CLINICAL CLIPS
PONV/PDNV: Implementing the ASPAN
Clinical Guideline
Ellen E. Sullivan, BSN, RN, CPAN
ASPANS Evidence-Based Clinical Practice
Guideline for the Prevention and/or Manage-
ment of PONV/PDNV is published and ready for
implementation.1 In March 2006, a multidisci-
plinary group with representation from the
American Society of Anesthesiologists (ASA),
the American Association of Nurse Anesthetists
(AANA), ASPAN, and pharmacists convened to
critique and rate the current evidence, develop
recommendations for practice, and improve
outcomes for patients related to the manage-
ment of PONV/PDNV.
ASPAN, ASA, and AANA will promote and dis-
seminate these guidelines throughout their re-
spected professions; however, endorsement
from professional societies is not the final step
in moving the guidelines to clinical implemen-
tation. The ultimate responsibility falls on indi-
vidual clinicians as they take an active role in
the implementation of the guidelines within
their respective settings. How difficult will this
be? It often takes years after research results are
reported before nurses become aware of re-
search findings, recognize the impact the find-
ings have on clinical practice, and actually in-
corporate research findings into practice.2
Perianesthesia nurses now have the opportu-
nity to take a leadership role in the implemen-
tation of evidence-based practice guidelines.
Are you up for the challenge?
Identification of Stakeholders
A multidisciplinary guideline requires a multidis-
ciplinary implementation approach, but how
are the appropriate individuals from various
disciplines identified? A good place to start is to
Journal of PeriAnesthesia Nursing, Vol 21, No 6 (December), 2006: pp 439-442
identify the primary stakeholders in the manage-
ment of PONV/PDNV. Although this seems like
a logical, relatively straightforward plan, it may
not be as easy as it appears. Using my own
institution, a large teaching hospital, as an ex-
ample, many stakeholders can be identified, but
even then, departmental representation or a key
individual in leadership will probably be over-
looked. Following the path that a perioperative
patient travels through our institution provides
a quick overview of possible stakeholders. The
patient begins the perioperative journey with
the admission process, which in our institution
is the Center for Preoperative Evaluation. Poten-
tial stakeholders in this department include the
Medical Director, nurse practitioners, and as-
sessment nurses. The patient is admitted the
day of surgery to the preoperative unit, then
moves into the intraoperative area. Preoperative
nurses, anesthesiologists, nurse anesthetists, an-
esthesia residents, and operating room (OR)
nurses are now added to the list of possible
stakeholders. Postoperatively, the patient may
be managed as an inpatient in the PACU Phase
I or as an outpatient in the Day Surgery Unit, a
combined Phase I and Phase II, so stakeholders
from these areas need to be identified. In addi-
tion, surgical residents and attending surgeons
Ellen E. Sullivan, BSN, RN, CPA, is a Nurse-in-Charge,
PACU, Brigham & Womens Hospital, Boston, MA.
Address correspondence to Ellen E. Sullivan, BSN, RN,
CPAN, Postanesthesia Care Unit, Brigham & Womens Hos-
pital, 75 Francis Street, Boston, MA 02061; e-mail address:
eesullivan@partners.org.
2006 by American Society of PeriAnesthesia Nurses.
1089-9472/06/2106-0009$32.00/0
doi:10.1016/j.jopan.2006.09.006
439
440
who write postoperative orders and discharge
instructions, as well as the staff on the nursing
units who manage inpatients during Phase II,
need to be considered as interested parties.
It is important to include support depart-
ments such as the pharmacy and information
systems department in the search for stakehold-
ers. The pharmacy department makes decisions
regarding the drugs included on formulary and
is knowledgeable of the related pharmacologic
expenses, an important factor because a great
percent of PONV/PDNV management is phar-
maceutical. Representation from the informa-
tion systems department can contribute to the
development of a template for computerized
order entry and tracking. Finally, the most im-
portant stakeholders to be identified are the
patient and their family or significant other.
At this point, there is a long list of individuals
from various disciplines who may be key stake-
holders that need to be involved in the imple-
mentation of the PONV/PDNV guidelines. If
you use this process to identify potential stake-
holders in your institution, a similar list will
probably be generated and questions will arise.
