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Corey R. Peterson DNP, CRNA, Lisa Stephens, DNP, CRNA,

Impact of ASPAN’s Evidence-based Clinical Practice Guideline for the Prevention and/or Treatment of PONV/PDNV. Corey R. Peterson DNP, CRNA, Lisa Stephens, DNP, CRNA, Marguerite Murphy, DNP, RN, Vallire Hooper, PhD, RN, CPAN, FAAN, Jan Odom- Forren , PhD, RN, CPAN, FAAN.

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Corey R. Peterson DNP, CRNA, Lisa Stephens, DNP, CRNA,

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  1. Impact of ASPAN’s Evidence-based Clinical Practice Guideline for the Prevention and/or Treatment of PONV/PDNV Corey R. Peterson DNP, CRNA, Lisa Stephens, DNP, CRNA, Marguerite Murphy, DNP, RN, Vallire Hooper, PhD, RN, CPAN, FAAN, Jan Odom-Forren, PhD, RN, CPAN, FAAN

  2. Postoperative & Postdischarge Nausea and Vomiting (PONV/PDNV) • 53 million ambulatory surgeries annually National Health Statistics Report (2009) • 30% - 50% incidence of PDNV (16 – 26.5 million incidents) Apfel et al., (2004) • Threats associated with PONV/PDNV − Pt dissatisfaction − Increased pain − MI − Wound dehiscence − Aspiration −Delayed discharge − Delayed return to function -Increased costs − Noncompliance w/discharge instruction Apfel et al., (2002)

  3. Postoperative & Postdischarge Nausea and Vomiting (PONV/PDNV) • Is a common anesthesia complication Apfel et al., (1999) • Is the most feared anesthesia complication by patients Awad (2006) • Is a complex physiologic phenomena Hornby, (2001) • Is largely preventable and treatable Habib et al, (2004)

  4. PONV/PDNV • PONV – first 24 hrs post – op • PDNV – after discharge • Predictable risk factors exist for PONV/PDNV Apfel et al.(2002) • Efficacious pharmacological interventions exist for PONV/PDNV Gan et al., (2007); Odom-Forren et al., (2006)

  5. Evidenced-Based Clinical Practice Guidelines (EBCPG) • In 2006 the American Society of PeriAnesthesia Nurses (ASPAN) published EBCPG for the prevention and/or treatment of PONV/PDNV ASPAN (2006) • ASPAN guidelines base the number of interventions given on a patient’s risk of PONV/PDNV • ASPAN guidelines are • Evidenced-based • Patient focused • Multidisciplinary • Cost conscience

  6. Problem Statement • PONV/PDNV is an ongoing complication • Efficacious interventions exist to prevent and/or manage PONV/PDNV • High quality EBCPG exist to guide anesthesia providers in the prevention and/or management of PONV/PDNV • No information exists regarding the level of adoption of these EBCPG by anesthesia providers

  7. From The Literature • EBCPG are effective and efficacious tools to improve healthcare delivery • Implementation of EBCPG is a complex process • PONV/PDNV is a common, significant complication of general anesthesia • High quality EBCPG exist to prevent and treat PONV/PDNV

  8. Areas Of Inquiry • What is the degree of adoption of the recommendations of the ASPAN PONV/PDNV guidelines • Is there a relationship between the appropriate application of the ASPAN guidelines and the incidence of PDNV • Is there a relationship between the incidence of PONV and the incidence of PDNV • Is there a cost savings associated with the use of the ASPAN guidelines

  9. Methodology • Secondary data analysis (N=94) • Primary Study • Primary Aim – to determine independent predictors of PDNV • Study Design • Multi-site prospective survey • No prescribed treatment regimen • Targeted sample size ~2000

  10. Demographic Information

  11. Surgical Information

  12. PONV/PDNV Risk Distribution

  13. Interventions Recommended vs. Administered Pearson’s product-moment correlation (r) = 0.21, N = 94, p= 0.004

  14. PONV & PDNV Incidence

  15. Discussion • Poor degree of adoption of the guidelines • 68% NOT treated according to the guidelines • 32% treated according to guidelines • Majority of patients received a single intervention • Higher risk tended to be undertreated • Lower risk tended to be overtreated • Pearson product-moment correlation • r=0.21 N=94 p=.004

  16. Discussion • Poor guideline adoption is consistent with recent research • McMenamin et al.(2010). • Chamie et al. (2011). • Shirvani et al. (2011). • Bhattacharyya et al. (2010). • Kooij et al. (2010). • Franck et al. (2010). • White et al (2008).

