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You are here: Home → Events → ANZCA Annual Scientific Meetings → 2007 ASM → Successful Reduction Of PONV In Paediatric Inpatients Through Multi-phased Evidence Based Intervention And Audit
 

Successful Reduction Of PONV In Paediatric Inpatients Through Multi-phased Evidence Based Intervention And Audit

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Greta M. Palmer, Royal Children’s Hospital, Melbourne

Purpose of Study

PONV is a common complication, not well described in general paediatric inpatient populations. Multiple interventions to reduce postoperative vomiting (POV) have been suggested, but not well evaluated in this sub-population. This study’s purpose was to reduce PONV in moderate-high risk inpatients. A series of interventions and audits are described (over 4 years) in a paediatric institution.

Method

Setting: Large tertiary children’s hospital where annually 18000 children have surgery and 2350 require postoperative analgesic infusions (PAI).

The first audit established baseline and subsequent yearly audits followed each intervention. The interventions were determined by previous audit results and current published evidence base.

Intervention 1 involved antiemetic prophylaxis guidelines revision and design of rescue prescription chart for 2 antiemetics with nurse and anaesthetist education.
Intervention 2 involved reinforcement of prophylaxis guidelines and prescription chart revision for 5 antiemetics.
Intervention 3 involved changing prophylaxis from cheaper dexamethasone/ metoclopramide to dexamethasone/anti5HT3 combination.

Result

  • Audit 1 identified age risk categories [POV incidence: age 2-5y 30%, 5-11y+ 60-66%)] and found high POV incidence and frequency with a high percentage of only single agent prophylaxis use and rescue prescription (i.e. not evidence based practice).
  • Audit 2 found reduced POV and improved prophylaxis administration and rescue prescription.
  • Audit 3 found further POV reduction and further improvement in administration and prescription practice. (Audit 3 also audited PONV in other inpatients, confirming PAI patients as high risk).
  • Audit 4 had similar results to audit 3 and excellent administration and prescription practice

Table: Audited prophylaxis administration, rescue prescription and PONV rates

 

Audit 1
2003

Audit 2
2004

Audit 3
2005

Audit 4
2006

Audit 4 vs Audit 1
 Reduction
% (95% CI

p value

 

 

PAI only

N=282

 

PAI only

N=285

 

PAI

N=195

 

Non-PAI

N=365

PAI only

Aged >2 y
Interim:
N= 176

Prophylaxis
Administration

65%

78%

82%

47%

100%

 

Prophylaxis
Administration
to age >2y
(2-5y–11y+)

47-80%

73-86%

71-90%

50-65%

100%

 

Prophylactic antiemetics
per guideline

Dex and Met 37%
(baseline)

Dexand
Met 53%

Dex and Met 66%

Dex and Met 62%

Dex and
anti-5HT3 100%

 

Rescue prescription
Of >2 antiemetics

42%

86%

85%

51%

100%

 

POV incidence

56%

39%

33%

6%

30%

26 (17-35)
p=0.00

POV frequency of
3 or more vomits

27%

17%

12%

4%

15%

12 (4-19)
p=0.03

PON incidence

40%

40%

30%

7%

31%

12 (3-21)
p=0.01

PONV incidence

64%

51%

44%

15%

49%

15 (6-24)
p=0.01

Conclusion

Through audit, we identified at-risk groups (older children requiring PAI) and sub-optimal antiemetic administration and prescription practice. Audits demonstrated a steady reduction in POV (from 56-30%) with the development of guidelines, user-friendly prescription charts and education. This study demonstrates that multi-phased interventions can lead to a sustained change in anaesthetic department practice.

Time of Presentation
0830

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