1 / 25

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.

chanel
Download Presentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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.

More Related