Who is at risk for postdischarge nausea and vomiting after ambulatory surgery?

BACKGROUND: About one in four patients suffers from postoperative nausea and vomiting. Fortunately, risk scores have been developed to better manage this outcome in hospitalized patients, but there is currently no risk score for postdischarge nausea and vomiting (PDNV) in ambulatory surgical patients. METHODS: We conducted a prospective multicenter study of 2,170 adults undergoing general anesthesia at ambulatory surgery centers in the United States from 2007 to 2008. PDNV was assessed from discharge until the end of the second postoperative day. Logistic regression analysis was applied to a development dataset and the area under the receiver operating characteristic curve was calculated in a validation dataset. RESULTS: The overall incidence of PDNV was 37%. Logistic regression analysis of the development dataset (n=1,913) identified five independent predictors (odds ratio; 95% CI): female gender (1.54; 1.22 to 1.94), age less than 50 yr (2.17; 1.75 to 2.69), history of nausea and/or vomiting after previous anesthesia (1.50; 1.19 to 1.88), opioid administration in the postanesthesia care unit (1.93; 1.53 to 2.43), and nausea in the postanesthesia care unit (3.14; 2.44-4.04). In the validation dataset (n=257), zero, one, two, three, four, and five of these factors were associated with a PDNV incidence of 7%, 20%, 28%, 53%, 60%, and 89%, respectively, and an area under the receiver operating characteristic curve of 0.72 (0.69 to 0.73). CONCLUSIONS: PDNV affects a substantial number of patients after ambulatory surgery. We developed and validated a simplified risk score to identify patients who would benefit from long-acting prophylactic antiemetics at discharge from the ambulatory care center.

Evidence-based case management practice-part II: meta-analysis: a primer for case managers.

OBJECTIVES: This article aims to (1) describe the steps in the development of a meta-analysis, (2) discuss the use of meta-analysis in developing an evidence base for case management practice, and (3) provide some basic guidelines for evaluating the meta-analysis. PRIMARY PRACTICE SETTINGS: Evidence-based practice (EBP) is a mandate for all healthcare professionals, regardless of setting. Although many institutions lack library resources, systematic reviews and meta-analyses are available from multiple sites on the Internet. FINDINGS/CONCLUSIONS: EBP is an essential element for professionals in the provision of safe, quality patient care. However, most healthcare professionals, including case managers, have little time to complete the extensive literature reviews and analyses required for evidence-based practice. Literature reviews completed by professional teams provide a solution for caregivers in their efforts to base practice on the best evidence. This article describes the quantitative literature review, meta-analysis, including definitions of terms, a description of the process, sources of meta-analyses, and basic guidelines for determining the quality of the review and applicability of the results to practice. IMPLICATIONS FOR CASE MANAGEMENT: Meta-analyses can provide access to the latest evidence for case managers with little time but great need for the most effective approaches to managing care. Meta-analyses provide a statistical analysis of multiple studies pooled to provide the most definitive interpretation of the data. Correctly analyzed and interpreted, meta-analyses can provide a sound basis for management of patient transitions from hospital to home and community. Meta-analyses describing the impact of various treatments allow the case manager to better prepare the patient and family for the healthcare issues the patient may face in recovering from a diagnosis and/or treatment.

Evidenced-based case management practice, part 1: the systematic review.

OBJECTIVES: This article aims to (1) describe the steps in the development of a systematic review, (2) discuss the use of systematic reviews in developing an evidence base for case management practice, and (3) present listings of agencies that provide systematic reviews on clinical topics and resources to evaluate systematic reviews for application to practice. PRIMARY PRACTICE SETTINGS: Evidence-based practice is mandated for all healthcare professionals regardless of setting. For nonacademic settings, a lack of library resources may make this mandate difficult to accomplish. Systematic reviews are available through agency Web sites and, therefore, are accessible to anyone with Internet access. FINDINGS/CONCLUSIONS: Evidence-based practice supports professionalism, patient safety, and quality care. However, most case managers, have heavy workloads and limited time to complete literature reviews adequate to provide a basis for clinical decision making. For that reason, systematic reviews are developed and published by a variety of professional groups, including clinicians, academics, researchers, and library systems. This article focuses on the systematic review and includes definitions, a comparison of types of reviews, the process for completing systematic reviews, sources of systematic reviews, and tools used to critique them. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Systematic reviews can be helpful tools to allow busy case managers to provide the safest and most effective care to their patients. They can support the development of guidelines specific to case management such as transitioning care to other institutions or to the patient's home, management of the patient in the community, and prevention of recidivism or unplanned return to an acute care setting.

Perianesthesia nursing advocacy: an influential voice for patient safety.

Perianesthesia nurses are called to advocate for their patients, promote a safe work environment, and contribute to the continued advancement of the nursing profession. Nurses must demonstrate vigilance in their nursing care to protect patients from harm. It is an ethical and legal responsibility to request physicians to review with patients their informed consents when they report they do not understand or have questions about the surgical procedure. Likewise, nurses need to alert managers and administrators when they experience unsafe work environments, such as actual or potential nurse staffing issues, unsafe nurse-to-patient ratios, medication errors, and nurse fatigue. This article focuses on the valuable role perianesthesia nurses play in patient advocacy by: (1) speaking out on behalf of the patient, (2) assuring a safe work environment, (3) assessing for nurse fatigue, and (4) advocating patient safety for the global nursing profession.

Development and initial testing of the perianesthesia safe practices instrument: an ASPAN pilot study.

The perianesthesia environment of care is a unique high-risk health care setting that has a high susceptibility to error because of the vulnerability of patients who are undergoing surgery and anesthesia as well as the high levels of activity in these units. Safe practice in this environment is essential to quality patient care and positive patient outcomes. Consequently, ASPAN conducted a descriptive cross-sectional pilot study to test initial reliability and validity of the Perianesthesia Safe Practices Survey Instrument. The instrument was designed to assess specific safe practices in perianesthesia areas by identifying the following: (1) what are the current perianesthesia safety practices, (2) what are the recommended safety practices that are not in place, and (3) what are the differences in safety practices within areas along the perianesthesia continuum of care. Thirty-six respondents found the instrument to be clear, easy to complete, and containing appropriate content. The alpha coefficients for internal consistency for the unit specific components were preadmission testing (.79), pre-op (.94), Phase I PACU recovery (.92), and Phase II PACU recovery (.90). The results of this pilot study provided information about areas of excellence and areas for improvement for safe clinical practice in the specialty setting, as well as initial reliability and validity for the safe practices questionnaire.

Patient safety: perianesthesia nursing's essential role in safe practice.

A safety culture that promotes best practices and best outcomes is important in today's healthcare environment. The perianesthesia environment of care is constantly challenged with the introduction of new technologies, improved medications, and advances in surgical and nonsurgical procedures. This practice is also marked by fast turnover, increasing volume, and, often, high-acuity patients. The integration of principles of safety and evidence-based principles is a core value of perianesthesia practice. The American Society of PeriAnesthesia Nurses (ASPAN) is committed to providing the foundation to support a culture of perianesthesia safety. This article will discuss the development of the ASPAN Safety Model by the ASPAN Safety Committee.