Development of the Emergency Department Nothing by Mouth Score to Safely Guide Oral Intake Decisions

Decisions regarding oral intake vary widely across specialties, reflecting differing specialty-specific practices and guidelines, and are often guided by clinician preference rather than standardized criteria. Inappropriate “nil per os” (NPO) status and variability can worsen a patient's emergency department (ED) experience, and may even be detrimental to clinical outcomes. The objective of this study was to identify key clinical domains associated with oral intake restrictions and recommendations in the acute care setting, in order to develop a standardized clinical decision tool.

We conducted a focused scoping review of PubMed to identify clinical factors associated with unsafe oral intake parameters in the acute care setting. Abstracts were included if they described clinical rationale for intake risks, and excluded if they pertained to inpatient nutrition or post-operative diets. A total of 364 publications were identified and 122 were screened prior to achieving thematic saturation. Abstracts were screened until no new emerging domains were appreciated. The parameters were operationalized into a point-based clinical decision tool.

42 articles met inclusion criteria and themes were clustered into five recurring domains: 1) Escalation risk of clinical acuity, 2) Dysphagia or aspiration risk due to impaired swallowing mechanics, 3) Neurologic impairment limiting airway protection, 4) Planned surgery or anesthesia, and 5) concern for gastrointestinal Obstruction. These domains comprise the ED-NPO score, a clinical decision tool incorporating point-based strata and predefined automatic NPO criteria. The tool stratifies patients into a full diet (score 0-1), clear liquid diet (2-3), or NPO (4+).

The ED-NPO Score provides a standardized, literature-informed framework for assessing safe oral intake in the emergency department. The score was designed for rapid bedside use by providers to improve consistency and align expectations between ED staff and consulting teams. Future validation is needed to assess the clinical impact and generalizability of such a tool.