Postdischarge Nausea and Vomiting Risk Assessment in Breast and Gynecologic Surgical Patients

Postdischarge nausea, vomiting, and retching often occur after the time of discharge from the postanesthesia care unit (PACU) in patients who have undergone outpatient surgeries. At a large mid-Atlantic Academic Hospital, 40% of gynecologic outpatient surgical patients had postdischarge nausea and vomiting (PDNV). The purpose of this quality improvement project was to implement and evaluate the effectiveness of and staff compliance with the Apfel Postdischarge Nausea and Vomiting Risk Assessment tool to improve PDNV risk screening in the PACU. This quality improvement project was part of an evidence-based practice project. After identification and recruitment of key stakeholders and unit champions, a force-field analysis, as part of Lewin's change theory, was completed to identify the driving and restraining forces. All PACU registered nurses received education on the risk assessment protocol using the Apfel risk assessment tool. The Apfel risk assessment tool has been validated to identify five independent risk factors for PDNV in outpatient ambulatory surgical populations. Implementation of the tool with data collection occurred for 8 weeks on all scheduled outpatient breast and gynecologic surgical patients. Staff compliance was measured throughout implementation. In patients with at least three risk factors present, the Apfel tool correctly identified the risk for PDNV in 68% of patients. In patients with four and five risk factors present, the tool correctly identified the risk for PDNV in 88% and 100% of patients, respectively. Compliance with the tool was high with an average compliance rate of 92% for the 8-week data collection period. Data analysis demonstrated that the Apfel risk assessment tool adequately predicted the risk for PDNV in outpatient surgical breast and gynecologic patients. Use of Lewin's change theory was successful in maintaining a high compliance rate throughout implementation. In addition, this quality improvement project resulted in increased compliance of the standing follow-up phone call policy. Efforts toward sustainment include expansion to all outpatient surgical populations and implementation of a PDNV prevention and management guideline.