1 Improving Perioperative Nausea and Vomiting Prophylaxis Protocol Compliance Allison Franz and Adam Traud Michigan State University College of Nursing 2 Table of Contents List of Appendices 3 Introduction 4 Background/Significance 4 Problem Statement/Clinical Question 6 Quality Improvement Framework 7 Search Methods 7 Review of Literature 7 Expected Outcome 10 Methods 10 Project Site and Population 12 Ethical Considerations/Protection of Human Subjects 12 Setting Facilitators and Barriers 13 The Intervention and Data Collection Procedure 14 Timeline 14 Measurement Instrument(s)/Tools 14 Cost-Benefit Analysis/Budget 15 Sustainability Plan 15 References 16 3 List of Appendices Appendix A: Apfel Score Assessment Tool 19 Appendix B: ASPIRE PONV-01 guidelines 20 Appendix C: IRB Approval 25 Appendix D: Appraisal of Evidence 26 Appendix D: Prisma Diagram 33 Appendix E: Articles from Literature Review 34 Appendix F: GANTT Chart 35 Appendix G: Budget 36 Appendix H: Fishbone Diagram 37 Appendix I: SWOT Analysis 38 4 Improving Postoperative Nausea and Vomiting Prophylaxis Administration Among Anesthesia Providers Postoperative nausea and vomiting (PONV) is a significant concern in anesthesia practice and a focus for quality improvement among anesthetists. Historically, evidence-based guidelines have sought to provide recommendations on identifying patients at risk for PONV and mitigating its effect with multimodal antiemetic strategies. An anesthesia department within a large teaching hospital uses the Anesthesiology Performance Improvement and Report Exchange (ASPIRE) guidelines to identify and manage patients at risk for PONV. These guidelines are intended to integrate best practices into anesthetic care and improve overall surgical outcomes in the state of Michigan. Compliance with such guidelines reduces postoperative complications and leads to better recovery after a surgical procedure. The anesthesia department currently has a PONV protocol in place that aligns with the ASPIRE guidelines but has not achieved the 90% compliance benchmark. This evidence-based quality improvement project describes interventions proposed to increase compliance with the PONV protocol. Background/Significance PONV describes nausea and/or vomiting or retching in the post-anesthesia care unit (PACU) or in the 24 postoperative hours immediately following administration of a general anesthetic (Stoops & Kovac, 2020). PONV is one of the most common anesthetic complications, affecting 30% of patients without risk factors and 70% of high-risk patients (Gress et al., 2020). 5 PONV is a significant concern as it delays recovery and is the number one cause of unexpected hospital admission or readmission in the outpatient surgical population. Patients experiencing PONV are at risk for pulmonary aspiration, wound dehiscence, dehydration and electrolyte imbalances. Further, PONV reduces patient satisfaction (Shaikh et al., 2016). In studies by Gan et al. (2020) and Hata & Hata (2017), PONV was the patient’s most persistent negative memory of the surgical procedure. Surprisingly, patients often rate PONV as a more negative experience than postoperative pain (Feinleib et al., 2021). Equally notable, the amount of nursing time and total cost of postoperative recovery for a patient with PONV is significantly greater than for patients not experiencing PONV (Gress et al., 2020). PONV increases healthcare costs for the facility and reduces patient flow in systems increasingly reliant on speed and efficiency (Gan et al., 2020). The pathophysiology of PONV is complicated, involving various pathways and receptors. The chemoreceptor trigger zone, vagal pathway in the gastrointestinal system, neuronal pathways from the vestibular system, reflex afferent pathways from the cerebral cortex, and midbrain afferents are the primary pathways implicated in stimulating vomiting (Shaikh et al., 2016). With stimulation of one of these pathways, the sensation of vomiting is activated via cholinergic, dopaminergic, histaminergic, or serotonergic receptors (Shaikh et al., 2016). Additionally, vomiting may also be induced by disruption of the gut or oropharynx, movement, pain, hypoxemia, and hypotension - all common events associated with general anesthesia (Shaikh et al., 2016). Current guidelines support the use of PONV risk factors to guide multimodal prophylaxis and management. Multimodal prophylaxis in patients with one or two risk factors indicates that 6 two pharmaceutical agents be administered while more than two risk factors indicates that three to four pharmaceutical agents be administered from different classes of antiemetics (5HT3 receptor antagonists, corticosteroids, antihistamine, dopamine-2 antagonists, NK-1 receptor antagonists, and anticholinergics) (Gan et al., 2020). A combination of different classes of antiemetics are more effective than monotherapy (Gan et al., 2020). Single antiemetic measures reduce the risk for PONV by approximately 30%, therefore, single agent therapy does not result in substantial risk reduction (Kranke et al., 2020). The incidence of PONV is mitigatable. The Apfel score assessment tool is often utilized