Implementing a Postoperative Nausea and Vomiting Protocol for Adult Patients Undergoing General Anesthesia Kayleigh Dodds, BSN, SRNA; Brennan Kulhanek, BSN, SRNA; Melinda Wander, BSN, SRNA Introduction Methodologies • The definition of postoperative nausea and vomiting (PONV) is typically defined as any • Conduct 30-day pre-implementation chart audit nausea, vomiting, or retching occurring during the first 24-48 hours after surgery. • Update PONV protocol to reflect 2020 Fourth Consensus Guidelines • PONV is associated with increased morbidity and mortality, increased hospital costs, • Collaborate with pharmacy to add Haldol to all operating room OmniCells and decreased patient satisfaction. Patient satisfaction is an important hospital quality metric indicator. Up to 80% of patients experience PONV. • Contact IT to create Electronic Medical Record (EMR) pop-up reminders • Anesthesia providers can administer medications that antagonize various receptors to • Educate anesthesia staff at monthly anesthesia meeting help prevent PONV (Dopamine 2, NK-1, Muscarinic, 5-HT-3, and Histamine 1). ○ Evidence-based review on PONV/PONV management, infographic, Fourth • The 2020 Fourth Consensus Guidelines are a comprehensive and evidence-based set Consensus Guidelines, recent studies on Decadron dosing for PONV of guidelines for PONV management. • Post infographics in all operating room suites • According to the Fourth Consensus Guidelines, risk factors for PONV include females, • Identify CRNA champion age < 50, non-smokers, post-operative opioid use, use of volatile anesthetics and/or nitrous oxide, gynecological procedures, and laparoscopic procedures. Patients with 1-2 • Send electronic follow-up to all anesthesia staff with same information provided at in- risk factors should receive 2 anti-emetics and those with >2 risk factors should receive person meeting 3-4 anti-emetics. • Conduct 30-day post-implementation chart audit • A mid-Michigan teaching hospital has inconsistent practice compliance with their PONV management protocol. The PONV protocol is also inconsistent with the 2020 Forth Consensus Guidelines. Results Purpose • The pre-implementation chart audit included 59 patients; 11 of these patients experienced PONV in the PACU • The purpose of this quality improvement initiative is aimed at reducing the rate of ○ PONV rate= 18.6% PONV in adult patients undergoing general anesthesia and improving the adherence to • Goal: decrease PONV rate to less than 10% an updated PONV guideline. • The post-implementation chart audit included 70 patients; 16 of these patients • Clinical Question: Will integrating an updated PONV guideline into practice experienced PONV in the PACU decrease the incidence of PONV in adult women ages 18-50 undergoing a general anesthetic for gynecological surgery? ○ PONV rate= 22.9% Literature Summary Conclusions ●Since evidence-based PONV management guidelines already exist, the literature was • Implementing an updated PONV guideline into practice did not decrease the incidence searched to learn how to best implement a guideline into practice. of PONV in adult women ages 18-50 undergoing a general anesthetic for gynecological surgery. ●Protocol implementation is more successful with the utilization of various implementation approaches versus using a singular approach. • Project limitations ○ Staff education, electronic follow-ups, infographics, and champions are all ○ Unable to make EMR pop-up reminders with IT, NK-1 antagonists frequently cited to facilitate PONV guideline implementation in anesthesia unavailable due to cost and supply issues, SRNAs did not rotate to site departments. during implementation, small sample size ●Barriers to guideline implementation are identified as cost and lack of time, resources, • Recommendations teamwork, and organizational support. ○ More research on how to overcome barriers to guideline implementation ●Research is lacking on how to overcome barriers and is recommended as a topic for ○ Survey staff to investigate cause of poor compliance future research Readiness for change assessment References ○ Dzwonczyk, R., Weaver, T., Puente, E., & Bergese, S. (2012). Postoperative Nausea and Vomiting Prophylaxis From an Economic Point of View. American Journal Of Therapeutics, 19(1), 11-15. Doi: 10.1097/mjt.0b013e3181e7a512 Gan, T., Belani, K., Bergese, S., Chung, F., Diemunsch, P., & Habib, A. et al. (2020). Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia, 131(2), 411-448. Doi: 10.1213/ane.0000000000004833 Li, S., Cao, M., & Zhu, X. (2019). Evidence-based practice: Knowledge, attitudes, implementation, facilitators, and barriers among community nurses—systematic review. Medicine, 98(39), e17209. Acknowledgements https://doi-org.proxy1.cl.msu.edu/10.1097/MD.0000000000017209 Majumdar, J. R. (2019). Effects of Midazolam on Postoperative Nausea and Vomiting and Discharge Times in Outpatients Undergoing Cancer-Related Surgery. AANA Journal, 87(3), 179–183. We would like to thank the following people for their support and assistance with this McArthur, C., Bai, Y., Hewston, P. 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Nurse Education Today, 70, 109–114. https://doi-org.proxy1.cl.msu.edu/10.1016/j.nedt.2018.08.026 6/16/22 9/30/22 8/20/22- 10/5/22 10/12/22 10/13/22- 9/22/22 10/11/22 Michigan State Haloperidol Pre-Implementation Anesthesia Staff Follow-up Post-Implementation University Added to All Audit Completed Education & Education Email Audit Completed Institutional Review Anesthesia Champion Sent to Board & Institutional OmniCells Chosen Anesthesia Staff Approval *Project was deemed non-research