Postdischarge Nausea and Vomiting Risk Assessment in Breast and Gynecological Surgical Patients

Abstract

Problem & Purpose: Postdischarge nausea and vomiting or retching occurs from the time of discharge from the post anesthesia care unit for patients who have undergone out-patient surgeries. At a large mid-Atlantic academic hospital, 40% of gynecological out-patient surgical patients had postdischarge nausea and vomiting. The purpose of this quality improvement project was to implement, and evaluate the effectiveness and staff compliance in the use of the Apfel Postdischarge Nausea and Vomiting Risk Assessment tool in order to improve postdischarge nausea and vomiting screening in the post anesthesia care unit. Methods: After identification and recruitment of key stakeholders and unit champions, a force-field analysis, as part of Lewin’s Change Theory, was completed to identify the driving and restraining forces. All post anesthesia care unit registered nurses received education on the risk assessment protocol utilizing the Apfel risk assessment tool. The Apfel risk assessment tool is validated to identify five independent risk factors for postdischarge nausea and vomiting in out-patient ambulatory surgical populations. Implementation of the tool with data collection occurred over eight weeks on all scheduled out-patient breast and gynecological surgical patients. Staff compliance was measured throughout implementation. Results: In patients with at least three risk factors present, the Apfel tool correctly identified the risk for postdischarge nausea and vomiting in 68% of patients. In patients with four and five risk factors present, the tool correctly identified the risk for postdischarge nausea and vomiting in 88% and 100% of patients respectively. Compliance of the tool was high with the average compliance rate of 92% over the eight-week data collection period. Conclusion: Data analysis demonstrated the Apfel tool adequately predicted the risk for postdischarge nausea and vomiting in out-patient surgical breast and gynecological patients. Lewin’s change theory was successful in maintaining a high compliance rate throughout implementation. Additionally, this quality improvement project resulted in increased compliance of standing follow-up phone call policy. Sustainment of the intervention includes expansion to all out-patient surgical populations and implementation of a postdischarge nausea and vomiting prevention and management guideline.