to depict a patient’s risk for PONV (Appendix A). The Apfel score takes into consideration the patient’s gender (females are more likely to develop PONV than males), smoking status (non-smokers are more at risk), history of PONV and/or motion sickness (patients with a history of motion sickness or vomiting after previous surgery are at increased risk for PONV), and postoperative use of opioids (a direct correlation exists between opioid use and risk for PONV) (Gan et al., 2020). This assessment tool provides an objective approach to predict the incidence of PONV, with a sensitivity and specificity between 65-70%, and should be used as a guide for prophylaxis (Gan et al., 2020). The use of risk stratification to guide multimodal antiemetic therapy has proven to be significant in the reduction of PONV (Kranke et al., 2020). Problem Statement The project site anesthesia department currently has protocols in place that align with the ASPIRE PONV-01 guidelines (Appendix B). According to the chief nurse anesthetist, deidentified query data indicates that the benchmark of 90% PONV prophylaxis compliance has not been met. 7 Clinical Question Will the use of an anonymous, publicly displayed visual feedback system and a restructuring of the electronic health records (EHR) reminders improve anesthesia provider compliance with the perioperative PONV guidelines? Quality Improvement Framework The plan-do-study-act (PDSA) cycle method of quality improvement is widely used within healthcare to implement, test, and adapt to a change in practice. The model is intended to be used as a cyclical, continuous improvement process that starts with planning changes based upon the results and findings of the previous cycle. This quality improvement project requires agility in a fast-paced, ever changing anesthesia department. The PDSA cycle method supports mid-cycle changes based on incremental, preliminary data. Search Methods Studies were identified using database searches of PubMed and CINAHL. The search terms utilized were: “postoperative nausea and vomiting” and “adherence” or “compliance”; full query details for the PubMed and CINAHL searches can be found in appendices A and B, respectively. Search filters limited results to English articles published no earlier than 2016, with available full text. Exclusion criteria consisted of case reports, pediatric populations, PONV from sources other than anesthesia, interventions by non-anesthesia staff, novel medication or administration methods, limited application to general practice, and non-pharmacological prophylaxis. Duplicates were removed before screening abstracts using the exclusion criteria. Articles remaining after screening underwent full text review before a final exclusion. Final 8 articles were then categorized based on method of compliance improvement as listed in Appendix C. Literature Synthesis Despite the well documented and widely accepted consequences of PONV, anesthesia provider compliance with evidenced-based prophylaxis protocols (local or multicenter) remains a major barrier to adequate PONV prevention (Dewinter et al., 2017; Kooij et al., 2017; Pym & Ben-Menachem, 2018; Smirk et al., 2018; Thomas et al., 2019). In response to this shortcoming, many tools and techniques have been developed to improve compliance with PONV prophylaxis. This literature review seeks to identify the most current recommendations for improving compliance with PONV prophylaxis administration and suggest a course of action for anesthesia departments seeking to improve their compliance rates. The Appraisal of Evidence Table and Synthesis Matrix are in Appendix A and C, respectively, detailing the evidence and themes for each study. Compliance to PONV protocol. Articles from the literature search were grouped into one of three categories based upon their preeminent method for improving compliance; categories selected were awareness, reminders, and simplification. While the articles differed in how they approached the problem of compliance, there was consensus that no singular effective method to permanently improve compliance. Indeed, several articles very clearly point out the opposite, acknowledging that despite significant improvements, facility metrics were still often not met (Pym & Ben-Menachem, 2018; Thomas et al., 2019). Several authors noted that compliance outcomes using these interventions may be influenced by the “Hawthorne effect” (Smirk et al., 2018, 9 Dewinter et al., 2017). Yet, while the data may be skewed repeated use and compliance with the guidelines may translate to permanent behavioral change. Despite the consensus that all interventions have the capacity to improve protocol compliance, the degree of improvement among studies varied wildly. Low starting compliance percentages have little effect on the final compliance rates, and compliance rates and incidence of PONV are not directly causatively linked. For instance, Pym and Ben-Menachem (2018) reported the lowest pre- and post-intervention compliance rates and yet had the lowest reported PONV rates. Of the chosen interventions to improve PONV protocol compliance, no methodology has a clear