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The quality improvement (QI) project implemented a postoperative nausea and vomiting (PONV) risk screening tool and introduced a risk-tailored prophylactic guideline to identify patients at risk for PONV and aimed to minimize PONV adverse events.
Design
This project represents the initial PDSA (Plan-Do-Study-Act) cycle for quality improvement with use of a pre-post design with two independent groups designed to compare PONV rates before and after implementation of an Apfel Simplified Risk Score screening and prophylactic guideline intervention.
Methods
The project implemented the screening of patient PONV risk using the Apfel Simplified Risk Score and a combination antiemetic drug class prophylactic guideline for adult patients undergoing elective same-day surgery procedures. An online education module was provided to anesthesia professionals and was reviewed in-person with the relevant anesthesia professional team prior to surgery. Pre-implementation (N=107) PONV outcomes were collected. Data collected from a retrospective chart review was used to compare pre- and post-implementation PONV rates (N=96) and determine post-implementation anesthesia professional adherence to guideline recommendations.
Findings
Forty percent of screened patients were identified as having an increased PONV risk with an Apfel Simplified Risk Score of 3 or 4. The PONV rates for the pre-group (19.6%) and post-group (22.9%) did not significantly differ (P=.5567). Anesthesia professional adherence to administration of the recommended number of antiemetic drug classes was 89.6%. A Spearman point-biserial correlation analysis indicated a significant positive relationship between Apfel Simplified Risk Score and PONV onset in the post-group (rs=0.21, P=.0428).
Conclusions
The Apfel Simplified Risk Score and prophylactic guideline increased identification of patients at risk for PONV but did not affect PONV rate despite a high anesthesia professional adherence to the guideline recommendations.
Postoperative nausea and vomiting (PONV) is an adverse event commonly experienced by patients following general anesthesia and is described collectively as nausea, vomiting, or retching that occurs within the first 24 hours following anesthesia.
Postoperative nausea and vomiting occurs in approximately 30% of all anesthetic cases, and up to 80% of cases involving patients with increased risk based on patient-specific, surgical, and anesthesia-specific factors.
Management of PONV continues to be a challenge of clinical importance as more surgeries are being performed in the ambulatory care setting with a focus on early patient mobilization and discharge.
Although PONV has minimal effects on mortality, it increases risk for many other complications. Dehydration, electrolyte imbalances, aspiration of gastric contents, wound dehiscence, and esophageal rupture are complications of PONV which may cause delayed post-anesthesia care unit (PACU) discharges and unanticipated postsurgical hospital admissions.
Due to delays in PACU discharge and unplanned hospital admissions, the associated cost of PONV in the same-day surgical setting is estimated up to $1.5 million in lost surgical revenue.
Implementation of postoperative nausea and vomiting guidelines for female adult patients undergoing anesthesia during gynecologic and breast surgery in an ambulatory setting.
As more surgeries are being performed in ambulatory care settings, effective PONV prophylaxis guidelines are necessary to help anesthesia providers enhance patient recovery, improve efficiency, and minimize costs.
Literature Review
The pathophysiology of nausea and vomiting is complex, which poses a challenge for anesthesia providers to effectively manage PONV symptoms. Symptoms of nausea and vomiting occur through several pathways involving the vomiting center of medulla which receives sensory information from the chemoreceptor trigger zone, vagal innervation of the gastrointestinal mucosa, reflex sensory pathways from the cerebral cortex, vestibular system activation, and midbrain activity.
The 2020 International Anesthesia Research Society's Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting advocates inhibiting the individual receptors leading to PONV using combination drug class prophylaxis.
Therapeutic drug classes include anticholinergics, dopamine receptor antagonists, antihistamines, 5-HT3 serotonin receptor antagonists, neurokinin-1 (NK-1) receptor antagonists, corticosteroids, and other medications with antiemetic properties, such as propofol.
quantified that 5-HT3 receptor antagonists, corticosteroids, and dopamine receptor antagonists independently and equally reduced PONV by 26% and propofol reduced risk by 19%, thus implying risk reduction can be maximized with combined interventions. Several studies have investigated combination therapies for the prevention of PONV with improved PONV outcomes. Dexamethasone paired with a 5-HT3 receptor antagonist is a common combination of prophylactic medications that has been well-studied and effective to significantly reduce PONV.
