1. Postoperative nausea and vomiting: Quality
improvement using the implementation of guidelines
and a post anesthesia care unit order set
Rachel Meyer, MD, FRCPC
Clinical Associate
Department of Anesthesia
St. Michael’s Hospital
Toronto, Ontario

2. Postoperative Nausea and Vomiting
A Quality Improvement Initiative
Problem:
Postoperative nausea and vomiting (PONV) occurs in 30% of all surgical patients. The
incidence of this complication increases to 80% in certain patient populations. PONV has
significant consequences including patient dissatisfaction/distress, prolonged recovery
room stay, unanticipated hospital admissions, increased cost and serious complications
such as wound dehiscence and aspiration.
The literature on PONV and provider practice at our center has been reviewed. There are
scoring systems for identifying patients at high risk of PONV and several guidelines for the
most effective management strategies for this complication. Although there is extensive
research on risk factors, prevention and treatment for PONV, at our site the
implementation of the evidence from these trials into clinical practice is not seen. Despite
the presence of relevant literature we do not have guidelines for the intraoperative and
postoperative management of PONV at our center.

3. Context:
This study will be begin on October 22, 2012 in the operating rooms and recovery
room at St. Michael’s Hospital in Toronto. The aim is decrease the incidence of PONV
in all surgical patients by improving provider practice in the prevention and
management of this complication.
Intervention:
A new recovery room order set for the management of PONV has been developed. As
well, new hospital guidelines for PONV were created. The order set and guidelines
were developed by a team of anesthesiologists, pharmacists and nurses. All operating
room and recovery room nurses have been educated on this project. Staff
anesthesiologists and anesthesia residents have been educated as well. The order
sets will be incorporated into the perioperative surgical packages and will be available
in the charts for all surgical patients. There will also be order sets available in the
recovery room. The guidelines will be available on the hospital intranet and in the
anesthesia office and recovery room.

4. Measurement:
Once the PONV order set and guidelines have been implemented, the rate of provider
use of the order set and the incidence of PONV will be plotted on a statistical process
control chart (p chart). Data will be collected from the anesthetic records and recovery
room nursing notes from orthopedic and gynecologic surgery patients. The mean rate
of use of the order sets and the mean incidence of PONV will be calculated every
week (for each patient population). Our efforts to change provider practice will be
reassessed and adjusted based on the rate of use of the order set and the change in
the incidence in PONV that is achieved. Physicians and nurses will be asked to provide
feedback on the order set and the appropriate adjustments will be made to improve
the utility of the order set.
Contribution to Quality Improvement:
Although there is extensive research on risk factors, prevention and treatment for
PONV, at our site the implementation of the evidence from these trials into clinical
practice is not seen. The purpose of this initiative is to improve patient care by
decreasing the incidence of PONV and therefore decreasing the consequences of this
complication. The development of PONV guidelines and a PONV order set will permit
the application of evidence into clinical practice and improve patient outcomes.