Background
Post-operative nausea and vomiting (PONV) results in patient dissatisfaction, longer post-anesthesia care unit (PACU) stays, and unanticipated hospital admissions (1,2,3). A patient’s Apfel score correlates with their risk of PONV and anti-emetics from different classes are additive in reducing PONV risk (1,2). Current guidelines recommend that patients at high risk for PONV (Apfel score of 3 or higher) receive at least 2 anti-emetic agents as PONV prophylaxis (3,4). Based on a random chart audit of our institution’s cases over a 2-month period, only 47.9% of patients at high risk for PONV received at least 2 anti-emetics. We implemented a resident quality improvement initiative to improve the preoperative PONV risk assessment process and the preoperative and intraoperative administration of at least 2 prophylactic anti-emetics for patients at high risk for PONV.
Methods
To improve preoperative PONV risk assessment, documentation of Apfel risk factors was incorporated into the preoperative evaluation and electronic medical record (EMR). The inclusion criteria were: adult (at least 18 years old), extubated prior to leaving the OR, Apfel score of 3 or higher, general inhalational anesthesia by an anesthesiology resident. Residents were educated on PONV-focused preoperative documentation, indications, contraindications, and dosing regimens for anti-emetic prophylaxis using department-wide presentations and reference cards. Weekly reminder pages were used to reinforce documenting Apfel risk factors and providing anti-emetic prophylaxis as part of routine anesthetic practice. Anti-emetic medications were added to the anesthesia cart to improve accessibility in the intraoperative period. Monthly audits were performed on all cases meeting inclusion criteria to analyze the number of prophylactic anti-emetics as well as the number of rescue anti-emetics given during the first 24 hours postoperatively. Quarterly emails provided data on overall performance to the department and constructive feedback to individual providers.
Results
In the first academic quarter, 568 resident cases met inclusion criteria and residents treated 77% of patients at high risk for PONV with at least 2 prophylactic anti-emetics. In the second academic quarter, 608 resident cases met inclusion criteria and residents treated 80% of patients at high risk for PONV with at least 2 prophylactic anti-emetics. Of the patients at high risk for PONV who received at least 2 prophylactic anti-emetics, 48% received rescue anti-emetics in first 24 hours postoperatively.
Conclusions
An increased awareness of PONV risk factor assessment, improved documentation in the EMR, repeated education, and frequent feedback on performance led to a sustained improvement in evidence-based anti-emetic prophylaxis for patients at high risk for PONV. Our data suggests that despite the administration of at least 2 anti-emetics for patients at high risk for PONV, there is still significant rescue anti-emetic administration in the first 24 hours postoperatively.
References
1) Apfel, CC, et al. (1999). Anesthesiology 91(3): 693-700.
2) Apfel, CC, et al. (2004). N Engl J Med 350(24): 2441-2451.
3) Gan, TJ, et al. (2014). Anesth Analg 118(1): 85-113.
4) “ASA PQRS Overview.” Anesthesia Quality Institute. 2016. www.aqihq.org/files//PQRS at a Glance_final.pdf