Dexamethasone combined with other antiemetics versus single antiemetics for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: An updated systematic review and meta-analysis.
Efficacy of palonosetron-dexamethasone combination versus palonosetron alone for preventing nausea and vomiting related to opioid-based analgesia: A prospective, randomized, double-blind trial.
Combination of 5-HT3 antagonist and dexamethasone Is superior to 5-HT3 antagonist alone for PONV prophylaxis after laparoscopic surgeries: A meta-analysis.
Drugs for preventing post-operative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: Network meta-analysis of randomized clinical trials and trial sequential analysis.
Alternative combinations using a 5-HT3 receptor antagonist with an anticholinergic and a 5-HT3 receptor antagonist with an antihistamine have also been effective in reducing PONV outcomes.
A randomized, double-blind, multicenter trial comparing transdermal scopolamine plus ondansetron to ondansetron alone for the prevention of postoperative nausea and vomiting in the outpatient setting.
Inclusion of a dopamine receptor antagonist is a useful prophylactic addition in high PONV risk patients. In female patients undergoing laparoscopic gynecologic procedures, prophylaxis with a dopamine receptor antagonist and dexamethasone significantly reduced PONV.
Haloperidol dose combined with dexamethasone for PONV prophylaxis in high-risk patients undergoing gynecological laparoscopic surgery: a prospective, randomized, double-blind, dose-response and placebo-controlled study.
Across a multitude of surgical procedures under general anesthesia, PONV prophylaxis with combination drug class therapies was superior and provides effective prophylaxis in sensitive patient populations.
However, administration of prophylactic antiemetics is not without risk. Antiemetics are associated with pharmacological side effects, including QT prolongation, headache, hyperglycemia, and extrapyramidal symptoms.
To avoid exposing patients to unnecessary risks, an objective measure to assess patient baseline risk for PONV is important to plan for safe and effective prophylaxis.
The Apfel Simplified Risk Score is an assessment tool that assesses patient risk for PONV based on the 4 most important factors, including a female gender, history of motion sickness or PONV, nonsmoking status, and postoperative opioid use.
found that patients undergoing inhalational anesthesia with no risk factors had a 10% PONV incidence, 1 risk factor had a 21% PONV incidence, two risk factors had a 39% PONV incidence, 3 risk factors had a 61% PONV incidence, and 4 risk factors was associated with a 79% PONV incidence. The Apfel Simplified Risk Score carries a sensitivity and specificity ranging from 65% to 70%.
The addition of decision support guidelines advocating combination drug class PONV prophylaxis to the Apfel Simplified Risk Score has yielded beneficial outcomes in clinical practice. Quality improvement initiatives across multiple centers have accomplished PONV reductions following the implementation of a prophylactic decision support tool.
Implementation of postoperative nausea and vomiting guidelines for female adult patients undergoing anesthesia during gynecologic and breast surgery in an ambulatory setting.
The addition of prophylaxis guidelines to baseline PONV risk screening has also increased anesthesia professional adherence to protocol instructions and increased the number of antiemetics administered in high PONV risk patients.
Implementation of postoperative nausea and vomiting guidelines for female adult patients undergoing anesthesia during gynecologic and breast surgery in an ambulatory setting.
The purpose of this QI project was to implement the Apfel Simplified Risk Score and combination drug class prophylaxis recommendations to reduce the rate of PONV during the immediate 24-hour postoperative period. The specific aims were to (1) reduce the rate of PONV during the immediate 24-hour postoperative period and (2) determine post-implementation anesthesia professional adherence to administration of recommended minimum number of combination antiemetic drug classes.
