Protocol addresses nausea and vomiting
Protocol addresses nausea and vomiting
Hydration, drug protocol produce results
Reduction or elimination of postoperative nausea and vomiting (PONV) not only makes your patients happier with their surgical experience but it also reduces the length of time patients stay in your postanesthesia care unit (PACU). Less time in the PACU means more beds and more staff available to handle more cases.
The staff at the day-surgery program at Lehigh Valley Hospital in Allentown, PA, knows the value of getting patients into surgery and out of the PACU on time.
"We have 24 beds in the PACU, and we routinely handle between 30 and 50 cases each day," says Anne L. Brown RN, CPAN, staff nurse in the Lehigh Valley ambulatory surgery center PACU. "If we have patients that stay extra time as a result of PONV, we are not able to start other surgeries on time because we have to wait on a bed for recovery."
Changes in the preadmission instructions to patients and the antiemetic protocol used for same-day surgery patients have resulted in a PONV rate of 5.7%, compared to rates reported in scientific literature between 20% and 30%.1
Brown and Roberta M. Hower, a patient care specialist for ambulatory surgical services at Lehigh Valley, decided to examine how to identify and treat patients at risk for PONV before surgery.
"We developed a tool to collect information on all patients who experienced PONV over a six-month period," explains Hower.
Nurses in the PACU would complete the form with information such as type of surgery, length of time in the operating room, type of anesthesia, previous history of PONV, other medical conditions, nothing-by-mouth (NPO) status upon arrival for surgery, and type of treatment for PONV. "The forms took less than a minute to complete," adds Hower.
Data from those forms was compiled by nurses working on the study, then analyzed to see which patients were most likely to develop PONV, explains Brown.
The study identified patients who were undergoing plastic surgery, orthopedic surgery, laparoscopic gynecological procedures, and general surgery as high risk for PONV, says Hower. "We also learned that being female, having a history of motion sickness or previous PONV, and being obese increased a patient’s risk of PONV."
A new look at NPO status
An interesting fact related to a patient’s NPO status was also discovered in the study. "We originally wanted to see if the patient who developed PONV followed NPO instructions, but what we discovered was that our instructions to be NPO for eight hours prior to surgery actually increased the incidence of PONV," says Hower.
The 3,885 patients in the study were separated into three NPO categories that were NPO for greater than eight hours, NPO between four and eight hours, and NPO for less than four hours. Sixty-five percent of the patients who were NPO for greater than eight hours experienced PONV as compared to 18% for patients who were NPO for 4-8 hours and 14% for patients who were NPO for less than four hours, says Hower.
Because of this information, same-day surgery patients are told they can drink 8-16 oz. of clear liquids up to two hours before surgery, says Brown. "We do have patients who have had previous surgeries that question this instruction, so our nurses have to reassure them that it is not only OK, but is actually better for them."
Another change in the preadmission process is an orange clip placed on the charts of patients who have one or more of the risk factors for PONV. "The clip alerts the nurses and anesthesiologists that this patient is at risk for PONV and the appropriate antiemetic protocol should be followed," explains Brown.
A patient at risk for PONV will be given 1 mg of droperidol prior to surgery and a combination of droperidol, Zofran, and dexamethasone in the operating room, says Hower.
While it is important to review the cost of drugs used, Hower points out the need to continually review costs in relation to their effectiveness." We had used Anzemet [Aventis Pharmaceuticals, Parsippany, NJ] over Zofran [Glaxo Wellcome, Research Triangle Park, NC] in many cases since the cost of Anzemet is $15 to $20 per dose, and Zofran’s costs range from $32 to $45 per dose," says Hower. "When we evaluated effectiveness, we found we often had to give two doses of Anzemet compared to one of Zofran."
Doubling the cost makes Zofran’s cost comparable, and being able to make the patient comfortable after only one dose increases patient satisfaction, she adds.
The hospital staff also justified costs by looking at extended time in the postanesthesia care unit, says Brown. "If a patient has to stay extra time to control PONV, you are looking at extra nursing time and a bed that can’t be used by another patient, which in a small day-surgery setting might result in delays in surgery start times."
Reference
1. Watcha MS, White PS. Post-operative nausea and vomiting: Etiology, treatment and prevention. Anesthesia 1992; 77:162-184.
For more information about the postoperative nausea and vomiting study, contact:
• Roberta M. Hower, RN MSN CCRN, Patient Care Specialist for Ambulatory Surgery Services, Lehigh Valley Hospital, 17th Chew St., Allentown, PA 18104. Telephone: (610) 402-3430. E-mail: [email protected].
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