1. 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. Postoperative & Postdischarge Nausea and Vomiting (PONV/PDNV)
53 million ambulatory surgeries annually National Health Statistics Report (2009)
30% - 50% incidence of PDNV (16 – 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)

3. Postoperative & Postdischarge Nausea and Vomiting (PONV/PDNV)
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)

4. PONV/PDNV 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)

5. Evidenced-Based Clinical Practice Guidelines (EBCPG)
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

6. Problem Statement 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

7. From The Literature
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

8. Areas Of Inquiry
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

9. Methodology 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

10. Demographic Information
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

11. Surgical Information 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

12. PONV/PDNV Risk Distribution
Risk Factor
Incidence (N/%)
Female Gender
66/70.2
Non-smoker
76/80.9
Hx PONV or MS
47/50
Post-op Opioids
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

13. Interventions Recommended vs. Administered
Level of Risk
Drugs Recommended
Drugs Administered (Mean ± SD)
Low
1.07 ± 0.64
Moderate 1
1.30 ± 0.93
Severe 2
1.56 ± 0.82
Very Severe
3 +
1.58 ± 0.76
Pearson’s product-moment correlation (r) = 0.21, N = 94, p = 0.004

14. PONV & PDNV Incidence 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

15. Discussion 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

16. Discussion 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).

17. Discussion
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

18. Discussion 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

19. Discussion Institutional antiemetic costs
Ondansetron $ Metaclopromide $0.29
Diphenhydramine $ Promethazine $0.46
Dexamethazone $ 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

20. Practice Implications
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?

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