corey r. peterson dnp, crna, lisa stephens, dnp, crna, marguerite murphy, dnp, rn, vallire hooper,...
TRANSCRIPT
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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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)
Postoperative & Postdischarge Nausea and Vomiting (PONV/PDNV)
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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)
Postoperative & Postdischarge Nausea and Vomiting (PONV/PDNV)
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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)
PONV/PDNV
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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
Evidenced-Based Clinical Practice Guidelines (EBCPG)
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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
Problem Statement
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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
From The Literature
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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
Areas Of Inquiry
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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
Methodology
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Age (Mean ± SD) 43 years ± 12.9 years
Race (N, %) African American 29/30.9
Caucasian 55/58.5
Latino 1/1.1
Other 9/9.6
ASA Physical Status (N,%)
I 20/21.3
II 58/61.7
III 16/17.0
Demographic Information
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Type Of Surgery (N,%) General 13/13.8
ENT 23/24.5
Gynecological 12/12.8
Orthopedic 33/35.1
Urologic 4/4.3
Other 9/9.6
Duration (hrs.) (Mean ± SD)
1.7 ± 0.8
Surgical Information
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PONV/PDNV Risk DistributionRisk Factor Incidence
(N/%)
Female Gender 66/70.2
Non-smoker 76/80.9
Hx PONV or MS 47/50
Post-op Opioids 66/70.2
Total Risk Factors Per Subject
Number of Subjects (N/%)
0 (Low Risk) 2/2.1
1 (Low Risk) 11/11.7
2 (Moderate Risk) 23/24.5
3 (Severe Risk) 34/36.2
4 (Very Severe Risk)
24/25.5
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Level of Risk Drugs Recommended
Drugs Administered (Mean ± SD)
Low 0 1.07 ± 0.64
Moderate 1 1.30 ± 0.93
Severe 2 1.56 ± 0.82
Very Severe 3 + 1.58 ± 0.76
Interventions Recommended vs. Administered
Pearson’s product-moment correlation (r) = 0.21, N = 94, p = 0.004
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Treatment Group (N=94)
Cases (N/%) Incidence of PONV (N/%)
Incidence of PDNV (N/%)
Undertreatment 41/44 13/32 30/73
Followed Guidelines
30/32 6/20 18/60
Overtreatment 23/24 2/9 10/43
Overall Incidence
21/22.3 58/61.7
PONV & PDNV Incidence
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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
Discussion
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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).
Discussion
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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
Discussion
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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
Discussion
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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
Discussion
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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?
Practice Implications
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Bhattacharyya, P., Paul, R., Nag, S., Bardhan, S., Saha, I., Ghosh, M., . . . Acharyya Ghosh, 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. Anesth Analg, 111(2), 515-519. doi: ANE.0b013e3181dd5899 [pii]
References
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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. Anesth Analg, 105(6), 1615-1620.
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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 Contin Educ Health Prof, 24 Suppl 1, S31-37.
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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. Anesth Analg, 99(1), 77-81.
References
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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
References
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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]
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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
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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. Anesth Analg, 107(2), 452-458. doi: 107/2/452 [pii]
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