Managing post-op nausea means faster discharge
Managing post-op nausea means faster discharge
Prophylactic medication, pre-op education helps
Postoperative nausea and vomiting due to anesthesia not only cause patient discomfort, but those symptoms are responsible for delays in discharge. Through changes in medication, preoperative education, and patient care procedures, same-day surgery managers and anesthesiologists report that they have reduced nausea and vomiting -- and saved staff costs.
One popular method has been the use of ondansetron, which inhibits seratonin. Ondansetron does not cause side effects, such as drowsiness, that are associated with other antiemetics, anesthesiologists say. Ondansetron is about seven times more expensive than other antiemetics, however, which has caused same-day surgery managers and anesthesiologists to evaluate their particular problem of postoperative nausea and vomiting.
The incidence of emesis related to a certain procedure can vary widely from institution to institution, says Mehernoor F. Watcha, MD, associate professor of anesthesiology at the University of Texas Southwestern Medical Center in Dallas. Routine use of prophylactic antiemetics is not recommended for all procedures, Watcha says.
"You should consider your own [facility's] incidence of emesis [and] the impact on patient time spent in the recovery room and make your own analysis of whether this drug will reduce cost to the hospital, cost to the patient, and overall societal costs," such as delays returning to work or other activities, he says.
Nausea and vomiting drop from 37% to 7%
Driscoll Children's Hospital in Corpus Christi, TX, measured the level of nausea and vomiting associated with tonsillectomies in 1989 and found that 37% of patients experienced that problem. When Driscoll day surgery began to use ondansetron two years later, the rate of nausea and vomiting dropped dramatically -- to just 7%.
"[Controlling nausea and vomiting] is not only important for the comfort of the patient, but it helps them later on" with a better postoperative recovery, says Bette Nelson, RN, CPN, day surgery nurse manager.
Nelson also changed some policies that she thinks have made a difference. Instead of drinking clear liquids postoperatively, tonsillectomy patients first suck on ice chips.
"It helps with the swelling, and it gets the liquids down that they need," Nelson says.
91% receive pre-op education
She also placed a greater emphasis on preoperative education. Now, 91% of patients and parents talk to a nurse preoperatively, compared to 50.6% in 1989. Parents are encouraged to bring their children in for a pre-op visit, but if they are unable to do that, they receive a pre-op phone call.
All patients are admitted at least an hour before surgery, and they receive preoperative teaching from a nurse as well as a visit from a child life specialist, who is trained in child development, Nelson says.
"The child life specialist tells them, 'You'll feel like your throat is going to hurt if you drink, but the opposite is true,'" Nelson says. "Knowing what to expect and cutting down on the anxiety helps the child afterward [with a better recovery]."
Still, Nelson credits ondansetron with most of the improvement in postoperative nausea and vomiting. The drug is given intraoperatively as a prophylactic.
"As the use of ondansetron goes up, the vomiting goes down," Nelson says. "The drug is a bit expensive, so sometimes you have to prove that there is an offset to that [cost]."
In fact, cost is a major factor in the use of ondansetron, Watcha says.
Watcha analyzed the costs of treating nausea and vomiting in the post-anesthesia care unit (PACU) versus using prophylactic medication and concluded that ondansetron would be cost-effective if 33% of patients experienced vomiting while still in the hospital or surgery center.1
Other, less-expensive agents may provide alternatives to ondansetron in preventing emesis, Watcha says. For example, perphenazine has been shown to be as effective as ondansetron without side effects.2 "Perphenazine is an old drug, but I think it needs to be re-examined in the outpatient setting," Watcha says.
Consider differences in patients
Watcha notes that such decisions about cost-effectiveness should take into account the differences in patient populations. For example, women of childbearing age undergoing laparoscopic gynecologic surgery have a higher rate of postoperative nausea and vomiting than other ambulatory surgery groups.
"Choose your patients with care," Watcha advises. "Use prophylactic antiemetics with patients who are at high risk for emesis."
To date, studies on prophylactic antiemetic drugs have not included information about patient return to work or patient preferences, Watcha notes. "These [issues] may justify the use of the more expensive drug," he says. "But until such time as we have such data, I would suggest that you use the less expensive drugs that have similar efficacy and side effect profile."