Methods
Design
This project represents the initial PDSA cycle for quality improvement with use of a pre-post design with two independent groups designed to compare PONV rates before and after implementation of an Apfel Simplified Risk Score screening and prophylactic guideline intervention. The pre-implementation period was a 1-month period prior to the intervention, and the post-implementation period was a two-week period following the introduction of the intervention. Anesthesia professional adherence to administration of the recommended minimum number of antiemetic drug classes as per guideline was evaluated during the post-implementation period only. This project was declared exempt by an academic Institutional Review Board (IRB).
Setting
The project was conducted within the perioperative setting of a 186-inpatient bed community hospital in the southeastern United States that performs more than 15,000 annual surgeries. The project setting has 19 operating rooms with 27 anesthesiologists and 36 Certified Registered Nurse Anesthetists (CRNAs) employed in the practice setting.
Sample
The patient sample was a convenience sample of adult patients ≥ 18 years of age undergoing elective same-day surgery procedures under general anesthesia with an American Society of Anesthesiologists (ASA) physical status of I, II, or III. The sample was limited to patients undergoing otolaryngology, head, and neck (OHN), breast, gynecologic, plastics, and laparoscopic general surgical procedures. Patients requiring emergency procedures or postoperative hospitalization were excluded. The pre-implementation sample included 107 patients who were selected based on the first patient cases meeting inclusion criteria during the 1-month pre-implementation period. The post-implementation sample included 96 patients who were recruited and screened over a 2-week post-implementation period. Pre- and post-implementation recruitment methods differed due to the limited 2-week period to conduct on-site patient screenings and the inability to implement the Apfel Simplified Risk Score and prophylactic guideline intervention within the electronic medical record (EMR) for continuing ongoing assessment.
The post-implementation sample of anesthesia professionals consisted of anesthesiologists and CRNAs who routinely care for the patient cases for which antiemetic adherence was evaluated. The number of anesthesia professionals who participated in the patient cases was not captured out of the total anesthesia professional staff.
Measures
Pre- and post-intervention demographic data included age, gender, ASA physical status, length of surgery (LOS), surgical service line, and use of an anesthetic airway device (endotracheal tube or laryngeal mask airway). Additional post-intervention demographic data included nonsmoking status, PONV history, motion sickness history, and Apfel Simplified Risk Score.
Presence of PONV was defined as at least one of the following administration of a rescue antiemetic in PACU or patient self-reported symptoms of nausea or vomiting during 24-hour postoperative phone call conducted by PACU nursing staff (no=0, yes=1). Onset of PONV was assessed in the pre- and post-intervention groups.
Rescue antiemetics were collected for the patients in the pre- and post-intervention periods. Rescue antiemetics was defined as administration of a single or combination of drugs, including ondansetron, dexamethasone, scopolamine patch, diphenhydramine, promethazine, aprepitant, metoclopramide, or haloperidol in the PACU prior to discharge.
Anesthesia professional adherence assessed during the post-intervention period only was defined as the administration of the recommended minimum number of antiemetic drug classes as stated in the prophylaxis guideline (each coded as no=0, yes=1). Administered antiemetic medications (no=0, yes=1) included those belonging to a possible 7 drug classes. The drug classes included 5-HT3 serotonin receptor antagonists (ondansetron), corticosteroids (dexamethasone), anticholinergics (scopolamine patch), H1 antihistamines (diphenhydramine, promethazine), NK-1 receptor antagonists (aprepitant), dopamine antagonists (metoclopramide, haloperidol), and propofol anesthesia (subhypnotic infusion or total intravenous anesthetic).
Procedures
The QI intervention implemented the paper screening of patients using the Apfel Simplified Risk Score and a combination antiemetic class therapy guideline modeled from the 2020 International Anesthesia Research Society's Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting.
