Impact of ASPAN’s Evidence-based Clinical Practice Guideline for the

Prevention and/or Treatment of

PONV/PDNV

Corey R. Peterson DNP, CRNA, Lisa Stephens, DNP, CRNA,

Marguerite Murphy, DNP, RN, Vallire Hooper, PhD, RN, CPAN, FAAN,

Jan Odom-Forren, PhD, RN, CPAN, FAAN

2

53 million ambulatory surgeries annually National Health Statistics Report

(2009)

30% - 50% incidence of PDNV (16 – 26.5 million incidents) Apfel et al., (2004)

Threats associated with PONV/PDNV− Pt dissatisfaction − Increased pain− MI − Wound dehiscence− Aspiration −Delayed discharge− Delayed return to function -Increased costs

− Noncompliance w/discharge instruction Apfel et al., (2002)

Postoperative & Postdischarge Nausea and Vomiting (PONV/PDNV)

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Is a common anesthesia complication Apfel et al., (1999)

Is the most feared anesthesia complication by patients Awad (2006)

Is a complex physiologic phenomena Hornby, (2001)

Is largely preventable and treatable Habib et al, (2004)

Postoperative & Postdischarge Nausea and Vomiting (PONV/PDNV)

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PONV – first 24 hrs post – op PDNV – after discharge Predictable risk factors exist for

PONV/PDNV Apfel et al.(2002) Efficacious pharmacological interventions

exist for PONV/PDNV Gan et al., (2007); Odom-Forren et al., (2006)

PONV/PDNV

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In 2006 the American Society of PeriAnesthesia Nurses (ASPAN) published EBCPG for the prevention and/or treatment of PONV/PDNV ASPAN (2006)

ASPAN guidelines base the number of interventions given on a patient’s risk of PONV/PDNV

ASPAN guidelines are◦ Evidenced-based◦ Patient focused◦ Multidisciplinary◦ Cost conscience

Evidenced-Based Clinical Practice Guidelines (EBCPG)

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PONV/PDNV is an ongoing complication Efficacious interventions exist to prevent

and/or manage PONV/PDNV High quality EBCPG exist to guide

anesthesia providers in the prevention and/or management of PONV/PDNV

No information exists regarding the level of adoption of these EBCPG by anesthesia providers

Problem Statement

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EBCPG are effective and efficacious tools to improve healthcare delivery

Implementation of EBCPG is a complex process

PONV/PDNV is a common, significant complication of general anesthesia

High quality EBCPG exist to prevent and treat PONV/PDNV

From The Literature

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What is the degree of adoption of the recommendations of the ASPAN PONV/PDNV guidelines

Is there a relationship between the appropriate application of the ASPAN guidelines and the incidence of PDNV

Is there a relationship between the incidence of PONV and the incidence of PDNV

Is there a cost savings associated with the use of the ASPAN guidelines

Areas Of Inquiry

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Secondary data analysis (N=94) Primary Study

◦ Primary Aim – to determine independent predictors of PDNV

◦ Study Design Multi-site prospective survey No prescribed treatment regimen Targeted sample size ~2000

Methodology

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Age (Mean ± SD) 43 years ± 12.9 years

Race (N, %) African American 29/30.9

Caucasian 55/58.5

Latino 1/1.1

Other 9/9.6

ASA Physical Status (N,%)

I 20/21.3

II 58/61.7

III 16/17.0

Demographic Information

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Type Of Surgery (N,%) General 13/13.8

ENT 23/24.5

Gynecological 12/12.8

Orthopedic 33/35.1

Urologic 4/4.3

Other 9/9.6

Duration (hrs.) (Mean ± SD)

1.7 ± 0.8

Surgical Information

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PONV/PDNV Risk DistributionRisk Factor Incidence

(N/%)

Female Gender 66/70.2

Non-smoker 76/80.9

Hx PONV or MS 47/50

Post-op Opioids 66/70.2

Total Risk Factors Per Subject

Number of Subjects (N/%)

0 (Low Risk) 2/2.1

1 (Low Risk) 11/11.7

2 (Moderate Risk) 23/24.5

3 (Severe Risk) 34/36.2

4 (Very Severe Risk)