Watcha also stresses that the issue of cost-effectiveness varies by institution. By reducing nausea and vomiting, some hospitals or surgery centers may see significant impact on the PACU turnover.
At Driscoll Children's Hospital, ondansetron made a substantial difference in the time patients spent in recovery. In 1989, tonsillectomy patients stayed in the PACU for an average of four and one-half hours before discharge.
"In 1993, the use of ondansetron went way down because of the expense," Nelson says. PACU stay increased to five hours. In 1995, when ondansetron was used, that stay had dropped to three and one-half hours.
Patients take control of treatment
The recent availability of an oral form of ondansetron gave Peninsula Surgery Center in Salisbury, MD, a way to maintain patient comfort postoperatively while limiting costs. The surgeons give patients a prescription for PO Zofran and advise them to fill it before their surgery, says administrative director Joe Walters, PA-C.
The patients take one pill the night before, one the morning of surgery, and one more if necessary after surgery, Walters says. The surgery center was paying $19 a vial for ondansetron, which added to overall case costs, he says. The center receives global fees and was not directly reimbursed for the medication, he says.
Now the patient has a choice about taking the antiemetic, which would be reimbursed through that pharmaceutical portion of the patient's insurance plan, Walters says. Beyond cost, it is a matter of patient control and information, he says.
"We try to get the patient involved as much as we can," he says. "In outpatient surgery, for the patients to be successful and do well, they've got to be motivated and involved."
The oral form of ondansetron seems to be just as effective as the IV version, Walters says. Peninsula Surgery Center is conducting a study to compare patients given the oral and IV forms, he says.
Preoperative medication works wonders
Other methods and medications have been used to successfully prevent postoperative nausea and vomiting. At Tallahassee (FL) Outpatient Surgery Center, the preoperative use of Zantac and the intraoperative use of droperidol and Raglan still left a major PACU problem. Discharges were delayed by one-half hour or more among general anesthesia patients because they couldn't tolerate liquids, says Judi Cleckner, RN, director of nursing.
"There were some days when we probably had 75% of the patients who had problems with nausea," Cleckner says.
By giving Phenergan preoperatively and propofol as an induction agent, Tallahassee Outpatient Surgery Center virtually eliminated nausea and vomiting, Cleckner says.
"Our patients are doing so well, now they could even leave before their hour in post-op," she says.
"Nobody was getting sick. It was amazing," says Melba Faurot, CRNA, nurse anesthetist. "It's like we finally found the answer."
Center studies less costly anesthetic
As a cost-containment measure, the Tallahassee Outpatient Surgery Center recently began a study comparing the less expensive anesthetic sodium pentothal to propofol. Initial results indicated that nausea and vomiting increased with pentothal, despite the continued use of Phenergan. The center has used ondansetron to treat nausea and vomiting, but doesn't use it prophylactically because of the cost.
Successful prevention of nausea and vomiting leads to direct cost savings because of the shorter recovery times, says Cleckner.
The Tallahassee center uses supplemental staff nurses on an as-needed basis.
"If surgeries get done sooner and patients are out the door, those nurses leave," she says.
The patients are also happier. "We've had people come in here who have never had an anesthetic without being sick," says Faurot. "They'll come to us and say I've never felt this good after surgery.'"
References
1. Watcha MF, and Smith I. Cost-effectiveness analysis of antiemetic therapy for ambulatory surgery. J Clin Anesth 1994; 6:370-377.
2. Desilva PHDP, Darvish AH, et al. The efficacy of prophylactic ondansetron, droperidol, perphenazine, and metroclopramide in the prevention of nausea and vomiting after major gynecological surgery. Anesth & Anal 1995; 81:139-143. *
For more information about controlling postoperative nausea and vomiting, contact:
* Bette Nelson, Day Surgery Nurse Manager, Driscoll Children's Hospital, 3533 S. Alameda, P.O. Drawer 6530, Corpus Christi, TX 78466-6530. Telephone: (512) 850-5329. Fax: (512) 878-4042.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.