Do all of these individuals need to be actively
involved in the planning and implementation of
the guidelines or should they merely be in-
formed of the process? What individuals need to
be approached initially to start planning for the
implementation of the PONV/PDNV guidelines?
Strategic Starting Points
Presentation of the guidelines to the key leaders
in the anesthesia department is a strategic start-
ing point because these individuals are key pa-
tient managers throughout the perioperative
period. This can be accomplished by one-on-
one conversations with anesthesia practitioners
and/or presentations to related committees. Is
there an Anesthesia Clinical Practice Committee
at your institution? This is an ideal setting to
initiate the discussion of ASPANs PONV/PDNV
clinical practice guidelines and the potential
impact on delivering cost-effective, quality pa-
ELLEN E. SULLIVAN
tient care. Is this committee multidisciplinary? If
not, this may be the ideal time for it to become
integrated with other disciplines, facilitating on-
going communication that will ultimately im-
prove patient care outcomes. As mentioned
earlier, pharmaceuticals are a key component of
management of PONV/PDNV and are closely
linked to the economic impact of the guideline
implementation. The availability of pharmaco-
logical agents and the associated costs makes
the Pharmacy Director or appointed represen-
tative a key stakeholder. Each health care insti-
tution should have a Pharmacy and Therapeu-
tics Committee, or some related committee,
with representation from pharmacy, physicians,
and nursing. The purpose of this committee is
to select drugs that the hospital will make avail-
able to patients, establish guidelines for medica-
tion administration, ultimately improving pa-
tient care. This forum is another strategic
starting point for the planning and implementa-
tion of the guideline.
Impact on Clinical Service Areas
During the planning phase, before the actual
implementation of the PONV/PDNV guideline,
it is important to consider the impact the guide-
line recommendations will have on patient care
and on the health care system and providers.
For example, health care institutions can
choose to use one of the simplified risk factor
identification tools suggested in ASPANs
PONV/PDNV guidelines. These tools are sup-
ported by the evidence to be predictive of the
incidence of PONV and improve decision mak-
ing regarding appropriate prophylactic treat-
ment measures for that patient.1 But how does
the completion of a PONV/PDNV risk assess-
ment scoring tool affect the preadmission test-
ing and preoperative holding areas? Most fac-
tors on the risk assessment tools are already
included in the current preoperative assess-
ment, so the addition of one or, possibly, two
factors should not impact the time it takes the
nurses or nurse practitioners to complete the
assessment. The risk assessment tool can also be
assessed via a phone screen or face-to-face on
ASPAN CLINICAL GUIDELINE FOR PONV/PDNV
the day of surgery. Risk assessment tools gener-
ate a point scale that then correlates the num-
ber of risk factors to the level of risk: low,
moderate, severe, and very severe, which will
then assist the anesthesia provider in determin-
ing the most beneficial prophylactic treatment.1
Communication of the risk assessment finding
is important; therefore, a procedure may need
to be developed to make the findings readily
available to all members of the anesthesia/surgi-
cal team in a clear, concise manner.
The PONV/PDNV clinical guideline makes the
recommendation to encourage healthy patients
undergoing elective procedures to drink clear
fluids as little as 2 hours before surgery.1 This
recommendation is based on evidence that ad-
equate hydration is a therapeutic intervention
in the prevention of PONV/PDNV.1 How easy
will it be to translate this recommendation into
actual practice? Consider that the ASPAN guide-
line recommendation reflects a recommenda-
tion included in ASAs evidence-based fasting
guidelines that were developed several years
ago.3 Are the ASA practice guidelines followed
or are many surgical patients still instructed to
take nothing by mouth (NPO) after midnight?
Are there ways to implement the recommended
NPO guidelines more effectively within our in-
stitutions? What are the barriers and how can
these barriers be overcome to improve patient
care?
