Quality Improvement: Do we really live by the guidelines? A look into PONV prophylaxis at UCH. June 6, 2016 Erin Zurflu, Laura Coats, Cara Crouch Faculty Advisors: Marina Shindell and Ben Scott

Understanding the problem WHAT WHY WHO WHEN HOW SEVERE WHAT - Overuse of antiemetics in the operating room and lack of compliance with current guidelines and recommendations. WHY - The medications we administer are not benign. Side effects, although rare for some of our commonly use medications are possible. Lack of regard for current guidlines/recommendations. Concern for quality metrics instead of thinking about our patients on a case to case basis. WHO – Anesthesia Providers, Patients, Post-operative care providers, Hospital System WHEN – This is not a new problem, and likely has been something that has been going on for some time. We often do things because "that is what we do" instead of considering patients on a case to case basis. *** Has anything changed since implementation of the PONV button in the pre-op?? HOW BAD IS THIS PROBLEM - This problem is not a severe issue, but something that should be considered. As physicians we should be asking ourselves why we do things and taking each patient into consideration (along with current guidelines and recommendations).

How did this problem develop? Incentives and Weekly Compliance Emails, “…everyone gets 2 antiemetics…” Habit Institutional Culture… It is just what we do. And then, we tried to change the culture by changing the incentives and assessing our patients’ risk for PONV. But, did anything change? But did it help?

Yesterday and Today Prior to implementation of the scoring system, majority of providers were scoring 100% on their compliance for PONV prophylaxis because they were giving 2 antiemetics. Today, most providers are scoring 100% on their compliance for PONV because they are clicking a box in their pre-op… … and they are still giving 2 antiemetics.

abi The truth of the matter is that without knowledge of what is right and wrong, no one is going to change a practice that has assumedly “worked” for so long. Medicine is filled with Consensus and Practice Guidelines that are established following review of literature by experts in the field. Everywhere we look there are guidelines being published or suggested to aid in our practice of anesthesiology. It came to my attention that many of the recommendations published are not well known or practiced by providers and therefore we decided to look into this further.

Data from uch Survey

Approximately 86% of our very low and low risk patients are receiving antiemetics. Almost 60% of those are receiving 2 or more antiemetics. Data from April 2016. Random Sampling of the great than 1800 anesthetics from

Methods for Change SMART Aim Statement: By December 2016, all anesthesia providers will be in compliance with ASA consensus guidelines for prophylaxis and treatment of PONV in all patients at UCH following implementation of new educational opportunities and improved access to resources. Projected intervention over the next 3 to 6 months. We would propose the following changes over that time: - Education - Changes in Quality Metrics/Incentive Measures Who would implement these things?

“… it would be nice if new guidelines were provided for us “… it would be nice if new guidelines were provided for us. Then I would change my practice…” - UCH Anesthesia Provider Education Implementation of a Brief “Consensus Guidelines” talk at the beginning or end of every Grand Rounds Lecture. Presented by any anesthesia provider. Addition of a consensus guideline statement in the already existing risk assessment score. Addition of a quick link from Epic to a list of consensus guidelines from the ASA, as well as other recently published guidelines.

Changes in Incentive/compliance measures People are motivated by this, however simply clicking a box is not improving patient care.

WHY Does it Matter? These drugs are not without side effects. They are not without cost. Zofran Dexamethasone Scopolamine Propofol (50ml) Hospital Cost vs Cost to Patient vs price billed to insurance Zofran – 0.28 Dex 10mg – 1.54 Scop Patch – 19.77 Prop 50 – 5.33 “When providing a patient more than 5 drugs, you are bound to have a drug-drug interaction.”

Measuring Change After instituting changes in Education and Quality Metrics/Incentives, I would propose a repeat EPIC search be performed to evaluate for change. Implementation of more complete PACU documentation of PONV to evaluate for increased occurrence of PONV with adherence to consensus guidelines.

Significance AND… It doesn’t have to stop with PONV. IMPROVED PATIENT CARE Decreased risk for side effects, drug interactions, and complications following anesthesia. Decreased cost to the medical system and improved margins for the hospital. AND… It doesn’t have to stop with PONV. And, maybe most importantly, it does not have to stop with PONV. The education on guidelines would expand into many other aspects of anesthesia and improve our care as a whole.

Conclusions Despite implementation of a pre-operative PONV assessment, consensus guidelines for PONV prophylaxis are not consistently being followed here at UCH. Guidelines are not well known/understood by providers. With the implementation of better education and easier access to resources, as well as restructuring of quality metrics and incentives to reward sound clinical decisions, care could be improved.

Thank you!! Special Thank You to the following individuals: Sean Clifford and Ken Bullard Marina Shindell and Ben Scott Melany Donnelly and Alison Brainard

Refernces Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg.2014; 118: 85–113. Kappen T, Moons K, et al. Impact of Risk Assessments on Prophylactic Antiemetic Prescription and the Incidence of Postoperative Nausea and Vomiting: A Cluster-randomized Trial. Anesthesiology 02 2014, Vol.120, 343-354. Tramer M, Reynolds J, Moore A, McQuay H. Efficacy, Dose-Response, and Safety of Ondansetron in Prevention of Postoperative Nausea and Vomiting : A Quantitative Systematic Review of Randomized Placebo-controlled Trials. Anesthesiology 12 1997, Vol.87, 1277-1289. Madan R., Bhatia A., Chakithandy S., et al. Prophylactic dexamethasone for postoperative nausea and vomiting in pediatric strabismus surgery: a dose ranging and safety evaluation study. Anesthesia and Analgesia. 2005;100(6):1622–1626. Henzi I, Walder B, Tramer MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg.2000; 90: 186–194. Bartlett R, Hartle AJ. Routine use of dexamethasone for postoperative nausea and vomiting: the case against. Anaesthesia 2013, 68, 889–898.