• Patient Engagement to Reduce Postoperative Nausea and Vomiting in Bariatric Surgery

      Ryschkewitsch, Samantha M.; Connolly, Mary Ellen (2021-05)
      Problem and Purpose: Laparoscopic bariatric surgery patients are at high risk for postoperative nausea and vomiting (PONV) due to a combination of demographic and iatrogenic factors including age, sex, laparoscopic surgery of greater than one hour duration, stomach size reduction, and increased requirements for intraoperative hypnotics and opioids. The incidence of PONV after bariatric surgery ranges between 54% and 79% in the literature (Groene et al., 2019). PONV places patients at risk for postoperative surgical complications including wound dehiscence, dehydration, aspiration pneumonia, delayed recovery, and increased length of stay (LOS). In an 800-bed urban American teaching hospital, increased LOS due to PONV occurred in 6% of laparoscopic bariatric surgery patients between 2018 and 2019. The purpose of the project is to implement patient engagement techniques to reduce PONV in laparoscopic bariatric surgery patients and evaluate the results of the implementation. The goal is to eliminate increased LOS that occurs due to intractable PONV. Methods: Literature review and synthesis supported the idea that patient engagement via daily postoperative coaching by nurses combined with a paper-based self-management tool improves surgical outcomes. The practice changes include patient engagement via coaching, provision of a postoperative daily goal sheet, and collaboration with the primary nurse in the postoperative phase to establish and meet daily goals of care. Implementation strategies include patient education, educational inservices provided to nursing staff, reminders provided to nursing staff, and inclusion of a nurse champion among project stakeholders. Results: Results showed incomplete adoption of the intervention with only 10% of all postoperative daily goal sheets returned complete by the end of the implementation phase. Median incidence of LOS increased between the preimplementation phase and implementation phase, while documented PONV decreased and antiemetic administration was unchanged. No definitive association between the intervention and outcomes could be determined. Conclusions: Conclusions regarding the efficacy of the intervention could not be drawn. PONV remains a valuable target for reduction in this population worthy of future quality improvement initiatives.
    • Reducing Emergency Department Referrals for Dehydration Following Bariatric Surgery

      Williams, Rhea T.; Bennett, DeNiece (2022-05)
      Problem: Following bariatric surgery, approximately 20-25% of post-surgical patients in the weight management clinic of a large academic medical center are referred to the emergency department (E.D.) for intensive treatment of symptoms related to dehydration. Current literature indicates that implementing dehydration prevention measures in post-bariatric surgery patients could decrease the number of these patients referred to the E.D. for treatment through additional surveillance and early intervention. Purpose: This quality improvement project aims to reduce the number of post-operative patients referred to the E.D. for treatment of dehydration through standardized screening and early identification of at-risk patients. This will translate into reduced E.D. referral rates and outcomes improvement with early identification of potential problems. Methods: Over fifteen weeks, the New Geriatric Dehydration Screening Tool (NGDST) was implemented in the outpatient bariatric surgery clinics of a large teaching hospital centrally located in a medium-sized city. Each post-operative care clinic provider completed education and training on the application of the NGDST, the recording and interpretation of results, and the new screening pathway for interventions. The NGDST was then implemented and utilized in screening post-operative patients within the first month of bariatric surgery. Results: There was one E.D. referral for dehydration during the NGDST implementation period, compared to fourteen E.D. referrals during the same time the previous year resulting in a 2% E.D. referral rate representing a significant reduction from the 20% rate before implementation. Conclusions: A standardized dehydration screening tool significantly decreased referrals to the E.D. for dehydration compared to the same period in the previous twelve months. Keywords: bariatric surgery, dehydration, post-operative care, dehydration screening tool, New Geriatric Dehydrations Screening Tool, NGDST