Will Apfel score awareness among caregivers improve postoperative nausea and vomiting (PONV) incidence and management in Day Surgery?

Background: Evidence supports Apfel Simplified Risk Score (SRS) as being effective in predicting postoperative nausea and vomiting (PONV) in patients following general anesthesia. Raising awareness of a person’s risk for PONV allows for prescription of antiemetics based on the Apfel SRS. Clinical Practice Guidelines (CPGs) for the management of PONV highlight first identifying patients’ risk to better manage anesthesia side effects. A team of nurses working in a tertiary hospital in Texas led a project using the Apfel SRS to improve PONV management. Purpose: To raise awareness of patients\u27 PONV risk perioperatively to improve patient outcomes of PONV events, prophylactic PONV medication administration, and PONV antiemetic use. Methods: A quality improvement project was completed March 9th through June 7th 2021 in a day surgery unit led by a frontline nurse and six additional bedside nurses. A form previously developed by the project lead in 2019 was used to communicate someone’s Apfel SRS by placing it on the front of patient charts. Nurses scored patients for PONV using Apfel scores. The sample included patients who received general anesthesia and who were discharged the same day. Excluded were any patients admitted to the hospital for further care. Data collected included the Apfel 4-point Likert scale score with 0-4 (0 = no PONV risk, 1 = low PONV risk, 2 = moderate PONV risk and 3-4 = high PONV risk) for each participant. Also included was a list of medications received before, during, and after surgery including anesthesia, pain medication, and antiemetics. Data also collected through chart review for each person included a record of PONV experienced after surgery. Follow-up phone calls were made by nursing staff to capture the presence of PONV 24 hours post-discharge. Data were analyzed using descriptive statistics. Results were also compared pre (2019) and post-project (2021) implementation. Results: PONV incidence decreased 8% from 2019 (N = 474) to 2021 (N = 419). PONV prophylaxis use increased between 2019 and 2021 for Zofran (18%), Dexamethasone (7%), Haldol (9%), and Versed (5%). Apprepitant was sparingly used (0.5%) in 2021. After implementing the new process, Zofran was readministered to patients versus the selection of another antiemetic class to control PONV twice. Antiemetic use was also measured. Phenergan was administered to 43% of patients who developed PONV. Phenergan administration was high compared to other antiemetic medications used to treat PONV in postoperative patients in this sample (Haldol 1% and Amisulpride 5%). In 2021, 71% of patients with PONV were given a PONV prophylactic medication. Conclusion: There was a notable decrease in PONV after implementation of the Apfel score being placed on the front of patient charts. Increase PONV risk awareness through use of Apfel SRS led to an increase in PONV prophylaxis administration. Implications: Based on our project results, use of Apfel scores may guide nurses and doctors towards earlier and more effective PONV management. Further assessment of Apfel score use and raised awareness impact on prescriptive practices and PONV control are needed to support our findings