  17. Discussion • Poor adoption of the ASPAN guidelines made it impossible to determine the efficacy of the guidelines • Trends • Patients with higher risks received more interventions • Patients who received more interventions had a lower incidence of PONV & PDNV

  18. Discussion • Incidence of PDNV was over 60% • Incidence of PDNV was 2 – 3 times the incidence of PONV • No additional interventions for PDNV • Short duration of action of antiemetics • Longer reporting period for PDNV

  19. Discussion • Institutional antiemetic costs Ondansetron $0.32 Metaclopromide $0.29 Diphenhydramine $0.60 Promethazine $0.46 Dexamethazone $0.83 Compazine $1.89 Scopolamine Patch $10.14 (A. Barnett, personal communications, September 5, 2011) • Institutional cost of antiemetic drug are insignificant in relation to other health care cost

  20. Practice Implications • Given • Poor adoption of even simple, well supported EBCPG • The more antiemetics given the lower the incidence of PONV/PDNV • Current first-line antiemetics have excellent safety profiles and negligible costs • Is it time to revise the ASPAN guidelines to recommend every patient receives the maximum number of antiemetics regardless of their risk?

  21. References • Bhattacharyya, P., Paul, R., Nag, S., Bardhan, S., Saha, I., Ghosh, M., . . . AcharyyaGhosh, D. (2010). Treatment of asthma: Identification of the practice behavior and the deviation from the guideline recommendations. Lung India, 27(3), 141-144. doi: 10.4103/0970-2113.68315 • Chamie, K., Saigal, C. S., Lai, J., Hanley, J. M., Setodji, C. M., Konety, B. R., & Litwin, M. S. (2011). Compliance with guidelines for patients with bladder cancer: Variation in the Delivery of Care. Cancer. doi: 10.1002/cncr.26198 • Fineout-Overholt, E. (2008). Synthesizing the evidence: how far can your confidence meter take you? AACN Adv Crit Care, 19(3), 335-339. • Franck, M., Radtke, F. M., Baumeyer, A., Kranke, P., Wernecke, K. D., & Spies, C. D. (2010). [Adherence to treatment guidelines for postoperative nausea and vomiting. How well does knowledge transfer result in improved clinical care?]. Anaesthesist, 59(6), 524-528. doi: 10.1007/s00101-010-1712-z • Frenzel, J. C., Kee, S. S., Ensor, J. E., Riedel, B. J., & Ruiz, J. R. (2010). Ongoing provision of individual clinician performance data improves practice behavior. AnesthAnalg, 111(2), 515-519. doi: ANE.0b013e3181dd5899 [pii]

  22. References • Gan, T. J., Meyer, T. A., Apfel, C. C., Chung, F., Davis, P. J., Habib, A. S., . . . Watcha, M. (2007). Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. AnesthAnalg, 105(6), 1615-1620. • Ginn, M. B., Cox, G., & Heath, J. (2008). Evidence-based approach to an inpatient tobacco cessation protocol. AACN Adv Crit Care, 19(3), 268-278; quiz 279-280. • Glickman, S. W., Baggett, K. A., Krubert, C. G., Peterson, E. D., & Schulman, K. A. (2007). Promoting quality: the health-care organization from a management perspective. Int J Qual Health Care, 19(6), 341-348. • Grimshaw, J., Eccles, M., & Tetroe, J. (2004). Implementing clinical guidelines: current evidence and future implications. J ContinEduc Health Prof, 24 Suppl 1, S31-37. • Guyatt, G. H., Naylor, D., Richardson, W. S., Green, L., Haynes, R. B., Wilson, M. C., . . . Jaeschke, R. Z. (2000). What is the best evidence for making clinical decisions? JAMA, 284(24), 3127-3128. • Habib, A. S., White, W. D., Eubanks, S., Pappas, T. N., & Gan, T. J. (2004). A randomized comparison of a multimodal management strategy versus combination antiemetics for the prevention of postoperative nausea and vomiting. AnesthAnalg, 99(1), 77-81.

