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Postoperative nausea (PON) is one of the most common undesirable outcomes after surgery and increases patient dissatisfaction, hospital costs, and risk for postoperative complications. This quality-improvement project implemented and evaluated the effect of aromatherapy on nausea in adult postoperative patients.
Design
Quality improvement project evaluating the inhalation of a blend of essential oils through an individual stick via an aroma stick.
Methods
This quality-improvement project was implemented in a postanesthesia care unit (PACU) in the Northeastern United States that averages 300 adult patients per month. Over the course of 12 weeks in the Fall of 2019, the project sample included all PACU registered nurses and patients with PON without allergies to inhalation agents or nasal surgery.
Findings
One hundred percent of PACU registered nurses (n = 20) were educated and demonstrated competence in the aromatherapy intervention; 70.6% (n = 36) of patients with PON used an aroma stick for PON treatment. Of the patients receiving the aroma stick for PON, 94.4% (n = 34) had improved PON scores.
Conclusions
Aromatherapy is an effective nonpharmacological treatment in reducing PON score for patients recovering from surgery. These results offer support for nursing practice to use aromatherapy as an additional method to enhance patient experience, improve outcomes, and reduce cost in recovery rooms.
PON is an undesirable surgical outcome that creates patient dissatisfaction and increases risk of recovery complications. Costs associated with PON average an additional $75 per patient.
Risk factors for patients experiencing PON include young age, female gender, nonsmoking status, history of motion sickness or PON, prolonged surgery, and type of anesthesia and surgery.
Antiemetic medication (ie, promethazine) can reduce PON, yet may become ineffective upon patient movement, as well as have side effects such as sedation.
Essential oil inhalation, or aromatherapy, has been studied as a nonpharmacological treatment method for PON in the Postanesthesia Care Unit (PACU). The method in which aromatherapy is administered (ie, gauze, inhaler, or patch) has no impact on PON outcomes as all delivery methods are associated with positive results for reducing PON.
Studies have examined various scents and essential oils including lavender, rose, ginger, spearmint, peppermint, cardamom, orange, 70% isopropyl alcohol, and water. In a randomized control study with 301 PACU patients with PON, a blend of essential oils was significantly more (P < .001) effective in reducing PON than 70% isopropyl alcohol.
Similarly, combining oils as a blend was found to be more effective for patients with PON in 184 PACU patients compared with the use of lavender and ginger alone, suggesting that the most effective essential oils to reduce PON is likely a blend.
Additional benefits of using a blend of essential oils for PON have also been identified. Antiemetic medication use is lower with inhalation of a blend of essential oils.
Reducing antiemetic medication usage reduces exposure to unsafe side effects, having a positive impact on patient satisfaction and recovery. In addition, patient-perceived aromatic effects were higher with blends of essential oils than those with an individual oil alone, suggesting an aromatic blend is a more beneficial PON treatment method.
In the PACU at an outpatient surgery center in an urban hospital, preimplementation data collection of patients with PON revealed about 30% of the patients in a month suffered from PON. Antiemetic medications were often provided in the operating room. However, many patients developed PON upon awakening, dressing, and transporting to their car. To prevent a prolonged PACU stay and enhance timely, safe patient discharge, registered nurses (RNs) in the PACU inconsistently used antiemetic medication. Instead, RNs followed normalized practice and offered alcohol swab inhalation, which is not consistent with standards of care.
Given the nausea severity in this project setting, an aromatherapy blend was offered first to patients with PON, and if not adequately relieved, medication was given. The purpose of this project was to improve nursing practice to enhance patient outcomes by implementing and evaluating the effect of an aromatherapy blend on patients with PON in a surgery center PACU. The RNs were educated on aromatherapy use, offered aroma sticks to patients with PON in the PACU, and assessed patient PON scores before and after the intervention.
Methods
Design, Setting, and Sample
The setting of this quality-improvement project was the PACU of an ambulatory surgery center in a small urban hospital on the US East Coast. The surgery center averages 300 patients per month. The population was adult postanesthesia surgical patients. The project received a Non-Human Subjects Research determination from the Institutional Review Board at the University of Maryland Baltimore as well as the organization of the project setting. Implementation of the process took place over the course of 12 weeks.
Inclusion Criteria
Adult patients with PON in the PACU.
