• Aromatherapy Blend for Postoperative Nausea in Ambulatory Surgery Patients

      Trandel-Korenchuk, Sarah C.; Bode, Claire (2020-05)
      Problem and Purpose: Postoperative nausea (PON) is one of the most undesirable outcomes after surgery, affecting 30% of surgical patients nationwide. PON increases patient dissatisfaction and risk for postoperative complications such as hematoma and dehiscence. In the Post-Anesthesia Care Unit (PACU) at an urban hospital outpatient surgery center, PON occurs in about a third of postoperative patients. Use of alcohol swab inhalation is ineffective and pharmacological methods can lead to prolonged PACU stays, decreased patient satisfaction and increased hospital costs. The purpose of this project was to implement and evaluate the effect of an aromastick on nausea in post-operative patients at a surgery center. Method: Implementation occurred over twelve weeks in the Fall of 2019. The first two weeks PACU RNs were educated and completed a competency around aromatherapy, aromastick use, and documentation. For the following ten weeks, PACU RNs offered aromasticks to patients with PON upon arrival to the PACU as a non-pharmacological means to mitigate nausea; anti-emetic medication was not withheld. The quantity of aromasticks provided and baseline and post-intervention PON scores were obtained to determine the effect of aromastick on PON. Results: 100% of PACU RNs (n=20) were educated and demonstrated competence in aromatherapy intervention, 70.6% of patients with PON utilized an aromastick for PON treatment, and of those patients who received an aromastick for PON 94.4% had improved PON scores. Conclusion: Aromatherapy is an effective non-pharmacological treatment in reducing PON score for patients recovering from surgery. These results offer support for nursing practice to utilize aromatherapy as an additional method to enhance patient experience, improve outcomes, and reduce cost in recovery rooms. Utilization of aromatherapy for nausea in other areas should be explored to enhance available non-pharmacological treatment methods for nursing practice.
    • Implementation of a Preoperative Risk Assessment for Post-Operative Nausea and Vomiting

      Soliman, Safa; Conley, Richard (2022-05)
      Problem: Currently 6.1% of post-surgical patients at this institution experience post-operative nausea and vomiting (PONV). Prophylactic measures for PONV are often based on provider preference, price, and availability contributing to significant variability in PONV prevention techniques. Since PONV risk ranges from patient to patient depending on risk factors such as gender, age, and type of anesthetic it is imperative preventative measures are individualized to each patient. Purpose: The purpose of this quality improvement project was to implement a preoperative risk assessment for adult surgical patients and evaluate its effectiveness in identifying patients at high-risk for PONV and guide anesthesia provider’s prophylactic interventions to decrease the incidence of PONV. Methods: Over 15-weeks a preoperative risk assessment was integrated into patient forms and filled out during intake. The anesthesia provider was expected to assess the risk score and administer preventative medications per the established PONV guideline. Data on compliance and post-operative nausea and vomiting rates was tracked throughout the implementation period. Results: The data reflected an average compliance of 96% and 90% with the documentation of PONV risk assessment on each patient’s perioperative record and identification of patients at high-risk for PONV during the first nine weeks of implementation. The anesthesia providers review of each patient’s risk score remained at an average of 54% during that time. Compliance with all three measures dropped significantly weeks 11 through 15 due to a clerical error which resulted in risk assessment not being included in the patient forms. During this time, the average compliance rate with risk assessment completion and high-risk identification was 18%. The compliance rate with the anesthesia provider’s review of the PONV score decreased to 17%. Conclusions: Due to the variable and limited nature of the compliance data, no statistically significant conclusions can be drawn. However, when compliance was at its highest, the rate of PONV trended down from a rate of 5% to 2.6% and as compliance dropped in November, PONV rates rose again to 4.5%.
    • Implementing Guidelines to Manage Postoperative Nausea and Vomiting in Laparoscopic Surgery Patients