  23. References • Hornby, P. J. (2001). Central neurocircuitry associated with emesis. Am J Med, 111 Suppl 8A, 106S-112S. • Instutute of Medicine. (2008). Knowing what works in health care: A roadmap for the nation. Retrieved from http://iom.edu/Reports/2008/Knowing-What-Works-in-Health-Care-A-Roadmap-for-the-Nation.aspx. • Joy-Joseph, L., Colin, J. M., Rosenstein, C. R., & Chinye-Onyejuruwa, F. (2010). An evidence-based approach for managing catheter-associated bloodstream infection in a level II neonatal intensive care unit. J Nurs Care Qual, 25(2), 100-104. • Johnston, L., & Fineout-Overholt, E. (2006). Teaching EBP: the critical step of critically appraising the literature. Worldviews Evid Based Nurs, 3(1), 44-46. • Jones, K. R. (2010). Rating the level, quality, and strength of the research evidence. J Nurs Care Qual, 25(4), 304-312. • Kooij, F. O., Klok, T., Hollmann, M. W., & Kal, J. E. (2010). Automated reminders increase adherence to guidelines for administration of prophylaxis for postoperative nausea and vomiting. Eur J Anaesthesiol, 27(2), 187-191. doi: 10.1097/EJA.0b013e32832d6a76

  24. References • McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., & Kerr, E. A. (2003). The quality of health care delivered to adults in the United States. N Engl J Med, 348(26), 2635-2645. • McMenamin, S. B., Bellows, N. M., Halpin, H. A., Rittenhouse, D. R., Casalino, L. P., & Shortell, S. M. (2010). Adoption of policies to treat tobacco dependence in U.S. medical groups. Am J Prev Med, 39(5), 449-456. doi: S0749-3797(10)00432-0 [pii] • Odom-Forren, J., Fetzer, S. J., & Moser, D. K. (2006). Evidence-based interventions for post discharge nausea and vomiting: a review of the literature. J PerianesthNurs, 21(6), 411-430. • Prior, M., Guerin, M., & Grimmer-Somers, K. (2008). The effectiveness of clinical guideline implementation strategies--a synthesis of systematic review findings. J EvalClinPract, 14(5), 888-897. • Rosenbrand, K., Van Croonenborg, J., & Wittenberg, J. (2008). Guideline development. Stud Health Technol Inform, 139, 3-21. • Shirvani, S. M., Pan, I. W., Buchholz, T. A., Shih, Y. C., Hoffman, K. E., Giordano, S. H., & Smith, B. D. (2011). Impact of evidence-based clinical guidelines on the adoption of postmastectomy radiation in older women. Cancer. doi: 10.1002/cncr.26081

  25. References • Shortell, S. M., Rundall, T. G., & Hsu, J. (2007). Improving patient care by linking evidence-based medicine and evidence-based management. JAMA, 298(6), 673-676. • Titler, M. (2007). Translating research into practice. Am J Nurs, 107(6 Suppl), 26-33; quiz 33. • White, P. F., O'Hara, J. F., Roberson, C. R., Wender, R. H., & Candiotti, K. A. (2008).The impact of current antiemetic practices on patient outcomes: a prospective study on high-risk patients. AnesthAnalg, 107(2), 452-458. doi: 107/2/452 [pii] • Wu, C. L., Berenholtz, S. M., Pronovost, P. J., & Fleisher, L. A. (2002). Systematic review and analysis of postdischarge symptoms after outpatient surgery. Anesthesiology, 96(4), 994-1003.

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