advantage. These findings are not necessarily unexpected, as the studies reviewed were designed for and carried out in separate facilities. It is likely that each anesthesia department is structured differently and has its own unique culture, practices, and response to change. In a study by Pym & Ben-Menachem (2018), easy to use protocol development and provider education was not an effective strategy to improve protocol compliance levels. However, “timely, individual feedback”, as accomplished through the use of a “greenie board” was far more successful, particularly for PONV prophylaxis (Smirk et al., 2018, p. 699). Posted anonymous feedback displays allows individual providers an opportunity to compare their performance with that of their peers. Potentially more punitive in nature, incentivization of compliance with PONV prophylaxis was resoundingly successful; simply announcing the future plan for the change created an immediate improvement in compliance (Hutson et al., 2019). The use of reminders, specifically clinical decision support tools within the anesthesia information management software (AIMs) system yielded mixed results. While improvement 10 was seen with any reminder used, simple reminders were not enough to sustain change (Gillman et al., 2019). Alarm fatigue and routine dismissal of reminders were contributing factors in the end compliance rates. Kooij et al. (2017) and Simpao et al. (2017) recommend preventing easy dismissal of reminders in the EHR and linking the reminders to clinical tools. Ensuring that reminders are not only meaningful, but actually attended to, may improve compliance (Kooij et al., 2017; Simpao et al., 2017). Simplification of existing protocols and algorithms may provide increased compliance through convenience and time saved (Dewinter et al., 2017; Thomas et al., 2019). A study by Thomas et al. (2019) focused on reducing PONV occurrence and used compliance metrics as a means to that goal. Trying to find a middle ground for prophylaxis protocol between “one-size-fits-all” and “risk-adapted” methods leads to promising results by simplifying existing risk adaptation models to improve ease of use (Dewinter et al., 2017, p. 160). Relevance to Clinical Problem Every single intervention described above improves PONV guideline compliance and reduces PONV. Although the degree of improvement varied greatly, the array of positive results suggests that while some efforts are more efficacious than others, any intervention is superior to inaction. It should be noted that ASPIRE guidelines differ from the recently released Consensus Guidelines for the Management of Postoperative Nausea and Vomiting (Gan et al., 2020). The hospital’s surgical population may benefit from an ASPIRE protocol update. Small changes to existing practice protocols holds promise in both meeting ASPIRE compliance measures and providing patients the care that is supported by current evidence. 11 Expected Outcome The expected outcome of this project is: Anesthesia department compliance with ASPIRE PONV-01 guidelines will reach 90% or greater by July 1, 2021. Methods To address poor PONV compliance, we plan to integrate interventions demonstrated in the literature to be effective. The quality improvement team will work with the information technology perioperative liaison to update existing AIMs reminders. Reminders will be updated to include the number of antiemetics recommended based upon the patient’s risk status. It will remain within the purview of the anesthesia provider to identify which medications and pharmacological classes will be appropriate for their patients’ specific needs and conditions. Secondly, to ensure that alerts and reminders are acknowledged and attended to, the quality improvement team and perioperative liaison will alter the structure of PONV alerts within the AIMs. Anesthesia providers will be required to select a reason why the department protocol was not followed. The intent of this initiative is to assess and study common reasons for not following department protocol and encourage providers to reconsider the decision to not follow protocol. Thirdly, the quality improvement team will develop a short, anonymous survey. The survey (and the results) will be distributed by the chief nurse anesthetist via interdepartmental e-mail. The results of the survey will be reviewed by the quality improvement team. The intent of this anonymous survey is to assess anesthesia provider’s current familiarity with the new PONV guidelines, identify misconceptions and assess the department’s willingness to embrace the new initiatives. Once survey data has been collected, an educational offering will be provided 12 to address identified knowledge gaps, address provider concerns, and present the proposed changes. Lastly, the “greenie board” method, described by Smirk et al (2018), will be implemented using data gathered by the EHR IT department and chief nurse anesthetist. As the data is available in excel format, a preliminary confidential list will be created that correlates staff to a “nickname” or placeholder name. This will allow the deidentification of data for publishing