24/25.5

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Level of Risk Drugs Recommended

Drugs Administered (Mean ± SD)

Low 0 1.07 ± 0.64

Moderate 1 1.30 ± 0.93

Severe 2 1.56 ± 0.82

Very Severe 3 + 1.58 ± 0.76

Interventions Recommended vs. Administered

Pearson’s product-moment correlation (r) = 0.21, N = 94, p = 0.004

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Treatment Group (N=94)

Cases (N/%) Incidence of PONV (N/%)

Incidence of PDNV (N/%)

Undertreatment 41/44 13/32 30/73

Followed Guidelines

30/32 6/20 18/60

Overtreatment 23/24 2/9 10/43

Overall Incidence

21/22.3 58/61.7

PONV & PDNV Incidence

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Poor degree of adoption of the guidelines◦ 68% NOT treated according to the guidelines◦ 32% treated according to guidelines◦ Majority of patients received a single intervention

Higher risk tended to be undertreated Lower risk tended to be overtreated

◦ Pearson product-moment correlation r=0.21 N=94 p=.004

Discussion

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Poor guideline adoption is consistent with recent research◦ McMenamin et al.(2010). ◦ Chamie et al. (2011). ◦ Shirvani et al. (2011). ◦ Bhattacharyya et al. (2010). ◦ Kooij et al. (2010). ◦ Franck et al. (2010). ◦ White et al (2008).

Discussion

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Poor adoption of the ASPAN guidelines made it impossible to determine the efficacy of the guidelines

Trends◦ Patients with higher risks received more

interventions◦ Patients who received more interventions had a

lower incidence of PONV & PDNV

Discussion

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Incidence of PDNV was over 60% Incidence of PDNV was 2 – 3 times the

incidence of PONV◦No additional interventions for PDNV◦Short duration of action of antiemetics◦Longer reporting period for PDNV

Discussion

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Institutional antiemetic costs Ondansetron $0.32 Metaclopromide $0.29 Diphenhydramine $0.60 Promethazine $0.46 Dexamethazone $0.83 Compazine $1.89 Scopolamine Patch $10.14

(A. Barnett, personal communications, September 5, 2011)

Institutional cost of antiemetic drug are insignificant in relation to other health care cost

Discussion

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Given◦ Poor adoption of even simple, well supported

EBCPG◦ The more antiemetics given the lower the

incidence of PONV/PDNV◦ Current first-line antiemetics have excellent

safety profiles and negligible costs Is it time to revise the ASPAN guidelines to

recommend every patient receives the maximum number of antiemetics regardless of their risk?

Practice Implications

21

Bhattacharyya, P., Paul, R., Nag, S., Bardhan, S., Saha, I., Ghosh, M., . . . Acharyya Ghosh, D. (2010). Treatment of asthma: Identification of the practice behavior and the deviation from the guideline recommendations. Lung India, 27(3), 141-144. doi: 10.4103/0970-2113.68315

Chamie, K., Saigal, C. S., Lai, J., Hanley, J. M., Setodji, C. M., Konety, B. R., & Litwin, M. S. (2011). Compliance with guidelines for patients with bladder cancer: Variation in the Delivery of Care. Cancer. doi: 10.1002/cncr.26198

Fineout-Overholt, E. (2008). Synthesizing the evidence: how far can your confidence meter take you? AACN Adv Crit Care, 19(3), 335-339.

Franck, M., Radtke, F. M., Baumeyer, A., Kranke, P., Wernecke, K. D., & Spies, C. D. (2010). [Adherence to treatment guidelines for postoperative nausea and vomiting. How well does knowledge transfer result in improved clinical care?]. Anaesthesist, 59(6), 524-528. doi: 10.1007/s00101-010-1712-z

Frenzel, J. C., Kee, S. S., Ensor, J. E., Riedel, B. J., & Ruiz, J. R. (2010). Ongoing provision of individual clinician performance data improves practice behavior. Anesth Analg, 111(2), 515-519. doi: ANE.0b013e3181dd5899 [pii]

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