The Apfel Simplified Risk Score quantifies PONV risk based on patient characteristics of a female gender, history of motion sickness or PONV, nonsmoking status, and intended postoperative opioid use. Each item contributed one point toward total risk score with possible cumulative scores ranging from 0 to 4 with higher scores indicating greater risk of developing PONV with corresponding 10%, 21%, 39%, 61%, and 79% risk. Based on the cumulative Apfel Simplified Risk Score, the guideline made recommendations for anesthesia professionals to administer a minimum number of antiemetic drug classes during the preoperative and intraoperative settings for optimal prophylactic coverage (Figure 1). Recommendations were also made to consider the use of regional anesthesia, ensure adequate hydration, induce and maintain anesthesia with propofol, and minimize the use of inhalational anesthetics as additional anesthetic considerations to minimize PONV risk. Furthermore, several common antiemetic drugs used in the practice setting were listed for anesthesia professionals to select as potential prophylactic options; however, final choice of medications was left to anesthesia professional discretion. Rescue drug treatments were instructed to be of a different drug class than agents administered for prophylaxis.
Figure 1Apfel Simplified Risk Score Screening Form and Prophylactic Guideline. Reprinted with permission from Duke University Hospital.
Prior to implementation, a 15-minute pre-recorded educational PowerPoint presentation and copy of the PONV screening form with prophylactic guideline (Figure 1) were distributed to anesthesia professionals via email. During the 2-week implementation period, PONV screening forms were completed for each patient in the preoperative setting and direct one-on-one education was provided to the relevant anesthesia professional team immediately prior to surgery. Completed screening forms were left within the patient chart for the anesthesia professional to review prior to and during surgery. At the end of the case, anesthesia professionals were asked to deposit the screening forms to a locked collection box in the post-anesthesia recovery area.
All demographic and outcome data were collected by retrospective chart review of the facility EMR.
Analysis Method
Descriptive statistics were used to detail patient characteristics and outcomes for the pre- and post-intervention groups, and post-intervention anesthesia professional adherence. Chi-square/Fisher Exact tests for categorical measures and Wilcoxon 2-Sample Test for continuous variables (due to non-normality of the data distributions) were employed to test for pre- versus post- group differences in patient characteristics and identify potential covariates. Logistic regression was conducted to test for group difference in PONV rates. Odds ratios and their 95% confidence intervals (CI) were used to address effect size. Non-directional tests were performed with the level of significance set at 0.05. All analyses were completed using SAS Version 9.2 statistical software.
Results
Patient Characteristics
The total sample was comprised of 203 patient cases, with 107 cases in the pre-implementation group and 96 cases in the post-implementation group (Table 1). The median age for the total sample was 54 years (range, 18 to 88). The pre- and post-groups differed significantly with regard to age and ASA status. Compared to the pre-group, the post-group was slightly older patients (Wilcoxon z=2.8, P=.0056) and a higher percent of patients whose ASA status was III (c2=9.8, df=2, p=0.0076). The 2 groups did not differ on any other patient characteristics (P> .05).
Table 1Patient Characteristics
Characteristic
Total (N=203)
Pre-group (n=107)
Post-group (n=96)
P-value
Median
Q1, Q3
Median
Q1, Q3
Median
Q1, Q3
Age, in years
54
43, 66
52
41, 62
58
46, 69
.0056
LOS, in minutes
97
65, 140
101
67, 141
93
60, 139
.6010
n
%
n
%
n
%
Female gender
151
74.4%
77
72.0%
74
77.1%
.4040
ASA status
.0076
ASA I
19
9.4%
15
14.0%
4
4.2%
ASA II
117
57.6%
65
60.8%
52
54.2%
ASA III
67
33.0%
27
25.2%
40
41.7%
Procedure type
OHN
81
39.9%
42
39.3%
39
40.6%
.8420
Breast
50
24.6%
25
23.4%
25
26.0%
.6585
Gynecologic
36
17.7%
19
17.8%
17
17.7%
.9928
General, laparoscopic
22
10.8%
13
12.1%
9
9.4%
.5255
Plastics
14
6.9%
8
7.5%
6
6.3%
.7306
Use of airway device
160
78.8%
83
77.6%
77
80.2%
.6460
PONV or MS history
39
40.6%
Nonsmoking status
87
90.6%
Apfel risk score
Score 1
20
20.8%
Score 2
37
38.5%
Score 3
34
35.4%
Score 4
5
5.2%
Note. LOS, Length of surgery; ASA, American Society of Anesthesiologists; OHN, Otolaryngology, head, and neck; PONV, Postoperative nausea and vomiting; MS, Motion sickness; Median (Q1=25th percentile, Q3=75th percentile) and Wilcoxon Two-Sample Test P-value reported for continuous measures due to kurtosis (age) and skewness (LOS); n (%) of N and chi-square/Fisher's Exact reported for categorical measures.
