The Effect of a Multifaceted Postoperative Nausea and Vomiting Reduction Strategy on Prophylaxis Administration Amongst Higher-Risk Adult Surgical Patients

Abstract

Postoperative nausea and vomiting (PONV) is a common and distressing problem for patients and increases the burden of care in post-anaesthesia care units (PACU). As such it has been a recent focus for quality improvement. Evidence-based guidelines have demonstrated the benefit of PONV risk stratification and prophylaxis, but may be underutilised in clinical practice. This prospective pre-/post-intervention study was conducted at an adult tertiary hospital in non-cardiac adult surgical patients at higher risk of PONV. The intervention included promotion of an evidence-based PONV guideline, and provision of individualised prescribing and patient outcome data to anaesthetists. Six hundred and twenty-eight patients with ≥2 risk factors for PONV following general anaesthesia for non-cardiac surgery were included (333 pre-intervention and 295 postintervention). Prior to the intervention, 9.0% (30/333) of moderate-and high-risk patients received antiemetic prophylaxis consistent with our guideline. Post-intervention, the rate of guideline adherence was 19.3% (57/295). In the high-risk PONV group, the time in PACU was significantly reduced post-intervention, 66 minutes versus 83 minutes (P=0.032). This institutionspecific PONV reduction strategy had a modest but significant effect on improving prophylaxis administration. However, our findings indicate that further efforts would be required to ensure fuller compliance with the current extensive evidence base for PONV management in higher-risk patients.

Pharmacist‐driven multidisciplinary initiative continuously improves postoperative nausea and vomiting in female patients undergoing abdominal surgery

“…10,11 High-quality clinical practice guidelines on PONV management have been developed, and they recommend prophylaxis administration based on PONV risk stratification. 3,8,12 However, their actual effects on clinical practice are limited [13][14][15][16] because of several reasons.…”

“…3,8,12 However, the implementation of these guidelines in routine clinical practice has been poor. 9,14,16,20,30 Some studies attempted to improve clinicians' compliance with PONV prophylaxis through different interventions, 13,15,20,[30][31][32][33] among which automated reminders were most commonly reported. 13,16,31,33,34 However, the real role about automated reminders remains controversial and is limited in PONV management.…”

“…24 Another strength was the enrolment of a series of patient-related outcomes. Many studies only reported outcomes about compliance with guidelines, which were intermediate measures rather than clinical outcomes 15,20,22,34 ; hence, the effects of PONV from an intervention perspective cannot be easily evaluated. The lack of clinical outcomes was a major concern in other studies on pharmacist-led interventions.…”

Dexasone and metoclopramide vs. granisetron in the prevention of postoperative nausea and vomiting

“…Previous studies have shown that patients regard vomiting as the most undesirable complication of anesthesia and qualify it as a more unpleasant sensation than pain [1,2]. The incidence of PONV in adult population is 30% [3], and in high-risk population such as gynecologic and laparoscopic surgery, it can be up to 80% [4,5].…”

Multifaceted approaches and PONV: A critical appraisal

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We read with interest the recent publication by Pym and Ben-Menachem regarding their use of a multifaceted reduction strategy in an effort to reduce the rates of postoperative nausea and vomiting (PONV). 1 The efforts of the authors to implement a quality improvement project in their hospital is admirable, and highlight a growing awareness for the continuous need to re-evaluate and improve upon current practices based on a cycle of feedback and appraisal of evidence, as highlighted by the recent guidelines published by the College. 2 In their discussion, the authors debated the lack of significant increase in prophylaxis prescribing, and a seemingly scant uptake of a promoted guideline on PONV prophylaxis, despite their use of a multifaceted reduction strategy.

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