The information gained from questionnaire I revealed a knowledge deficit. Of the participants, 94.4% (n=17) were not familiar with the Simplified Apfel score. This score identifies people at increased risk of developing postoperative nausea and vomiting (PONV). Part of the in-service consisted of a detailed discussion on the score and how to use it. Questionnaire I revealed that only 27.8% (n=5) were currently using preoperative fluid therapy in their plan of care. The in-service provided information from the literature review regarding the use of preoperative fluid therapy to decrease PONV to the Certified Registered Nurse Anesthetists (CRNAs). Of the CRNAs’ responses on questionnaire II, 100% reported they used preoperative fluid therapy to some extent in their plan of care over the 2-week time frame. This finding indicated a 72.2% increase in CRNAs use of preoperative fluid therapy in their plan of care. Furthermore, 100% of participants agreed the educational in-service did influence their decision to use preoperative fluid therapy. The mean value of CRNAs that utilized preoperative fluid therapy increased from 0.28 to 1 after participating in the in the educational in-service.
The primary purpose of this project was to create a practice change for CRNAs to incorporate preoperative fluid therapy to prevent PONV in at risk patients for PONV. The primary goal of this project was fulfilled; namely, a 72.2% increase in the use of
preoperative fluid therapy and 100% of CRNAs selected yes to the question, “did the educational in-service influence your decision to use preoperative fluid therapy?”
Limitations
Limitations of this project included the inability to eliminate bias because of the nature of this project’s convenience sample, which means that participants will meet the candidate requirements for the study (Melnyk & Fineout-Overholt, 2015). Another limitation was the small sample size. Only 18 of 40 CRNAs at this facility participated in the study because of variation in the daily CRNA scheduling at this facility.
Future Practice Implications
Continuing education on evidence-based practices is important in medical and nursing professions to provide the best care for patients. Offering educational in-services to CRNAs is one way to help them keep current on best practices and recognize
knowledge deficits. Educational in-services are also a good way to refresh concepts and generate new practices. CRNA students are in a unique position to offer seasoned CRNAs the most current literature regarding best practices.
Conclusion
The 18 CRNA participants indicated on questionnaire II that the educational in- service influenced their decision to use preoperative fluid therapy in their plan of care. Furthermore, 100% of the CRNA participants used preoperative fluid therapy to some extent over the 2-week time frame after they participated in the educational in-service, as compared to only 27.8% before the in-service. The PICO question for this project is: In CRNAs (P), will presenting an educational in-service (I) on the use of preoperative fluid therapy to decrease PONV in high risk populations effect their willingness to change practice (O) compared to CRNAs who do not participate in the educational in-service (C) over the course of 2 weeks (T). The results of this study confirm that the answer to this
PICO question is yes. The results and knowledge gained from this project can be shared with other anesthesia providers through presentations and at related conferences.
APPENDIX A – DNP Essentials Table A1.
DNP Essentials
I. Scientific Underpinnings for Practice relates to this doctoral project in terms of the development of nursing science through researching and adding to knowledge of preoperative fluid therapy use
II. Organizational and Systems Leadership for Quality Improvement and System Thinking
relates to this doctoral project in terms of the use of clinical scholarship and evidence-based research that will enhance CRNA knowledge III. Clinical Scholarship and Analytical Methods
for Evidence-Based Practice
IV. Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care
V. Health Care Policy for Advocacy in Health Care VI. Interprofessional Collaboration for Improving Patient and Population Health Outcomes
relates to this doctoral project by a collaboration with CRNAs to discuss the benefits of
preoperative fluid therapy use to decrease PONV to promote better patients’ post-anesthetic outcomes.
VII. Clinical Prevention and Population Health for Improving the Nation’s Health
VIII. Advanced Nursing Practice
APPENDIX B - Simplified Apfel Score Table A2.
Simplified Apfel Score
Risk Factors Points
Female Gender 1
Non-Smoker 1
History of PONV 1
Postoperative Opioids 1
Sum = 0…4
(Apefel et al., 1999; Gan et al., 2014)
Table A3.
