1. POSTOPERATIVE/POST DISCHARGE NAUSEA & VOMITING IN A MULTISPECIALTY AMBULATORY SURGERY CENTER JUDY LONG MSN, RN, CCRN, CNRN, CPAN, CAPA

2. OBJECTIVES Learner will be able to list risk factors for PONV/PDNV in patients having procedures requiring anesthesia. Learner will be able to discuss study design, data points, and collection strategies Learner will be able to identify outcomes identified through analysis of data Learner will be able to list lessons learned from process

3. DISCLOSURES I have no conflict of interest disclosures.

4. DEFINITIONS PONV N&V that occurs within the first 24 hours following surgery Early: 2-6 hours after surgery ( in PACU) Late: 6-24 hour period Delayed: Occurs beyond 24 hours in inpatient setting PDNV N&V that occurs after discharge Occurs beyond the initial 24 hours after D/C

5. DEFINITIONS CONT. Prophylaxis Treatment Multispecialty ASC Single Specialty ASC

6. INCIDENCE 71 million surgical procedures performed in US annually 31 million of these procedures are ambulatory 20 – 30% of patients having surgery will experience PONV (14,000,000 - 21,000,000) May be as high as 70% in high risk patients

7. WHY DO WE CARE? Adverse effects of PONV range from patient discomfort to post-operative morbidity Increased cost Patients fear nausea & vomiting more than post-op pain

8. ADULT PONV RISK FACTORS Female Non-smoker <50 years old History of PONV or motion sickness General vs regional anesthesia Use of volatile anesthetics and nitrous Duration of anesthesia Postoperative opioids Type of surgery PATIENT FACTORSSURGERY FACTORS

9. PEDIATRIC PONV RISK FACTORS Surgery >/= 30 minutes Age >/= 3 History of PONV or history of PONV in relative Strabismus surgery

10. CONSENSUS GUIDELINE Published January, 2014 by Tong, et al Review and revision of previous guidelines published in 2003 & 2007 Comprehensive review of hundreds of published articles on PONV since 2007 Includes risk factors, prevention strategies, covers both adult & pediatric patients

11. HISTORY OF STUDY Joint effort between management and staff of Glasgow Ambulatory Surgery Center and Anesthesia Services PA Goals: Identify rate of PONV/PDNV in patients having anesthesia at Glasgow Ambulatory Surgery Center Identify practice patterns related to PONV prevention Improve patient experience and quality of patient care provided

12. STUDY DESIGN Identify risk factors for PONV/PDNV Identify prophylaxis patterns Identify incidence of PONV/PDNV Share information with staff

13. DATA COLLECTION PROCESS Risk factors documented in Pre-anesthesia Evaluation Anesthesia providers document care provided on anesthesia record Data collected via chart review Post-op incidence documented on data collection tool by PACU RN(s) Post discharge incidence documented on data collection tool by RN as reported by patient during post-discharge phone call

14. PROCESS CONT. Case and patient information downloaded from anesthesia billing system Data collection tool collected and entered by ASPA staff into Excel Data from tool combined with chart review data Analysis completed Reports generated and provided to Glasgow Ambulatory Surgery Center staff monthly

15. INITIAL DATA POINTS Demographics Age Gender Case information Providers Case type Case length Anesthesia information Anesthesia Prophylaxis Patient factors Risk factors Incidence

16. EVOLVED DATA POINTS History of gastric diversion Clear liquids

17. FINDINGS Case mix Study compliance PONV/PDNV incidence PONV 3% Prophylaxis patterns Impact of clear liquid initiation on PONV

18. CASE BY SURGERY SITE Endoscopy1730 Ortho429 ENT165 Podiatry153 Intra-abdominal138 Soft Tissue / Biopsy86 Major Plastic Surgery80 Eyes72 Pelvic55 Rectal19 Cardiology5

19. CASE BY ANESTHESIA TYPE MAC2124 General with LMA217 General with ETT176 MAC with Regional151 General124 General with LMA with Regional83 General with Regional27 General with Mask13 MAC with Bier Block5 MAC with LMA4 MAC with Regional with LMA4 General with ETT with Regional2 General with Regional with Mask2

20. ANESTHESIA TYPE BY SURGERY SITE (ENDOSCOPY REMOVED ALL ARE MAC CASES)

21. PATIENTS W/NAUSEA IN PACU 2990 total patients No2816 Yes96 Not Documented78

22. PACU VOMITING 96 total patients with nausea in PACU *There were no patients that had vomiting that did not have nausea No2900 Not Documented78 Yes12

23. PATIENTS WITH NAUSEA IN PACU BY SURGERY SITE

24. LESSONS LEARNED Collaboration Multidisciplinary Flexibility Triple Aim Data is the future!

25. QUESTIONS?