POSTOPERATIVE/POST DISCHARGE NAUSEA &

VOMITING IN A MULTISPECIALTY

AMBULATORY SURGERY CENTER

JUDY LONG MSN, RN, CCRN, CNRN, CPAN, CAPA

OBJECTIVES

• Learner will be able to list risk factors for PONV/PDNV in patients having procedures requiring anesthesia. • Learner will be able to discuss study design, data points,

and collection strategies• Learner will be able to identify outcomes identified

through analysis of data• Learner will be able to list lessons learned from process

DISCLOSURES

I have no conflict of interest disclosures.

DEFINITIONS

• PONV• N&V that occurs within the first 24 hours following

surgery• Early: 2-6 hours after surgery ( in PACU)• Late: 6-24 hour period• Delayed: Occurs beyond 24 hours in inpatient setting

• PDNV• N&V that occurs after discharge • Occurs beyond the initial 24 hours after D/C

DEFINITIONS CONT.

• Prophylaxis• Treatment• Multispecialty ASC• Single Specialty ASC

INCIDENCE

• 71 million surgical procedures performed in US annually• 31 million of these procedures are ambulatory• 20 – 30% of patients having surgery will experience PONV

(14,000,000 - 21,000,000)• May be as high as 70% in high risk patients

WHY DO WE CARE?

• Adverse effects of PONV range from patient discomfort to post-operative morbidity• Increased cost• Patients fear nausea & vomiting more than post-op pain

ADULT PONV RISK FACTORS

• Female• Non-smoker• <50 years old• History of PONV or motion

sickness

• General vs regional anesthesia• Use of volatile anesthetics and

nitrous• Duration of anesthesia

Postoperative opioids• Type of surgery

PATIENT FACTORS SURGERY FACTORS

PEDIATRIC PONV RISK FACTORS

• Surgery >/= 30 minutes• Age >/= 3• History of PONV or history of PONV in relative• Strabismus surgery

CONSENSUS GUIDELINE

• Published January, 2014 by Tong, et al• Review and revision of previous guidelines published in

2003 & 2007• Comprehensive review of hundreds of published articles

on PONV since 2007• Includes risk factors, prevention strategies, covers both

adult & pediatric patients

HISTORY OF STUDY

• Joint effort between management and staff of Glasgow Ambulatory Surgery Center and Anesthesia Services PA• Goals:• Identify rate of PONV/PDNV in patients having anesthesia at

Glasgow Ambulatory Surgery Center• Identify practice patterns related to PONV prevention• Improve patient experience and quality of patient care

provided

STUDY DESIGN

• Identify risk factors for PONV/PDNV• Identify prophylaxis patterns • Identify incidence of PONV/PDNV• Share information with staff

DATA COLLECTION PROCESS

• Risk factors documented in Pre-anesthesia Evaluation• Anesthesia providers document care provided on anesthesia

record• Data collected via chart review• Post-op incidence documented on data collection tool by

PACU RN(s)• Post discharge incidence documented on data collection tool

by RN as reported by patient during post-discharge phone call

PROCESS CONT.

• Case and patient information downloaded from anesthesia billing system• Data collection tool collected and entered by ASPA staff

into Excel• Data from tool combined with chart review data• Analysis completed• Reports generated and provided to Glasgow Ambulatory

Surgery Center staff monthly

INITIAL DATA POINTS • Demographics• Age• Gender

• Case information• Providers• Case type • Case length

• Anesthesia information• Anesthesia• Prophylaxis

• Patient factors• Risk factors• Incidence

EVOLVED DATA POINTS

• History of gastric diversion• Clear liquids

FINDINGS

• Case mix• Study compliance• PONV/PDNV incidence • PONV 3%

• Prophylaxis patterns• Impact of clear liquid initiation on PONV

CASE BY SURGERY SITE

Endosco

pyOrth

oEN

T

Podiatry

Intra-ab

dominal

Soft Ti

ssue /

Biopsy

Major P

lastic S

urgery

Eyes

Pelvic

Rectal

Cardiology

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1730

429

165 153 13886 80 72 55 19 5

Endoscopy 1730Ortho 429ENT 165Podiatry 153Intra-abdominal 138Soft Tissue / Biopsy 86Major Plastic Surgery 80Eyes 72Pelvic 55Rectal 19Cardiology 5

CASE BY ANESTHESIA TYPE

MAC

Genera

l with

LMA

Genera

l with

ETT

MAC with

Regional

Genera

l

Genera

l with

LMA w

ith Reg

ional

Genera

l with

Regional

Genera

l with

Mask

MAC with

Bier Block

MAC with

LMA

MAC with

Regional

with LM

A

Genera

l with

ETT w

ith Reg

ional

Genera

l with

Regional

with M

ask0

500

1000

1500

2000

2500

2124

217 176 151 124 83 27 13 5 4 4 2 2

MAC 2124General with LMA 217General with ETT 176MAC with Regional 151General 124General with LMA with Regional 83General with Regional 27General with Mask 13MAC with Bier Block 5MAC with LMA 4MAC with Regional with LMA 4General with ETT with Regional 2General with Regional with Mask 2

ANESTHESIA TYPE BY SURGERY SITE(ENDOSCOPY REMOVED ALL ARE MAC CASES)

General General with ETT

General with ETT with Regional

General with LMA

General with LMA with Regional

General with Mask

General with Regional

General with Regional with

Mask

MAC MAC with Bier Block

MAC with LMA MAC with Regional

MAC with Regional with

LMA

0

50

100

150

200

250

300

350

400

450

Cardiology ENT Eyes Intra-abdominal Major Plastic SurgeryOrtho Pelvic Podiatry Rectal Soft Tissue / Biopsy

PATIENTS W/NAUSEA IN PACU

2990 total patients

94%

3%3%

No Yes Not Documented

No 2816

Yes 96

Not Documented 78

PACU VOMITING96 total patients with nausea in PACU

*There were no patients that had vomiting that did not have nausea

97%

3% 0%

No Not Documented Yes

No 2900Not Documented 78Yes 12

PATIENTS WITH NAUSEA IN PACU BY SURGERY SITE

Cardiol-ogy

En-doscopy

ENT Eyes Intra-ab-dominal

Major Plastic

Surgery

Ortho Pelvic Podiatry Rectal Soft Tis-sue /

Biopsy

No 4 1699 149 67 133 69 388 53 151 17 83

Not Documented 1 41 3 4 4 1 14 3 5 NaN 2

Yes NaN 15 16 1 6 11 35 4 4 2 2

5%

15%

25%

35%

45%

55%

65%

75%

85%

95%

No Not Documented Yes

LESSONS LEARNED

• Collaboration• Multidisciplinary• Flexibility• Triple Aim• Data is the future!

QUESTIONS?