The use of the complementary intervention, P6
acupoint stimulation, is included as a guideline
recommendation.1 The ASPAN PONV/PDNV
guideline suggests that the perianesthesia
nurse consider including information regarding
the use of over-the-counter acupressure and
acustimulation devices during preoperative ed-
ucation of high-risk patients or patients express-
ing concern over having PONV/PDNV. These
devices are available in drugstores at minimal
cost. They are considered easy-to-use and have
minimal, if any, side effects. Communication to
the anesthesia provider and the OR staff is es-
sential if the patient plans to use acupoint stim-
441
ulation as a component of PONV/PDNV man-
agement. Perioperative health care providers
need to recognize that the patient may plan to
wear the bands throughout the perioperative
period. A policy or procedure may need to be
developed to insure that the devices can safely
remain in the correct position over the P6 pres-
sure point throughout the perioperative period,
unless contraindicated. Acupoint stimulation
devices may be applied in preparation for the
ride home from an ambulatory setting.
In the postoperative setting, it will be important
for the nurse to be aware of the risk assessment
findings identified preoperatively and the pro-
phylactic interventions, if any, that have been
provided. The PONV/PDNV guideline recom-
mends postoperative assessments to include
verification of adequate hydration and blood
pressure, and specifics regarding postoperative
nausea.1 Assessment of postoperative nausea,
using a verbal descriptor scale, a 0 to 10 scale,
or a visual analog scale, is recommended on
admission and discharge to the PACU and more
frequently as indicated (ie, high-risk patient,
after administration of an opioid or antiemetic).
If a prophylactic agent was used and rescue treat-
ment is necessary, it is important to use an agent
that affects a different receptor site than the pro-
phylactic agent. Aromatherapy can also be consid-
ered for management of postoperative nausea.1
Implementation of postoperative orders by
nurses in the PACU can be challenging. PACU
nurses are often responsible for the implemen-
tation of postoperative orders from a variety of
health care providers, ie, the general postoper-
ative orders that will ultimately move with the
patient to the general surgical floor, the pre-
printed standing orders from the Anesthesia
Department for as-needed PONV management,
and any additional orders written by other pro-
viders. A multidisciplinary Pharmacy and Ther-
apeutics Committee should be helpful in de-
signing a plan or template that meets the
requirements of the various disciplines and fa-
cilitates communication effectively across the
442 ELLEN E. SULLIVAN

continuum as patients move from the OR to the
PACU Phase I or Phase II, or on to the surgical
floors.
It is important to consider PDNV in the ambu-
latory settings. Once the patients risk for PDNV
is determined nurses can institute a plan to
appropriately lower the risk by following the
Management of PDNV algorithm in the
PONV/PDNV guideline. Management of PDNV
should be included in all outpatient discharge
References
1. American Society of PeriAnesthesia Nurses. Evidence-
based clinical practice guideline for the prevention and/or
management of PONV/PDNV. J Perianesth Nurs. 2006;21:
230-250.
2. Melnyk BM, Fincout-Overholt E. Advancing knowledge
through collaboration Leadership. 2006;32(2):3p.
education, and outpatient follow-up assess-
ments need to include routine assessment of
PDNV.1
Perianesthesia nurses have an opportunity to
truly make a difference in patient care by ad-
dressing an issue that has an enormous impact
on patient comfort and satisfaction. Lets join
forces with other disciplines within our institu-
tions and see what we can accomplish by work-
ing together in the implementation of clinical
practice guidelines.
3. American Society of Anesthesiologists. Practice guide-
lines for preoperative fasting and the use of pharmacologic
agents to reduce the risk of pulmonary aspiration: Application
to healthy patients undergoing elective procedures. Available
at: http://www.asahq.org/publicationsAndServices/NPO.pdf.
Accessed September 4, 2006.

ERRATUM
In the article, The ASPNs EBP Conceptual Model: Framework for Perianesthesia
Practice and Research, by Myrna Eileen Mamaril MS, RN, CPAN, CAPA; Jacqueline M.
Ross MSN, RN, CPAN; Dina Krenzischek MAS, RN, CPAN; Denise OBrien MSN, APRN,
CPAN, CAPA, FAAN, CS-C, Linda Wilson PhD, RN, CPAN, CAPA, B-C, Martha Clark MSN,
RN, CPAN; Terry Clifford MSN, RN, CPAN, and Vallire Hooper MSN, RN, CPAN
(Journal of PeriAnesthesia Nursing 21:157-167, 2006) there is a correction. The title
was listed incorrectly. The correct title is ASPANs EBP Conceptual Model: Framework
for Perianesthesia Practice and Research.