within the department using placeholder names that will be shared only to those they belong to. In this way, individual providers will be able to identify their own performance in relation to their peers, in a non-punitive way. Project Site and Population The mid-Michigan hospital is a 733-bed, Level 1 Trauma Center and teaching hospital located in Lansing, Michigan. Services provided at the hospital include cardiothoracic and vascular medicine, oncology, bariatric care, pediatric medicine as well as obstetrics and gynecology. There are 55 certified registered nurse anesthetists (CRNAs) and 40 anesthesiologists that serve the 22 operating rooms at the Michigan hospital. Ethical Considerations/Protection of Human Subjects Michigan State University (MSU) Internal Review Board (IRB) approval was obtained prior to initiating this quality improvement project (Appendix C). Prior to IRB approval, the project underwent a College of Nursing internal review. Although the facility has an independent IRB process, the facility’s chief CRNA Chris, deemed this project as a departmental quality improvement process and not research. 13 Patients will not be directly involved, as this quality improvement project aims to improve provider compliance with established protocols and anesthesia provider practice expectations. As such, decisions regarding the selection of specific medications for use during patient cases will not be made. Instead, providers will be reminded of existing MPOG guidelines in use at the hospital, which provide a selection of drug classes to be used as first and second line antiemetics for adult patients undergoing general anesthesia. The anesthesia department chief CRNA will ensure that all data is deidentified prior to analysis and preparation for display. Setting Facilitators and Barriers While there exists a significant population of providers who meet or exceed adequate administration of PONV prophylaxis medication to their patients undergoing general anesthesia, the facility average as a whole has struggled to meet and sustain the 90% benchmark goal. Information from the chief CRNA indicates that there is no provider group that is largely responsible for the performance shortfall and similarly, identifying and correcting for outliers will not meet the goal metric. This information led the quality improvement team to focus efforts on methods that address the entire anesthesia provider population within the department. As described above, a significant portion of providers meet or exceed the benchmark, indicating a pool of potential early adopters. Even so, these high performers could serve to act as facilitators, and not barriers to the project. During the educational phase, we will seek champions from the pool of high performers to offer input and feedback to the educational offering before presenting to the department in its entirety. Alternatively, poor compliance providers, lack of protocol knowledge, along with an increasingly rapid-pace operating room schedule may present as barriers to the success of the 14 project. It is not entirely clear if poor compliance is a product of true non-compliance or poor documentation of PONV prophylaxis administration, presumably due to time constraints. Improving AIMs reminders should improve documentation and reduce compliance issues related to incomplete charting. Stakeholders include anesthesia staff, the chief nurse anesthetist, patients, and post-anesthesia recovery staff. Anesthesia staff will primarily be engaging with the adjusted AIMs reminders, as well as finding their place on the display board. The chief nurse anesthetist will provide deidentified data and post the publicly displayed roster of compliance within the anesthesia department. Patients will not have any responsibilities, apart from ideally enjoying a reduced occurrence of PONV. Similarly, post-anesthesia recovery staff will have no increased responsibilities. Data Collection Procedure Our intervention for this PDSA cycle will consist of the implementation of a “greenie board”, as described by Smirk et al. (2018). Data will be provided by the chief CRNA at the hospital, from data that is already collected to track ASPIRE guideline measures. Provider names will be obscured using an anonymous “nickname” or placeholder name so that they are able to compare their individual PONV compliance scoring to that of their individual peers. After reviewing and formatting the data for the most recent month, the “greenie board” will be constructed and placed on display within the surgical services area of the hospital. Updates to the “greenie board” will be made monthly, using the most recent available data. 15 Timeline MSU and hospital IRB approval is expected in April, 2021. The project timeline (Appendix D) will take place over a 14-week implementation phase (May 3 through August 9, 2021). May data is expected to be available in early June. Monthly data will be available after the respective month. Measurement Instrument(s)/Tools and Data Collection Procedure Monthly MPOG tracking data is already being collected, including PONV compliance tracking. Data is collected through the