients self‐restrict food or fluid intake out of fear or misunderstanding [9]. Staff‐related issues include protocol drift over time—especially as trained personnel rotate out or new staff arrive without formal induction to the new protocol [14]. Without regular audits, visual prompts, or refresher training, initial gains in protocol compliance tend to subside [12]. Both staff and patient factors may have limited the correct utilisation of .FAST despite its relative simplicity, underscoring the need for sustained efforts to align practice with evidence‐base guidelines long‐term. Tradition embeds itself into clinical medicine, but these findings reinforce that with effort and education rapid progress can be achieved, and we need to continue challenging the dogma.

Another limitation of this study included difficulty in determining precise fasting durations. Fasting duration calculations relied on recorded start times on EMR; the timestamp when IVF was charted for NBM or the default protocol start‐times such as midnight for FFMN. There was no way to confirm IVF started at this time, presenting difficulties in determining precise fasting durations. Likewise, confirmation that a patient remained fasted in practice through continual observation is not feasible from a resource perspective, which may underestimate fasting times in instances where verbal orders were given to fast prior to written notes or where patients may have come in to hospital already fasted.

Finally, the EMR system was highly useful in facilitating the incorporation of a long fasting protocol statement into a short phrase (.FAST) that could easily and quickly be incorporated into a patient's notes. However, replicating this methodology may be more challenging in settings reliant on paper records. Implementation in a paper‐based setting will likely require multiple staff education sessions and visual aids.

For future implementation, the key takeaway from this study is that best‐practice fasting protocol adherence can lead to meaningful improvements—reducing staff time, intravenous fluid use, and associated costs—through targeted education and smart phrase EMR system integration. These outcomes were achieved within a short timeframe, highlighting the impact of focused educational efforts. Examples of the educational materials used are included (Annex A and Figure 3), with the aim of supporting future .FAST implementation in other hospitals across Australia. While the use of EMR systems helps streamline the process, comparable benefits may also be attainable in paper‐based systems through comprehensive team education to ensure accurate and consistent documentation.

5. Conclusions

This study demonstrates that implementing best‐practice fasting protocols like .FAST can significantly reduce IVF use, shorten fasting times, and yield measurable cost and time savings, particularly relevant during this global IVF shortage. With 47% uptake in just 3 months, .FAST improved ANZCA guideline adherence without compromising patient safety or surgical cancellations. The .FAST protocol led to a significant reduction in IVF use compared to all other fasting protocols, and significantly reduced median patient time fasted. Compared to the earlier EU2WU6 protocol, .FAST achieved lower IVF use and greater projected resource savings. Continued education, follow‐up audits, and addressing barriers to adoption will be key to sustaining improvements. The study highlights how technology‐enabled, evidence‐based fasting protocols can enhance patient care and operational efficiency, with scalable benefits across hospital systems. This paper also provides educational materials for ease of future implementation.

Author Contributions

Denna Fryer: conceptualization, investigation, methodology, visualization, writing – review and editing, formal analysis, data curation. Ché Marfleet: writing – original draft, review and editing, investigation. Alexandra Jolley: writing – review and editing, formal analysis. Kristy Mansour: writing – review and editing. Benjamin Loveday: writing – review and editing. Soon Lau: supervision, writing – review and editing.

Disclosure

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Annex A FAST Education Brief.

Annex B FAST Education Poster.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.