PONV history, motion sickness history, smoking status, and Apfel Simplified Risk Scores were collected for the post-group only as these were measured components of the intervention (Table 1). Prior to the guideline implementation, the project setting did not have a formal protocol for PONV risk screening. In the post-group, 40.6% reported having PONV or motion sickness history, 90% of patients were non-smokers, and 40.6% had an Apfel Simplified Risk Score of 3 or 4.
Outcomes
The patient's PONV rate during the immediate 24-hour postoperative period for the total sample was 21.2% (Table 2). The PONV rates for the pre-group (19.6%) and post-group (22.9%) did not significantly differ (c2=0.3, df=1, P=.5567). Because the 2 groups differed on age and ASA, a multivariable logistic regression analysis was conducted to test for group differences in the probability of PONV after covarying for age and ASA status (ASA I/II vs ASA III). Neither group, age, or ASA were significantly related to the onset of PONV (all P>.05). The covariate-adjusted odds ratio for PONV for the post-group relative to the pre-group was 1.33 (95% CI: 0.66 to 2.66, P=.4265).
Table 2Project Outcomes
Outcomes
Total (N=203)
Pre-group (n=107)
Post-group (n=96)
P-value
n
%
n
%
n
%
PONV
43
21.2
21
19.6
22
22.9
.5667
Adherence
—
—
—
—
86
89.6
Median
Q1, Q3
Median
Q1, Q3
Median
Q1, Q3
Total drug classes
2.0
2.0, 3.0
2.0
2.0, 3.0
2.5
2.0, 3.0
.1264
n
%
n
%
n
%
Antiemetic medications
Ondansetron
191
94.1
101
94.4
90
93.8
Dexamethasone
168
82.8
85
79.4
83
86.5
Propofol infusion
66
32.5
33
30.8
33
34.4
Scopolamine patch
57
28.1
27
25.2
30
31.3
Diphenhydramine
41
20.2
18
16.8
23
24.0
Promethazine
11
5.4
5
4.7
6
6.3
Aprepitant
2
1.0
1
0.9
1
1.0
Metoclopramide
1
0.5
0
0.0
1
1.0
n
%
n
%
n
%
Rescue medications
Ondansetron
34
16.7
19
17.8
15
15.6
Diphenhydramine
5
2.4
3
2.8
2
2.1
Promethazine
5
2.5
1
0.9
4
4.2
Scopolamine patch
2
1.0
2
1.9
0
0.0
Dexamethasone
1
0.5
1
0.9
0
0.0
Haloperidol
1
0.5
0
0.0
1
1.0
Note. PONV, Postoperative nausea and vomiting; Adherence, Anesthesia professional adherence to administration of recommended minimum number of drug classes; Antiemetic medications, Pre- or intra-operative antiemetic drugs administered; Rescue medications, Postoperative antiemetic drugs administered; n (%) and 2 × 2 chi-square results reported for PONV; Median (Q1=25th percentile, Q3=75th percentile) and Wilcoxon 2-Sample Test results reported for total antiemetic drug classes administered due to skewness.
A slightly higher PONV rate was observed in the post-group despite high anesthesia professional adherence to the prophylactic guideline instructions. The anesthesia professionals’ adherence to the administration of recommended minimum number of combination antiemetic drug classes was 89.6% for the 96 post-implementation cases.