Epic EHR charting software used within the preoperative, intraoperative, and postoperative areas at the hospital. Raw data contains the name, identification number, and role of anesthesia providers at the hospital, and their compliance with the MPOG PONV-01 measure as demonstrated by a percentage value. The chief CRNA will removing anesthesia provider identification characteristics prior to the student members viewing of the data. Microsoft Excel will be used to analyze the de-identified data for outliers, averages, and trends, as well as for converting data to a format for display with alias identifiers. Cost-Benefit Analysis/Budget The budget for intervention implementation and evaluation is detailed in Appendix E. Total estimated cost of the interventions is $6,000. The budget takes into consideration the number of hours the Chief CRNA, the IT staff, and the quality improvement team will spend implementing these interventions as well as the dollar amount per hour. The project will not generate income. However, if successful the project would prevent costly admissions, readmissions, and prolonged PACU stays. Sustainability Plan 16 An excel template was developed to allow for the seamless importing of up-to-date deidentified data. This easy-to-use template, with use instructions, is available to the chief CRNA and can be used after project completion to continue to track PONV guideline compliance. As sustainability is closely linked to provider buy-in, the project team plans to identify contributing factors that prevent providers from consistently following the PONV guidelines by distributing an anonymous survey. The project team intends to address these departmental concerns during the project to improve project outcomes and sustain provider compliance. 17 References Dewinter, G., Staelens, W., Veef, E., Teunkens, A., Van de Velde, M., & Rex, S. (2017). Simplified algorithm for the prevention of postoperative nausea and vomiting: A before-and-after study. British Journal of Anaesthesia, 120(1), 156–163. https://doi.org/10.1016/j.bja.2017.08.003 Feinleib, J., Kwan, L. H., & Yamani, A. (2021, January 27). Postoperative nausea and vomiting. UpToDate. https://www.uptodate.com/contents/postoperative-nausea-and-vomiting Gan, T. J., Belani, K. G., Bergese, S., Chung, F., Diemunsch, P., Habib, A. S., Jin, Z., Kovac, A. L., Meyer, T. A., Urman, R. D., Apfel, C. C., Ayad, S., Beagley, L., Candiotti, K., Englesakis, M., Hedrick, T. L., Kranke, P., Lee, S., Lipman, D., … Philip, B. K. (2020). Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia, 131(2), 411–448. https://doi.org/10.1213/ANE.0000000000004833 Gillmann, H.-J., Wasilenko, S., Züger, J., Petersen, A., Klemann, A., Leffler, A., & Stueber, T. (2019). Standardised electronic algorithms for monitoring prophylaxis of postoperative nausea and vomiting. Archives of Medical Science : AMS, 15(2), 408–415. https://doi.org/10.5114/aoms.2019.83293 Gress, K., Urits, I., Viswanath, O., & Urman, R. (2020). Clinical and economic burden of postoperative nausea and vomiting: Analysis of existing cost data. Best Practice & 18 Research Clinical Anaesthesiology, 34, 681-686. https://doi.org/10.1016/j.bpa.2020.07.003 Hata, T. M., & Hata, J. S. (2017). Preoperative Assessment and Management. In P. G. Barash, B. F. Cullen, R. K. Stoelting, M. K. Calahan, M. C. Stock, R. Ortega, S. R. Sharar, & N. F. Holt, Clinical anesthesia (8th ed., pp. 585–611). Wolters Kluwer. Hutson, L. R., Ragsdale, S. A., & Vacula, B. B. (2019). Relation of improved postoperative nausea/vomiting quality metric to physician incentive pay. Baylor University Medical Center Proceedings, 32(1), 5–8. rzh. https://doi.org/10.1080/08998280.2018.1540681 Kranke, P., Meybohm, P., Diemunsch, P., & Eberhart, L. (2020). Risk-adapted strategy or universal multimodal approach for PONV prophylaxis? Best Practice & Research Clinical Anaesthesiology, 34, 721-734. https://doi.org/10.1016/j.bpa.2020.05.003 Kooij, F. O., Klok, T., Preckel, B., Hollmann, M. W., & Kal, J. E. (2017). The effect of requesting a reason for non-adherence to a guideline in a long running automated reminder system for PONV prophylaxis. Applied Clinical Informatics, 8(1), 313–321. https://doi.org/10.4338/ACI-2016-08-RA-0138 Multicenter Perioperative Outcomes Group [MPOG]. (2017). Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) PONV-1. https://spec.mpog.org/Spec/Public/24 Pym, A., & Ben-Menachem, E. (2018). The effect of a multifaceted postoperative nausea and vomiting reduction strategy on prophylaxis administration amongst higher-risk adult 19 surgical patients. Anaesthesia and Intensive Care, 46(2), 185–189. https://doi.org/10.1177/0310057X1804600207 Shaikh, S. I., Nagarekha, D., Hegade, G., & Marutheesh, M. (2016). Postoperative nausea and vomiting: A simple yet complex problem. Anesthesia Essays and Researches, 10(3), 388-396. https://doi.org/10.4103/0259-1162.179310 Simpao, A., Tan, J., Lingappan, A., Gálvez, J., Morgan, S., Krall, M., Simpao, A. F., Tan, J. M., Lingappan, A. M., Gálvez, J. A., Morgan, S. E., & Krall, M. A. (2017). A systematic review of near real-time and point-of-care clinical decision support in