Simplified Apfel Score
(Apfel et al., 1999; Gan et al., 2014)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% # of Risk Factors
PONV
Risk 0 1 2 3 4APPENDIX C - Questionnaires Questionnaire I
1) How long have you been a Certified Registered Nurse Anesthetist? a) 0-5 years
b) 6-10 years c) 11-15 years d) >15 years
2) What is your gender? a) Male
b) Female
3) What is your age category? a) 25-35 years old
b) 35-45 years old c) 45-55 years old d) >55 years old
4) Are you familiar with the Simplified Apfel score? a) Yes
b) No
5) Do you currently use preoperative fluid therapy in your plan of care to decrease PONV?
a) Yes b) No
Questionnaire II
1) How many times did you use preoperative fluid therapy as part of your plan of care?
a) 1-5 times b) 6-10 times c) >10 times
2) Were there any barriers that prevented you from using preoperative fluid therapy?
3) Did the educational in-service influence your decision to use preoperative fluid therapy?
a) Yes b) No
APPENDIX F – Educational In-service Handout
Educational In-service
Background and Significance
• PONV still occurs in up to 25%-30% of all surgeries and up to 70% in high risk populations.
(Lambert et al.,2009) • PONV has been linked to negative complications such as extra time spent in the
post-anesthesia care unit (PACU), extended patient stay, patient discontent, increased hospital expenses, and morbidity.
(Lambert et al., 2009) • The Society for Ambulatory Anesthesia (2014) lists adequate hydration as one of
the strategies to help reduce PONV, and, include it in their consensus guidelines for the management of PONV.
(Gan et al., 2014)
Recognizing High Risk Populations
• The Simplified Apfel Score (1999) is a useful tool in identifying those patients at increased risk of developing PONV.
• The score lists four characteristics: (a) female gender, (b) non-smoker, (c) history of PONV, and (d) postoperative opioids.
(Apfel et al., 1999) • Even if no risk characteristics are present, the patient is still at a 10% chance of
developing PONV; the possibility of developing PONV rises to 20%, 40%, 60%, and 80% for each added risk factor.
(Apfel et al., 1999; Gan et al., 2014) • The type of surgery has been shown to effect PONV; laparoscopic abdominal
surgeries and gynecological procedures carry a greater risk of the patient developing PONV.
• The length of the procedure and the use of volatile anesthetics are significant indicators for the development of PONV.
(Apfel et al., 2012a; Chatterjee, 2011)
Risk Factors Points
Female Gender 1
Non-Smoker 1
History of PONV 1
Postoperative Opioids 1
Sum = 0…4
(Apfel et al., 1999; Gan et al., 2014)
Mechanism of Action
• The exact way in which preoperative fluid therapy decreases PONV remains unclear.
(Adanir et al., 2008; Yavux et al., 2014) • Reoccurring theories suggest:
o Anesthesia agents create a state of hypovolemia leading to
hypoperfusion that causes the release of endogenous catecholamines such as dopamine and serotonin.
o The hypovolemic state generated by anesthesia agents causes
gland; studies have shown that patients with increased levels of ADH experience more episodes of PONV.
(Adanir et al., 2008; Chaudhary et al., 2008; Yavux et al., 2014)
Fluid Therapy
• After reviewing the literature, the dosage ranged from 5-30ml/kg up to 1 liter of crystalloids approximately 1 hour before anesthesia induction.
(Adanir et al., 2008; Ali et al., 2003; Apfel et al., 2012b; Chaudhary et al., 2008;Ghafourifard et al., 2015; Lambert et al., 2009; Magner et al., 2004; Turkistani et al., 2009; Yavux et al., 2014)
• In one study, the crystalloids were given using the 4-2-1 rule up to 1 liter of fluid while other studies gave 1-2 liters of crystalloids preoperatively at the discretion of the anesthesia provider.
(Lambert et al., 2009) • Not all patients are candidates for preoperative fluid therapy; patients with heart (CHF), Kidney (ESRD on dialysis), liver, respiratory, or neurologic conditions could experience adverse effects from excess fluids.
(Adanir et al., 2008) References
Adanir, T., Aksun, M., Ozgurbuz, U., Altin, F., & Sencan, A. (2008). Does preoperative hydration affect postoperative nausea and vomiting? a randomized, controlled trial. Journal of
Laparoendoscopic & Advanced Surgical Techniques, 18(1), 1-5.
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Ali, S. Z., Taguchi, A., Holtman, B., & Kurz, A. (2003, April 22nd). Effect of supplemental pre-operative fluid on postoperative nausea and vomiting. Anesthesia, 58, 780-784. Retrieved from
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