Screening and strategies to prevent postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) is a common untoward effect of anesthesia and is associated with patient discomfort, increased recovery room stays, unplanned admissions, decreased patient satisfaction, and surgical wound dehiscence at substantial cost. In the recovery room of a similarly-sized U.S. Military Health System (MHS) hospital, patients with PONV stay 68% longer,1 adding annual costs that would exceed $220,000 at our mid-sized facility. PONV-associated wound dehiscence, evisceration, unplanned admissions, and litigation would increase this estimate. Practitioners and nurses can reduce the incidence of postoperative nausea and vomiting, by using an evidence-based risk scoring strategy aimed at prevention of PONV.2
PICO. In post-surgical patients, will implementation of the Apfel Simplified Score to assess risk for postoperative nausea and vomiting, coupled with an evidence-based clinical practice guide, compared to using no scoring system, improve practitioner adherence to evidence-based guidelines for the prevention of postoperative nausea and vomiting?
Rationale. The Apfel Simplified Score is a tool that helps practitioners quantify patient risk for PONV, allowing patients at risk to receive appropriate prophylaxis.3 For patients at high risk for PONV (~80%), appropriate prophylaxis can decrease incidence of PONV by 56%.3,4 Conversely, patients with low risk for PONV can be spared inappropriate treatment and unwanted side effects. Avoiding inappropriate treatment also helps contain MHS costs. The score is simple, easy to use, and more reliable than risk estimation by a practitioner.5 We propose to implement the Apfel score in a way that maximizes its effectiveness as an evidence-based practice intervention.
Design and methods. Initial data collection will retrospectively examine PONV prophylaxis and PONV rate in 60 patient records, comprising 20 patient records meeting inclusion criteria from each of these three services: orthopedics, gynecology, and general surgery. These services comprise the highest volume of surgical patients at our facility and represent a large proportion of surgical patients within the MHS. Following this baseline data collection, anesthesia practitioners and post-anesthesia nursing staff will be trained to use the Apfel score over a 2-week period with multiple sessions to capture all staff. Apfel score calculators will be made available using two methods to maximize convenience and accessibility in case of technical limitations: 1. An auto-calculated score in the Essentris electronic medical record (EMR) “PreAnesthesia Eval” and “PreAnesthesia (Re)Eval” notes, 2. A handwritten score sheet kept in the paper record binder at the bedside. Defense Health Agency Perioperative Working Group approval has been granted to move forward with the proposed Essentris change. Treatment algorithm cards based on the most recent PONV guidelines will be affixed to each anesthesia machine and preoperative terminal to enable practitioners to make informed decisions about managing patients at risk for PONV. Two weeks after training and introduction of the Apfel score, matching post-implementation data will be collected from orthopedic, gynecologic, and general surgical patient records until 20 records from each service have met inclusion criteria, for a total of 60 records. Pre-implementation and post-implementation comparisons will include: Apfel score, antiemetics administered, provider adherence with PONV prophylaxis recommendations, and rates of PONV. The investigators will compile risk factors from the preimplementation data to determine the pre-implementation Apfel score for each record.

Relevance. This project will seek to change how our anesthesia practitioners and nurses evaluate and manage PONV, and it should have lasting effects well beyond the implementation period. Embedding the intervention in the EMR will assist in sustainment over time. Not only will the project have positive effects at the facility level, but we further expect staff to carry this knowledge to their next assignment and further build on lessons learned from this project.