anesthesia information management systems. Journal of Clinical Monitoring & Computing, 31(5), 885–894. rzh. https://doi.org/10.1007/s10877-016-9921-x Smirk, A. J., Nicholson, J. J., Console, Y. L., Hunt, N. J., Herschtal, A., Nguyen, M. N. H. H., & Riedel, B. (2018). The enhanced recovery after surgery (ERAS) Greenie Board: A Navy-inspired quality improvement tool. Anaesthesia, 73(6), 692–702. https://doi.org/10.1111/anae.14157 Stoops, S., & Kovac, A. (2020). New insights into the pathophysiology and risk factors for PONV. Best Practice & Research Clinical Anaesthesiology, 34, 667-679. Thomas, J. S., Maple, I. K., Norcross, W., & Muckler, V. C. (2019). Preoperative Risk Assessment to Guide Prophylaxis and Reduce the Incidence of Postoperative Nausea and 20 Vomiting. Journal of PeriAnesthesia Nursing, 34(1), 74–85. rzh. https://doi.org/10.1016/j.jopan.2018.02.007 21 Appendix A Apfel Score Assessment Tool 22 Appendix B ASPIRE PONV-01 guidelines 23 24 25 26 27 Appendix C IRB Approval 28 Appendix D Appraisal of Evidence Author Purpose of the Type of Study Population / Outcomes How does this relate to Study Limitations Study (Observationa Setting your project? l, Randomized, etc) Dewinter et To improve Quasi-Experi “all adult Simplifying the The study findings suggest Chart audits were limited to al. PONV and mental patients (≥18 PONV algorithm that both PONV rates and “two arbitrarily chosen PONV yr.) admitted to used resulted in a rates of compliance with weeks” prophylaxis our 33% reduction in PONV protocol can be administration postanaesthesi PONV, and a improved by simplifying Study design lends itself to using a a care unit significant the protocol used to overestimating results due to simplified (PACU) who improvement in determine prophylaxis staff awareness of algorithm had undergone prophylaxis requirements of patients observation. elective administration was non-cardiac witnessed Staff may have received non-day-case other supplemental surgery under education on PONV general prophylaxis independent of anesthesia” the algorithm change. 412 patients Exact reason for improved between two PONV rates is unclear audits (improved algorithm, improved compliance, or increased anti-emetic administration). Gillmann et “ to examine Retrospective 10,604 Adult 6% of patients Adherence to PONV Actual rates of PONV are al. strengths and observational surgical experienced PONV. prophylaxis was unknown, as PACU staff did weaknesses of patients Patients approximately 50%, not chart the presence of the local experiencing PONV PONV, despite the ability to 29 (anesthesia on average, stayed despite software and do so. PONV occurrence information nearly twice as long decision support tools. was estimated using PONV management in PACU, and rated treatment documented systems) their pain Insufficient PONV during PACU stay. AIMS-based numerically over prophylaxis was associated algorithm in double those who with nearly tripled rate of PONV occurrence was only prevention of did not experience PONV. Apfel scoring was measured within PACU, and PONV.” PONV. associated linearly with not after discharge or probability of PONV. transfer from PACU. Gender of anesthesia provider did not have a Dosage and timing of opioid correlation with PONV, administration was not unlike gender of patient. considered in this study. Patients with low Apfel scores (0-1) were likely to receive excess prophylaxis, while patients with high Apfel scores received insufficient prophylaxis nearly exclusively. Patients receiving insufficient prophylaxis were often eligible for the medications they did not receive. >90% of patients receiving insufficient prophylaxis would have met prophylaxis goals with ondansetron or Haldol administration. Hutson et To determine Retrospective Prophylactic Incentivizing PONV All locations involved in Data reviewed was al. the observational PONV prophylaxis the study exceeded 90% de-identified and did not effectiveness administration administration benchmark for prophylaxis allow for further 30 of records for created a statistically administration following investigation into the incentivizing 50,408 significant increase the study. circumstances surrounding PONV high-risk in the rate of the data. prophylaxis patients prophylaxis Preop evaluation administration administration. containing a visible PONV It was not possible to Rescue therapy risk score, along with identify the reason a administration Incentivizing incentivization, was medication was given, records for prophylaxis also strongly associated with whether for PONV or for 87,893 PACU resulted in decreased improved prophylaxis off-label use. patients (all rescue therapy use among all patients. patients in PACU in patients Renumeration amount was receiving receiving general chosen arbitrarily, and no general anesthesia. study was done to determine anesthesia over the optimal level to achieve 2 years) Simply announcing the greatest impact the plan to tie prophylaxis administration to incentives in the future created an immediate increase in PONV prophylaxis administration. Kooji et al. To determine Observational 2594 Control Utilization of By implementing