• Implementation of Postoperative Nausea and Vomiting Screening and Referral Practice Change

      Bilbao, Maryanne E.; Franquiz, Renee (2022-05)
      Problem: Postoperative nausea and vomiting (PONV) is defined as nausea and vomiting experienced 24-48 hours after surgery and can have as high as an 80% incidence rate. This leads to patient dissatisfaction and physical injury (such as esophageal injuries, wound dehiscence, and pulmonary aspiration). Risk factors of PONV include patient specific factors (being female, non-smoker or having a history of nausea and vomiting), surgical factors (certain surgeries such as breast or laparoscopic surgeries) and anesthesia factors (use of anesthetic gas, opioids, and duration of anesthesia). The project site has an exceedingly high PONV rate affecting 41.5% of patients undergoing laparoscopic gynecologic and breast surgeries. Identifying patient risk factors can inform PONV prevention for each patient population. Purpose: The purpose of this Quality Improvement project is to implement a preoperative PONV screening process to quantify PONV risk in patients receiving laparoscopic gynecologic and breast surgeries and refer for intraoperative management. Methods: The Apfel postoperative nausea and vomiting screening tool is a valid, evidence-based tool used in practice to quantify the PONV risk factors of gender, smoking status, postoperative use of opioids and history of nausea and vomiting. A new practice was implemented to screen patients undergoing elective breast and laparoscopic surgeries using the Apfel screening and refer patients for risk-stratified postoperative nausea and vomiting interventions. Results: A total of 177 patients were eligible for this QI project with 109 patients receiving breast surgery and 68 receiving laparoscopic gynecologic surgery. Apfel screening adherence among anesthesia providers is 56% with a referral rate of 80% to the intraoperative PONV protocol. Postoperative nausea and vomiting incidence declined from 41.5% to 36%. Conclusion: Preoperative Apfel screening is an effective and feasible practice change to guide patient specific prophylaxis for PONV that is supported by the literature and may reduce the need for antiemetic rescue medication in the post anesthesia care unit.