Exclusion Criteria
Patients allergic to inhalation products or those who had nasal surgeries.
Implementation
Leadership support from nursing, pharmacy, anesthesia, and surgeons was obtained to financially support the initiative and encourage nursing staff engagement in this practice change. Implementation of the practice change occurred over 12 weeks. During weeks one and two, PACU RNs (n = 20) were educated on aromatherapy and how to document its use and effect in the electronic health record (EHR). An education lesson plan, algorithm (Figure 1) for and simulations on the use of the aroma stick, and copies of the competency checklist were created and provided to each RN during in-person education sessions before implementation. At completion of the education sessions, facilitated by the project leader, the PACU RNs completed a competency checklist to validate their knowledge and increase self-confidence in implementing and documenting the new intervention in their practice.
Figure 1Algorithm for aroma stick use for postoperative nausea.
During weeks three through twelve, RNs assessed the patients' PON severity on the patient's arrival to the PACU using an evidence-based pre-existing Likert scale (0 = none, 3 = severe) that was housed in the EHR. If PON was present, as per the algorithm, the RN offered and educated the patient on the available essential oil aromatherapy option. The PACU RNs reassessed the patient's PON within 30 minutes after the aromatherapy treatment and documented the PON score along with the intervention in the EHR. The project leader sent bimonthly email reminders and provided weekly in-person reminders to RNs regarding the importance of educating patients on the aroma stick and documenting its use and effect in the EHR. Conversations via the project leader occurred weekly in person with the RNs during huddle meetings to hear personal and patient comments on intervention.
Data Collection
Measures collected included staff's attendance at the education program and aroma stick use and effect on the patient's PON scores. Aroma stick use and effect data were obtained through an audit created by IT to run weekly. It provided PON intervention and PON score. Data were collected with no patient identifiers and stored on a password-protected computer.
The number of aroma sticks used for PON was measured by counting the number of times PACU RNs documented aroma stick use for the patient. The effect of aroma stick use was captured by comparing the PON score before PON intervention and the score after aroma stick utilization. In addition, PACU RNs' comments and reported patient remarks discussed in huddle and in-person conversations on the unit were recorded by the project leader.
Statistical Analysis
Data were analyzed using basic statistics. To determine the percentage of patients with PON who received an aroma stick, the number of patients who received aroma sticks was divided by the number of patients with PON. Finally, to determine the effectiveness of the aroma stick, the preintervention PON Likert scale score was subtracted from the postintervention PON score. The number of patients who experienced a reduction by at least one point on the three-point scale over the number of patients who received an aroma stick indicated the percent of patients who experienced a reduction in PON with aroma stick use.
Findings
All 20 PACU RNs were educated and completed a competency checkoff during the first 2 weeks of project implementation. During the subsequent 10 weeks of implementation, 51 patients experienced PON. Preimplementation numbers estimated 30% of patients may have benefitted from aromatherapy; however, during implementation, only 20% of patients experienced PON. Basic demographics of these patients were not collected. These patients had received a variety of surgery including general, plastic, orthopaedic, breast, and facial as well as different types of anesthesia ranging from general to monitored anesthesia care.
During the 10 weeks of aromatherapy implementation, 70.6% or 36 of 51 patients experiencing PON were provided aroma sticks. Of the 36 patients who received aroma sticks for PON, 34 or 94.4% experienced a one-point deduction (mild to none PON) in PON scores within 30 minutes after use. Aroma sticks were not used for moderate and severe nausea ratings. Of the 36 patients with PON, 10 patients received both antiemetics and aroma sticks at the same time, and 2 patients (5.9%) did not experience a reduction in nausea, subsequently requiring antiemetics.
Verbal feedback provided by RNs in huddle conversations included limitations and benefits to aroma stick application with patients experiencing PON (Table 1). Limitations included patient status and documentation of aroma stick use and effect. Patients either refused the use of an aroma stick because of a personal request for medication as a primary intervention, or were sufficiently sedated and unable to follow instructions on use. Owing to high patient volume and quick patient turnover, RNs admitted to occasionally failing to document the use and effect of the aroma sticks. RNs noted that the benefits of using the aroma sticks for patients with PON included patient satisfaction, ease of use, and quicker patient discharge. Nurse's verbal comments during huddle conversations and written comments collected in the EHR via the project leader noted the patient's expressed enthusiasm for aroma sticks' (1) ability to relieve nausea symptoms, (2) pleasant smell, and (3) takeaway option upon discharge because aroma sticks can be used for up to 3 months. Ease of opening and use allowed the patient to use the aroma stick independently. Furthermore, RNs remarked that they engaged in practice change by substituting the alcohol inhalation for aromatherapy. RNs recognized this practice change reduced the use of antiemetics to avoid unnecessary sedation, which aided in quicker, safer discharge.