an Due to long study period, the case control patients computer-based additional step before provider perception may effectiveness request for reason dismissal of automated have been changed by of requesting a 27,332 behind not reminders, patients outside factors not related to reason for preoperative administering received increased PONV point of care reminders PONV patients prophylaxis was prophylaxis without an utilized. prophylaxis seen to improve inappropriate increase in non-adherence 11,270 prophylaxis to administration. It is not possible to drawn OR/PACU high-risk patients causative conclusions, only patients while associations. simultaneously 31 reducing Preop reminders were less The control group size is prescription to effective than OR/PACU disproportionate to the low-risk patients. reminders. intervention groups. Reasons for not Long term learning effect User feedback was not administering may occur over years with sought. prophylaxis were a reminder in place. subjective disagreement with risk estimate, unintentional non-adherence, and failure to document administered medications Pym and Determining Interventional Patients The rate of PONV While the introduction of a The study only looked at Ben-Menac the cohort undergoing prophylaxis local guideline and PONV in patients while in hem effectiveness general administration for education improved PACU and did not of anesthesia and non-low risk prophylaxis administration determine occurrence of late evidenced-bas admitted to patients more than rates, nearly half of PONV. ed education PACU after. doubled following moderate risk patients and and guideline 581 education and over 80% of high-risk The study did not determine use on PONV pre-interventio guideline patients received provider review of data prophylaxis n, and 521 dissemination, along insufficient prophylaxis. provided nor did the authors post-interventi with individualized assess providers on patients. information on Despite modest increases interpretation of data. provider prescribing in prophylaxis practice in administration rates, PACU Occurrence of PACU PONV comparison to length of stay was was not determined by departmental rates. demonstrably improved. charting of PONV, but the administration of PONV Patient rates of The occurrence of PONV rescue medication. PONV were reduced in PACU was associated by nearly 50%. with an increase in PACU 32 High-risk patient length of stay by 30 PACU length of stay minutes. was significantly reduced. “repeated and further interventions would be Patients who required to create a received adequate sustained and more marked prophylaxis but still improvement.” experienced PONV remained in PACU The transfer of evidence for a shorter into clinical practice is duration than those dependent upon who did not receive implementation adequate prophylaxis. Simpao et To review Systematic Studies of Exposure to PONV CDS tools are only Very few studies examined al. available data review clinical risk prediction CDS effective when both the use of CDS tools for regarding the decision tools improved situational awareness and PONV prophylaxis effectiveness support (CDS) prophylaxis option awareness are in administration, despite a of clinical tools within administration, but view and in mind. relatively high decision anesthesia not the occurrence implementation of support tools information of PONV. Exposure anesthesia information in anesthesia management to a CDS tool that management software. information systems (not provided specific management EHR), recommendations Most available research on software on published in was associated with CDS tools is based upon selected English a reduction in custom or proprietary categories of language peer PONV, particularly software. This fragmented perioperative reviewed in high-risk patients. implementation reduces the care. journals applicability of data from a between Moderate evidence particular system to other January 1 2000 exists to support the systems. and December use of CDS tools to 31 2015. improve the rate of This review did not include the use of context-sensitive 33 25 articles PONV prophylaxis checklists, a tool that the were selected. administration. authors admit may be effective in guiding provider care and warrants further investigation. Smirk et al. To evaluate the Interventional All patients “Greenie board” use Many potential barriers to Little data exists on the use effectiveness assigned to was associated with provider compliance with of personalized feedback of using a ERAS over a an estimated 7-34% bundled care initiatives can within the healthcare “Greenie 12-month increase in be mitigated using “timely environment. board” period (194 administering at individualized feedback”, feedback patients) at an least 2 antiemetics and allowing providers to Some providers found the system to meet Australian by anesthesia benchmark themselves feedback system punitive in compliance hospital providers. against peers. nature, despite the goals in anonymized data contained enhanced Compliance among Individualized performance within. recovery all 8 ERAS goals feedback is more protocol studied were