The total antiemetic drug classes administered did not significantly differ in the post-group (median=2.5, range=1 to 5) relative to the pre-group (median=2.0, range=1 to 5, Wilcoxon z=1.6, P=.1264). Figure 2 presents the relative distribution of the total antiemetic drug classes administered for each group, and shows the increase in the percent of patient cases who received more than 3 total antiemetic drug classes in the post-group. The most common antiemetic medication administered was ondansetron, followed by dexamethasone. Further, ondansetron was also the most common antiemetic drug administered as a rescue agent for PONV in both groups (pre: 17.8%; post: 15.6%).
Figure 2Total Antiemetic Drug Classes Administered. This figure is available in color online at www.jopan.org.
A Spearman point-biserial correlation analysis indicated a significant positive relationship between Apfel risk scores and the onset of PONV in the post-group (rs=0.21, P=.0428). Increasing risk scores were associated with an increasing likelihood of a PONV. Specifically, the PONV rate was 10%, 22%, 26%, and 60% for those with a risk score of 1, 2, 3 and 4, respectively.
Discussion
This initiative implemented the Apfel Simplified Risk Score and prophylaxis guideline for PONV management in adult patients undergoing ambulatory OHN, breast, gynecologic, plastics, and laparoscopic general surgery procedures. The Apfel Simplified Risk Score has been well documented in the literature as a measure of assessing patient PONV risk.
Findings of a significant positive relationship (rs=0.21, P=0.0428) between Apfel Score and PONV onset is consistent with the body of literature suggesting the utility of the Apfel Simplified Risk Score in PONV management.
Despite this association, PONV rate slightly increased from 19.6% in the pre-intervention group to 22.9% following project implementation, albeit this increase was nonsignificant. Although PONV rates increased in the post-intervention group, only 5.2% of patients were assigned an Apfel Simplified Risk Score of 4, indicating the highest level of PONV risk. The components of the Apfel Simplified Risk Score of female gender, nonsmoking status, history of PONV or history of motion sickness, and postoperative opioid use are well established independent risk factors of PONV.
While factors of a female gender, nonsmoking status, history of PONV or history of motion sickness are objective patient characteristics, the anticipated use of postoperative opioids introduces subjectivity in screening for anesthesia professionals. This subjectivity in assigning patient risk factors may have contributed to the underscoring of patient PONV risk, leading to undertreatment of high PONV risk patients, thus contributing to the small increase in PONV presence in the post-intervention group. Furthermore, PACU nurse adherence to conducting the 24-hour postoperative phone call for the total sample was only 58.6% which may have led to the underreporting of PONV across both groups.
Staff education on the Apfel Simplified Risk Score and PONV prophylaxis intervention was shared through a pre-recorded online presentation, printed PONV screening form handouts, and informal in-person discussions in the preoperative setting during implementation. All educational materials were supported by facility anesthesia leadership. Anesthesia professionals followed recommended guidelines with a high adherence rate of 89.6%, suggesting staff motivation in support of QI PONV prophylaxis. Further, the median number of antiemetic drug classes administered increased from 2.0 classes to 2.5 classes in the post-intervention group, indicating an increase in the percent of patient cases who received 4 and 5 antiemetic drug classes in the post-group. However, low anesthesia professional viewership of the online educational presentation may suggest anesthesia professionals have an existing practice of routine PONV prophylaxis, thus falsely representing the observed anesthesia professional adherence rate of 89.6%. The virtual educational presentation was sent to 63 anesthesia professionals and was only accessed 33 times. Direct one-on-one education in the preoperative setting may have also contributed to challenges in anesthesia professional workflow and was a barrier to staff engagement. As one CRNA reported, despite expressing an interest in participating, education immediately prior to surgery risks anesthesia-related delays in surgical start time, thus incurring financial costs for the facility. These barriers to effective education make the high anesthesia professional adherence rate difficult to interpret as a measure of anesthesia professional engagement.