Table 1Comments from Registered Nurses and Reported Patient Remarks on Aromatherapy Use in Postanesthesia Care Unit
Barriers
Facilitators
Themes
Comments
Themes
Comments
Patient status
-
Patient heavily sedated/did not want to be awoken to inhale
-
Patient refused aroma stick
Patient satisfaction
-
Patient enjoyed smell and relief of nausea
-
Patient liked the option to take it home and use for 3 mo
Documentation
-
Failed to document use and effect on nausea after use
Easy use
-
Easily accessible and easy to open
-
Involved patient, encouraging independence
Eased turnover
-
Did not have to use medication which helped to discharge patient faster
Unexpected facilitators to enhancing the implementation of this practice change included PACU RNs willing to accept the new intervention and adopt it into practice, ease of use of the aroma sticks, IT's willingness to create a personal audit tool for data gathering, and the EHR documentation process similar to the established policy. Unit leadership unexpectedly changed mid-implementation; however, support for the project remained. Barriers to project implementation included aroma sticks and antiemetics being provided to the patient at the same time, potentially muddying the results and effects, and occasional forgetfulness of the RNs to use the aroma stick when indicated for the patients with PON, and documenting each usage and its effect.
Unintended consequences of this project included the reduction in the number of antiemetics pulled from the automated medication dispenser and additional unit supply cost. The amount of antiemetics used for the 1 month before implementation was 36.5% (119 antiemetics pulled from automated medication dispenser with 326 patient cases/month). During the 2-month implementation, the number of antiemetics used was 26% (89 antiemetics removed with 378 patient cases/month) and 21.1% (80 antiemetics removed for 378 patient cases/month), respectively. Moreover, aroma sticks cost $3.15 per stick, and a total of 300 aroma sticks were purchased which resulted in costing the unit budget $315. Prior use of alcohol swabs cost $3.50 per box of 200 packets, and antiemetic medication costs between $0.18 and $1.89 per dose. Despite the increase in costs for the aroma sticks when compared with alcohol, savings were associated with avoiding the need to contact and require time from anesthesiologist for patient monitoring and safe, timely discharge.
Discussion
Implementing the use of an evidence-based aromatherapy essential oil blend for patients in the PACU of an ambulatory surgery center provided support for treatment options that improve PON outcomes. All PACU RNs were educated and trained to integrate aromatherapy into the current postoperative care practice, and their knowledge was confirmed by passing a competency to increase performance proficiency of aromatherapy implementation. The majority of the patients with PON received an aroma stick, suggesting that the RNs updated their practice to provide evidence-based practice care. A positive association was found between patients with PON and the use of an aroma stick, as almost all patients experienced reduced PON scores after aroma stick use.
Offering the aroma stick to patients allowed the PACU RNs to see a positive impact on patient outcomes. Comments expressed by RNs on the benefits of use were positive reinforcements for their continued implementation and sustained practice. Increased satisfaction with aroma stick use may assist the patient's autonomy in their care and ability or confidence to manage their recovery after discharge. Faster discharge from the PACU encouraged aroma stick use by the nursing staff in this setting because of the high patient volume and limited space, thus improving efficiency. Despite bimonthly email and in-person reminders, RNs did not always document the use and effect of the aroma stick when provided to the patient. This confounded data collection on aroma stick use and effect. The RNs noted aroma sticks were beneficial for most patients except for those who were heavily sedated, with a known allergy to specific essential oil, or who refused the option.
The literature supports the use of inhaled aromatherapy essential oil blend as an effective method to reduce PON using (1) similar measurement methods (ie, Likert scale for PON), (2) different inhalation methods (ie, pad, inhaler), and (3) various recovery settings (ie, inpatient or outpatient PACU).
