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A5052
AN EVIDENCE-BASED PRACTICE PROTOCOL TO REDUCE NAUSEA IN THE BARIATRIC SURGERY PATIENT

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PURPOSE & AIMS
•Improve postoperative experience of female bariatric surgery patients through reducing post-operative nausea & vomiting (PONV), â length of stay (LOS), and â variability among providers.
•Identify, implement & evaluate an evidence-based PONV care bundle in the female patient undergoing laparoscopic sleeve gastrectomy or roux-en-y gastric bypass.
•Educate nurses to objectively assess & document nausea using the nausea  numeric rating scale in the electronic health record and assess compliance to documentation of the rating scale after PONV bundle implementation.
•Document the Simplified PONV Impact Scale
•Compare pre-PONV bundle implementation LOS to post-PONV implementation LOS.
BACKGROUND
Bariatric Surgery LOS at our center was 2.2 days, higher than the 1.6 day national average. A root-cause analysis found occurrence of PONV:
•High (25%) causing á LOS.
•Inconsistent treatment for preventing PONV among surgeons, anesthesiologists, and certified nurse anesthetists.
•Is an issue that reduces patient satisfaction.
•Is associated with á morbidity and LOS.
•Use of care bundles has improved patient outcomes and â LOS.
DESIGN
•Quality improvement project
•Pilot test of the PONV bundle – implementation December 1, 2016 to March 3, 2017
•Pre & post implementation evaluation
•N=30 in each group (pre/post implementation)
Inclusion Criteria:
•Medical records of female patients between age 18-75
•Underwent elective laparoscopic sleeve gastrectomy or roux-en-y gastric bypass
Exclusion Criteria:
•Medical records of patients who underwent open or revisional surgery
•Medical records of males
•Opioid dependent patients
•Allergies or other physiologic contraindication to medications used in bundle
Measurement Tools:
•PONV Impact Scale (clinical significance vs no clinical significance)
•Nausea Numeric Rating Score (0=none, 1=mild, 2-3=moderate, 4-5=severe)
RESULTS
•Statistically significant reduction in mean LOS between the pre and post implementation groups (p = 0.001).
•Pre-intervention mean LOS was 2.40 days compared to post-intervention mean of 1.63 days.
•Rate of PONV after bundle implementation decreased to 13%.                                          
• 12.5% of patients had clinically significant PONV on postoperative day one.
• 87.5% had PONV that was not clinically significant on postoperative day one.
• Nurse compliance in documentation of nausea was 50%.
•No association found between use of aprepitant or whether a UGI was done & nausea on postoperative day one.
•Provider compliance of the bundle was 57%.
CONCLUSION
•Enhanced recovery after surgery pathways, care bundles, & consensus guidelines to prevent PONV; provide standardized evidence-based care, â postoperative adverse events, and á patient satisfaction.
•This perioperative antiemetic care bundle mirrors the same focus on improved patient care while maintaining safety through evidence-based standardized care.
•A root-cause analysis of extended LOS for bariatric surgery patients initiated this quality improvement project and identified the problem of PONV.
•This antiemetic care bundle in the post-implementation group of patients studied â LOS, contributed to â PONV, and may â provider variability in management of PONV.
REFERENCES
ASMBS/American Society of Metabolic and Bariatric Surgery. (2010). Retrieved from

Gan, T., Diemunsch, P., Habib, A., Kovac, A., Kranke, P., Meyer, T., Watcha, M., Chung, F.,Angus, S., Apfel, C., Davis, P., Hooper, V., Lagoo-Deenadayalan, S., Myles, Nezat, G.,Philip, B., & Tramer, M. (2014). Consensus guidelines for the management ofpostoperative nausea and vomiting. Anesthesia & Angalesia, 118(1), p. 85-113

Lois, A., Frelich, M., Sahr, N., Hohman, S., Wang, T., & Gould, J. (2015). The relationship between duration of stay and readmission in patients undergoing bariatric surgery. Surgery, 158(2), 501-507

Sinha, A., Singh, P., Williams, N., Ochroch, E., & Goudra, B. (2014). Aprepitant’s prophylactic efficacy in decreasing postoperative nausea and vomiting in morbidly obese patients undergoing bariatric surgery. Obesity Surgery, 24,225-231

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