all successful than didactics or Despite demonstrating increased, with the education alone. improvements in rate of complete compliance, only PONV ERAS compliance Improved compliance is rates were improved overall. increasing 25-42%. most notable when feedback is presented close The authors did not consider to the time when the non-anesthesia factors in decision is made. their study and did not include non-anesthesia Feedback must be providers or processes. sustained, timely, and evidence based or there is a The applicability of the risk of regression to findings of this study are pre-feedback levels. limited by the sample groups’ small size. Thomas et To implement Retrospective 314 adult Administration of The use of a risk Surgical time length in the al. a standardized, chart review female PONV prophylaxis assessment tool increases post-intervention group was targeted of data pre- non-pregnant to moderate and the use of PONV statistically significantly 34 approach to and patients high-risk patients prophylaxis in high-risk longer than the PONV post-intervent admitted to increased, with the patients while reducing the pre-intervention group. prophylaxis ion PACU percentage of rates of over-treatment in administration following undertreated patients low-risk patients. The sample group (females to improve gynecological dropping by undergoing gynecological compliance surgery, approximately half. High risk patients who are procedures) had a and reduce divided into adequately treated with disproportionately high rate PONV pre- and Reduction in PONV PONV prophylaxis of high-risk patients, which occurrence post-interventi occurrence overall experience significantly may limit the applicability on groups was not significant, less PONV. to other centers. but high-risk patients’ occurrence Provider involvement and Provider compliance limited however was compliance plays a the success of the project. significantly profound role in the reduced, from 79% presence of PONV. Post-operative opioid use to 29%. was not assessed, as it Provider compliance may requires providers to make The rate of PONV be falsely skewed in the subjective judgements. occurrence in all short term, due to the patients receiving Hawthorne effect. the appropriate number of anti-emetic drugs was reduced drastically, particularly in high-risk patients. An increase in provider compliance was seen. Compliance in high-risk patients more than tripled, however over half of all high-risk patients 35 still did not receive adequate prophylaxis. 36 Appendix E PRISMA diagram 37 Appendix F Articles from PubMed and CINAHL meeting exclusion and inclusion criteria Category First Publication Summary author’s Year surname Awareness Pym 2018 Guideline development and use along with education improve adherence but still leave much room for improvement. Hutson 2019 Highly visible risk assessments and incentivization of prophylaxis was profoundly successful. Smirk 2018 Timely, individualized feedback and the ability to anonymously compare self-compliance against peers improves compliance substantially. Reminders Gillmann 2017 Compliance is low despite clinical decision systems. Kooji 2017 Requiring more than simple interaction with clinical decision systems raises compliance. Simpao 2016 Clinical decision systems are only effective in the presence of situational and option awareness. Simplification Dewinter 2017 Simplified algorithm increases compliance and reduces PONV. Thomas 2018 Standardized protocol improves provider compliance, a crucial aspect of prophylaxis. 38 Appendix G GANTT Chart 32 Appendix H Estimated Budget PONV Project Financial Plan FY 2021-22 Personnel Expenses Hours/yr. Dollars/hour Dollars Chief CRNA 20 $90 1,800.00 IT staff 50 $30 $1,500.00 QI team 90 $30 2,700.00 Subtotal 6,000.00 Other Expenses Anticipated increase in prophylaxis spending - Revenue Anticipated Savings - Expenses 6,000.00 Revenue - Net total (6,000.00) 40 Appendix I Fishbone Diagram 41 Appendix J SWOT SWOT Analysis for PONV Quality Improvement Project INTERNAL FACTORS INTERNAL FACTORS STRENGTHS (+) IMPORTANCE WEAKNESSES (–) IMPORTANCE PONV protocol decreased Lack of time for education compliance problem High High for CRNAs identified CRNAs are receptive to No routine PONV High High change education among staff Staff is receptive to PONV medications not education on PONV High High available/stocked in Pyxis prophylaxis CRNAs want positive Possibly outdated PONV patient outcomes and High High protocol quality care Facility wants to reach High 90% ASPIRE benchmark Staff is highly motivated Moderate EXTERNAL FACTORS EXTERNAL FACTORS OPPORTUNITIES (+) IMPORTANCE THREATS (–) IMPORTANCE Ensure PONV medications Competing priorities for High Moderate are available CRNAs time Utilize evidence-based protocol for based on High Increased costs - supplies High patient's risk factors One time staff education on importance of PONV High Reminder fatigue Moderate prophylaxis Identify CRNA New nurses/grads "champions for change" to Moderate Low incorporated into staff empower staff Encourage MDA education and adherence Moderate Staff not accepting change Moderate to protocol