      Homayouni, Del; Alessandrini, Erica (2022-05)
      Problem: Postoperative nausea and vomiting (PONV) is estimated to affect 30% of patients for 24 to 48 hours after general surgery, and up to 80% of patients who are considered high-risk. PONV causes distress, discomfort, and subsequent reduction in patient satisfaction. Furthermore, PONV can cause postoperative complications such as incisional stress, bleeding, fluid and electrolyte disturbances, and aspiration. In this community hospital, it was reported approximately 10% of surgical patients experience PONV. While this rate appears lower than the national average, PONV rates have been increasing during the past year and continue to rank high in measures of patient dissatisfaction, prompting administration and anesthesia staff to examine current practice. When baseline data was measured, the PONV rate was 44%. Purpose: The purpose of the doctor of nursing practice project was to reduce PONV among laparoscopic surgical patients in the perioperative setting by identifying patients at high risk for PONV and implementing an evidence-based prophylactic medication protocol based on risk levels. Methods: Anesthesia providers were educated about the incidence of PONV, common risk factors contributing to PONV, and the multimodal prophylactic medications to administer based on the PONV risk score. Data collection via chart audit was performed to evaluate PONV rates and the use of the prophylactic medication protocol by anesthesia providers. Results: 119 eligible patients were scheduled for laparoscopic surgery during project implementation. Documentation of the PONV risk assessment score in the preoperative note occurred 29% (n=34) of the time, and adherence to the prophylactic PONV medication protocol based on risk score was 29% (n=35). Despite the low adherence rate, PONV rates decreased to 25% during the 14-week period. Conclusions: Implementation and adherence to the evidence-based PONV guidelines is a
    • 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.
    • Postoperative Nausea and Vomiting Prevention in Patients Undergoing Spinal Surgery

      Johnson, Jordan L.; Aguirre, Priscilla (2022-05)
      Problem & Purpose: The postoperative nausea and vomiting rates at a university teaching hospital have consistently been 3.5-5% higher than the medical system’s average. Postoperative nausea and vomiting can lead to an increased length of hospital stay and thus increased cost to the hospital. Severe complications include suture dehiscence, esophageal rupture, aspiration, dehydration, and electrolyte imbalances. The purpose of this quality improvement project is to implement and evaluate the effectiveness of the Modified Apfel screening tool and subsequent prophylactic treatment in adults undergoing elective spinal surgery at a large university teaching hospital. Methods: A Modified Apfel screening tool and a corresponding prophylactic treatment guideline were made available to all anesthesia providers at a large university teaching hospital. Anesthesia providers used the tools to screen for postoperative nausea and vomiting risk and provided prophylactic treatment to adult elective spinal surgery patients. The risk scores were documented within the anesthesia record. Compliance with screening, prophylactic treatment, and postoperative nausea and vomiting occurrences were tracked via chart audits. Results: Chart audits were completed for 550 spinal surgery patients over a 15-week period. Median anesthesia provider compliance with Modified Apfel tool screening, and prophylactic treatment for a Modified Apfel score greater than or equal to three, was 54.5% and 69%, respectively. The median percentage of spinal surgery patients not requiring an antiemetic within 24 hours of surgery improved from 82.7% (baseline) to 88.4%. Conclusions: The implementation of the Modified Apfel screening tool and prophylactic treatment guideline is a feasible and sustainable intervention. Provider compliance with screening and treatment leads to lower postoperative nausea and vomiting rates. Incorporating screening tools into the preoperative assessment is an important practice for anesthesia providers.
    • Postoperative Nausea and Vomiting Reduction using the Apfel Screening and Treatment Tool

      Escalante Romero, Maria; Aguirre, Priscilla (2022-05)
      Problem & Purpose: Postoperative nausea and vomiting is a complication that predisposes patients to numerous adverse events including dehydration, electrolyte disturbances, aspiration, and rehospitalization. The evidence-based Apfel risk tool can predict postoperative nausea and vomiting in high-risk patients and can guide anesthesia providers to administer prophylactic treatment. Screening patients undergoing high-risk surgical procedures is not routinely implemented at a university hospital which has resulted in elevated postoperative nausea and vomiting incident rates, approximately 3.4-5% when compared with the medical system’s average. This quality improvement project aims to implement the Modified Apfel risk tool to screen and prophylactically treat adult patients undergoing elective ear, nose, and throat surgeries at a university hospital. Methods: Adult patients scheduled for elective ear, nose, and throat cases were screened using the Modified Apfel tool and were treated based on their Apfel score. Compliance on screening patients using the tool and adherence to the prophylactic treatment guideline were collected daily. Additionally, data on patients who required antiemetic rescue treatment within 24 hours postoperatively was also collected daily. Run charts were used to analyze all data. Results: Fifteen weeks of data were collected and analyzed for 329 patients. A total of 135 patients (41%) were screened for postoperative nausea and vomiting with the Modified Apfel tool, 105 (78%) received treatment based on their score, and 124 patients did not receive rescue antiemetic treatment during the recovery period (92%). Overall, the implementation of the Modified Apfel tool guided anesthesia providers to administer prophylactic PONV treatment to ENT patients based on their Apfel score, thus reducing PONV in the recovery period. Conclusions: Although 100% provider compliance of screening patients with the risk tool was not achieved, the findings suggest that the implementation of the Modified Apfel tool and treatment guideline may decrease the use of rescue antiemetics in the recovery period. Therefore, utilizing the Apfel tool and treatment guideline to improve postoperative nausea and vomiting rates are feasible interventions that could be implemented in the clinical setting.