Recommendations
Nurses across the perioperative setting are in the unique position to identify patients at increased PONV risk by documenting patient histories, providing combination drug class prophylactic antiemetic medications, and administering appropriate rescue treatments in PACU. Extending educational reach to preoperative and PACU nurses promotes nurse-driven patient advocacy and may offer additional insight to the efficacy of this intervention.
Furthermore, implementation of the PONV risk screening and prophylactic decision support tool within the EMR offers an opportunity for increased visibility and efficiency in planning prophylaxis. The EMR with implementation of clinical decision support tools communicates pertinent, patient-specific information to healthcare providers in a timely manner. Risk-tailored PONV prophylaxis developed within the EMR has been used successfully to increase anesthesia professional adherence, increase administration of antiemetics, and decrease the outcome of PONV.
Digital quality improvement approach reduces the need for rescue antiemetics in high-risk patients: A comparative effectiveness study using interrupted time series and propensity score matching analysis.
Similarly, electronic health record alerts have been implemented to address anesthetic challenges of timely antibiotic administration, intraoperative hypotension, and blood glucose management.
The implementation of PONV risk screening and clinical decision support tools within the EMR is an area of potential value to reduce PONV complications and enact departmental change.
Future PONV prophylaxis guidelines could be updated to include emerging antiemetic agents and new drug classes. The reentry of droperidol, a dopamine receptor antagonist, in clinical practice offers an opportunity to explore additional drug coverage which could provide positive PONV outcomes.
Limitations
This was a QI project implemented in in the United States during the COVID-19 pandemic. Initial plans to implement this project within the facility EMR were twice delayed and software development was paused due the increasing risks and demands placed on healthcare providers. Failing to implement the Apfel Simplified Risk Score and prophylactic guideline intervention in the EMR resulted in a small sample size and different pre-and post-implementation patient sample recruitment methods which precluded ongoing assessment. Limited sample size was restricted due to manual chart review and data collection. Data was not recorded on the sample of anesthesia professionals who participated in the patient cases, thus the observed anesthesia professional adherence may reflect a limited sample.
Conclusion
The Apfel Simplified Risk Score is an effective tool that assesses a patient's baseline PONV risk and has implications in guiding patient-specific antiemetic prophylaxis. The QI project found a strong correlation between Apfel Simplified Risk Score and PONV onset; however, resulted in a marginal increase in PONV despite a high anesthesia professional adherence to antiemetic recommendations. The removal of subjectivity from PONV risk screening, emphasis on nursing education, and EMR implementation may help to minimize PONV events. Planning prophylaxis with a risk-tailored strategy has the utility to identify patients at increased risk for PONV and alert anesthesia professionals of patients who may benefit from anesthetic modification.
References
Apfel CC
Läärä E
Koivuranta M
Greim CA
Roewer N
A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers.
Implementation of postoperative nausea and vomiting guidelines for female adult patients undergoing anesthesia during gynecologic and breast surgery in an ambulatory setting.
Dexamethasone combined with other antiemetics versus single antiemetics for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: An updated systematic review and meta-analysis.
Efficacy of palonosetron-dexamethasone combination versus palonosetron alone for preventing nausea and vomiting related to opioid-based analgesia: A prospective, randomized, double-blind trial.
Combination of 5-HT3 antagonist and dexamethasone Is superior to 5-HT3 antagonist alone for PONV prophylaxis after laparoscopic surgeries: A meta-analysis.
Drugs for preventing post-operative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: Network meta-analysis of randomized clinical trials and trial sequential analysis.
A randomized, double-blind, multicenter trial comparing transdermal scopolamine plus ondansetron to ondansetron alone for the prevention of postoperative nausea and vomiting in the outpatient setting.
Haloperidol dose combined with dexamethasone for PONV prophylaxis in high-risk patients undergoing gynecological laparoscopic surgery: a prospective, randomized, double-blind, dose-response and placebo-controlled study.
Digital quality improvement approach reduces the need for rescue antiemetics in high-risk patients: A comparative effectiveness study using interrupted time series and propensity score matching analysis.
Conflict of interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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