Background
Postoperative nausea and vomiting (PONV) is a common side effect of general anesthesia that reduces patient satisfaction, increases costs, and can result in serious complications. The current Society for Ambulatory Anesthesia (SAMBA) guidelines recommend administering at least 2 prophylactic antiemetics to high risk patients, and can be interpreted as administering the same number of prophylactic antiemetics as PONV risk factors[1]. The SAMBA guidelines inspired a quality improvement project by the anesthesia residents at UCSF. Given this setting of increased attention to PONV prophylaxis, we investigated how often residents administered at least as many antiemetics as PONV risk factors, and examined what barriers providers face when trying to do so.
Methods
We retrospectively reviewed all general anesthesia cases involving adult patients at UCSF hospitals between July 1, 2016 and February 28, 2017. Inclusion criteria included administration of inhaled anesthetic or nitrous oxide >30 minutes, and having resident involvement in the case. We defined compliance as the percentage of cases in a time period for which the number of prophylactic antiemetic medications given was greater than or equal to the patient’s Apfel score. PONV was defined as the administration of an antiemetic in the PACU. We subsequently created a survey to identify barriers to providing 2 or more antiemetic interventions to high risk patients and ways to overcome those barriers. This survey was administered to all 71 anesthesia residents at UCSF.
Results
We evaluated 5485 PACU stays corresponding to 5040 unique patients. 2849 of 3209 (11.2%) PACU stays with a compliant number of anti-emetics had PONV, while 1942 of 2276 (14.7%) PACU stays with a noncompliant number of antiemetics had PONV (p<0.001).
In the survey, with a 60% response rate, residents reported the following barriers to providing antiemetics to high risk patients: cumbersome charting (51%), difficulty administering antiemetics preoperatively (37%), few antiemetic options in the OR cart (33%), contraindications (30%), difficulty identifying high risk patients (16%), and insufficient time due to other responsibilities (12%).
Residents identified several interventions that would facilitate providing at least 2 antiemetics to high risk patients: 61% suggested more streamlined charting, 61% suggested more medication options in the OR cart, 29% suggested more antiemetic choices in the intra-op macros, and 22% suggested education sessions regarding antiemetic choices.
Conclusions
When providers are able to administer the same number of prophylactic antiemetics as PONV risk factors, there is a lower incidence of PONV. From a survey of anesthesia residents, the main barriers to providers in achieving this goal are: cumbersome charting, difficulty administering antiemetics pre-op, lack of antiemetic options in the OR cart, and contraindications. While our current study focuses on reducing incidence of PONV, further work is needed to identify low-value administration of antiemetics (e.g. giving more antiemetics than necessary to low-risk patients).
References
1. Gan TJ et al. Anesth Analg 2014; 118(1): 85-113.
