ASC Durango (Colo.) recently underwent its first AAAHC survey and achieved accreditation. One of the areas the ASC was praised by surveyors for was its quality assessment and performance improvement studies. One such study looked at the surgery center's PACU times and the ASC discovered it had some patients staying longer than four hours.
ASC Durango identified one of the causes of the extended stays was a lack of a post-operative/post-discharge nausea and vomiting policy. The ASC developed such a policy and when it restudied the extended stays, they had decreased significantly because of the PONV standardization, says Ms. Desko.
Below is a sample version of ASC Durango's adult post-operative nausea and vomiting policy discharge you can adapt for use in your own surgery center.
Sample Adult Post-Operative/Post-Discharge Nausea and Vomiting (PONV/PDNV) Policy
Prepared by:_____________________ Authorized by:____________________________
This policy will explain the procedure for assessing the degree of risk for PONV in adult patients (>15yrs) preoperatively. It addresses the perioperative drug therapy these patients may receive depending on their risk level and explains the documentation required. The intent of this policy is to meet the Society for Ambulatory Anesthesia (SAMBA) Guidelines for the Management of PONV with the goal of optimizing patient outcomes and value for PONV.
Guideline 1: Identify Patients' Risk for PONV
Guideline 2: Reduce Baseline Risk Factors for PONV
Guideline 3: Administer PONV Prophylaxis Using One to Two Interventions in Adults at Moderate Risk for PONV
Guideline 4: Administer Prophylactic Therapy with Combination (>2) Interventions/Multimodal Therapy in Patients at High Risk for PONV
Guideline 5: Administer Prophylactic Antiemetic Therapy to Children at Increased Risk for PONV; as in Adults, Use of Combination Therapy Is Most Effective). Currently follow anesthesiologist's individual orders for pediatric patients.
Guideline 6: Provide Antiemetic Treatment to Patients with PONV Who Did Not Receive Prophylaxis or in Whom Prophylaxis Failed
1. Identification and Assessment of Patients' Risk for PONV
- Screening for preoperative assessment of PONV risk (a section of the Pre-operative Record) is completed by the nursing staff at the time of the preadmission phone call or upon admission on the day of surgery.
- Risk factors will be assessed and checked as they apply
- History of Motion Sickness OR History of PONV
- Expected post operative opioid use
- Patient risk and risk tolerance will be stratified by the anesthesiologist depending on the number of risk factors present and relative tolerance for risk of PONV.
- Low risk (<10%): 0 factors
- Moderate risk (10-40%): 1-2 factors
- High risk (>40%): 3-4 factors
(This is a lower risk tolerance than defined in the SAMBA Guidelines)
2. Reduction of Baseline Risk Factors and Prophylaxis for PONV
- Anesthesiologist will determine methods to reduce baseline risk (see flow chart below)
- PONV prophylaxis will be managed by the anesthesiologist and recorded on the Anesthesia Record.
3. Rescue Antiemetic Treatment For Post-op Patients with PONV
- If "PONV Protocol" is checked, signed and dated by the anesthesiologist in the Pre & Post-anesthesia orders follow the PONV Rescue Protocol for management. If these orders are signed, the RN may write an MD order for the next dose "per protocol".
- Documentation of the medications given will be recorded on the PACU/Phase II Recovery record.
4. Antiemetic Doses (adult) and Timing of Drugs Available at ASC Durango:
- Dexamethasone 4-8mg IV at induction
- Ondansetron 4mg IV before the end of surgery
- Promethazine 2.5-6.25 mg IV at induction (must be diluted to 2.5mg/ml and injected only in a free-flowing IV)
- Droperidol 0.625mg IV (2hrs of ECG monitoring required after administration)
- Scopolamine patch 1.5 mg on admission
- Dimenhydrinate (Dramamine) 12.5-25 mg or 1mg/kg IV timing not well defined (alternative treatment to promethazine in PONV Rescue Protocol)
- Diphenhydramine (Benadryl) 12.5-25 mg IV q6h prn (use if patient has an allergy to dimenhydrinate)
Source: ASC Durango (Colo). Adapted and reprinted with permission.