Therefore, the results of this project were anticipated. Moreover, an unintended reduction in the number of antiemetic medications pulled per month was observed during implementation. Coincidentally, this reduction aligned with the RNs' feedback that suggested aroma stick use reduced the need for antiemetic medication in this group of PACU patients. Enhanced patient satisfaction and the unintended positive consequence of reduced antiemetic medication findings are also supported by the literature.
Although reduction in antiemetic use is multifactorial, the absence of any other concurrent parallel initiative points to aroma stick practice reduced the need for use of antiemetics. While aroma sticks cost more than other interventions, in general, the additional costs incurred from antiemetic use are still significantly higher.
A project strength included sustainability methods. From the start of implementation, methods for persistent long-term change included ensuring the current annual budget includes aroma stick costs, the method for restocking, ordering, and storing, as well as a continual audit analysis. The project leader spoke with new management to advocate for the future budget to include aroma stick cost. The unit's inventory management specialist took initiative to order and restock aroma sticks directly from the vendor in the future. When aroma sticks arrive, the charge RNs will place aroma sticks on the unit in the designated spot, and PACU RNs will restock their supply cart with aroma sticks as needed. Finally, the project leader added audits to full-time PACU RNs to continue monthly analysis on aroma stick use and effect on PON. Sustainability methods in place will allow for the continued use of aromatherapy for PON.
Project limitations that threatened internal validity include lack of consistent documentation of aroma stick use and effect, confounding variables (ie, anesthesia type), dual treatment with antiemetics, and specific implementation methods (ie, education method) designed specifically for this unit. While RNs were provided reminders, the high volume of patients required efficient documentation and often failed to record use and PON score. This resulted in incomplete data collection. Confounding variables such as the type of anesthesia provided during surgery or the delivery of antiemetics or narcotics to the patient before transferring to PACU by the doctor or nurse anesthetist were not included in the project development, limiting the ability to decipher the aroma stick's true effect on PON. Although the provided algorithm indicated aromatherapy as an optional first-line PON treatment, PACU RNs occasionally provided antiemetics concurrently with aroma sticks, confounding the true effect of the aroma stick on PON. To enhance data analysis, future quality-improvement projects should create charting alerts to (1) prioritize aroma stick use before medication (if not contraindicated) and (2) require documentation of nausea intervention/score, as well as collect data on (1) patient demographics, (2) type of anesthesia and narcotics, and (3) PACU length of stay.
Specific implementation design including methods of education, placement of aroma stick, and EHR audit were unique to this unit, affecting the ability to generalize the results of the aroma stick use/effect from this setting. However, the implementation success and positive outcomes in aroma stick education, use, and outcomes support implementation methods that may be considered for use and replication in other surgical settings. Quality-improvement projects and future research should investigate the impact of limiting factors on aroma stick use and PON outcomes. Research would assist in identifying different factors that may impact and interact with the effect of aroma stick use for nausea mitigation or relief, as well as to explore which other populations might benefit. Also, the cost-benefit of aroma stick use on nursing resources, recovery time, and antiemetic use should be investigated. Given successful use of aromatherapy in this project, additional research should investigate aromatherapy as an alternative or complimentary treatment method for other patient conditions such as pain in the PACU and anxiety in the preoperative area.
Conclusions
The positive outcomes of this project and the literature support aromatherapy as an effective nonpharmacological treatment in reducing PON score for patients recovering from surgery. Therefore, these results support aromatherapy as a therapeutic means to improve care used alone or complementary to conventional methods. Initial buy-in through successful education efforts around the use and implementation, in addition to sustainability measures will further advance the use of aroma sticks use as an adjunct nonpharmacological treatment method for PON in this PACU.
Replication of this quality-improvement project in other PACUs should be considered. Multiple benefits, including the ease of use, minimal cost, and successful improvement in patient outcomes, should encourage implementation of this practice change in other settings. This practice will provide an opportunity for RNs to have additional nonpharmacological treatment methods to enhance patient outcomes and satisfaction.
This project along with current literature support aromatherapy as a nonpharmacologic adjunct to improving patient outcomes. Further research and additional quality-improvement projects will enhance awareness of and knowledge around the use of aromatherapy on patient outcomes.
References
Brown L.
Danda L.
Fahey 3rd., T.J.
A quality improvement project to determine the effect of aromatherapy on postoperative nausea and vomiting in a short-stay surgical population.
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