Background

Our bariatric surgery team identified length of stay (LOS) as higher than national average. A root-cause analysis identified postoperative nausea and vomiting (PONV) as a cause for prolonged LOS, occurrence of PONV was high (25%). Surgeons, anesthesiologists, and certified registered nurse anesthetists provided variable practice in the management of PONV. Variability in care increases risk for morbidity and can be prevented through use of care bundles or guidelines.

Methods

A multidisciplinary team developed an evidence-based care bundle to reduce PONV and LOS. A pilot of the care bundle was performed from December 1, 2016 to March 3, 2017. A retrospective chart review identified comparable patients pre-PONV bundle (N=35). Data from 30 female patients, who underwent laparoscopic sleeve gastrectomy or roux-en-y gastric bypass and received the bundle were analyzed. Excluded were open or revisional cases, those with opioid tolerance, chronic kidney disease, congestive heart failure with ejection fraction 30% or less, and allergies or physiologic contraindication to medications used. The PONV care bundle focused on all phases of care from the preoperative phase to discharge. The PONV Impact Scale, numeric rating scale assessing nausea, and LOS, were used to evaluate effectiveness of the bundle. Other data collected were patient demographics (APFEL score, body mass index, gender, and age), use of postoperative upper gastrointestinal series (UGI), length of surgery, start time of surgery, vasopressor use, and percentage of compliance to the PONV care bundle. Descriptive data was analyzed. Pre-/post-implementation data was compared using independent samples t-test to evaluate the effectiveness of the PONV care bundle.

Results

There was a statistically significant reduction in mean LOS between the pre and post implementation groups (p=0.001). Pre-intervention LOS was 2.4 days compared to post-intervention of 1.63 days. The rate of PONV after bundle implementation decreased to 13%. After implementation, 12.5% of patients had clinically significant PONV and 87.5% had PONV that was not clinically significant on postoperative day one. Nurse compliance in documentation of nausea was 50%. Provider compliance of the bundle was 57%. No association found between use of aprepitant or whether an UGI was done and nausea on postoperative day one.

Conclusions

An antiemetic care bundle was developed from a root-cause analysis of extended LOS for bariatric surgery patients. The antiemetic care bundle in the post implementation group of patients studied had decreased LOS, contributed to reduced PONV, and may reduce provider variability in management of PONV.