A question from a young, frustrated PACU nurse got us thinking: "Why do some CRNAs give intra-operative PONV and pain prophylaxis and others do not?" Her frustration stemmed from having to play catch-up when patients don't receive nausea and pain prophylaxis in the operating room. As you know, it's much better to prevent PONV and pain in the OR than to try to rescue patients in PACU. Rescuing requires more than twice as much medication, tends to be less effective and prolongs PACU stays. Here's how we got all 25 of our nurse anesthetists to standardize their prophylactic practices.

No 2 CRNAs are alike
Nationally, between 22% and 25% of patients experience some degree of PONV in the first 24 post-operative hours. Our group mirrored those averages, but many of our CRNAs consistently showed much lower rates of nausea or post-op pain. To move from individual to group excellence, we needed buy-in from the whole team. Our rallying cry was that the entire staff is committed to giving the best possible care.

I reviewed 8 weeks' worth of computerized anesthesia and PACU records and found that no 2 of the 25 nurse anesthetists in our outpatient day surgery unit treat PONV and pain exactly the same way. From one practitioner to the next, I found differences in the drugs they administered as well as the timing and dosing, anesthetic technique and fluid administration.

Our hospital measures 50 criteria, including pain and nausea requiring post-op treatment. The data we collected never seemed to filter down to the CRNA staff in a timely manner. Many anesthetists actually didn't know how their patients fared in PACU due to production pressure for fast turnovers. Patients often were discharged home or admitted to the main hospital for observation before the CRNA could check on them.

Nurse anesthetists are educated to be independent practitioners. The biggest challenge would be encouraging people to change some outmoded practices. I turned to the evidence-based practices I found in the literature and employed a little psychology. I knew that the only way to change practice was to prove to practitioners that what they were doing was not in the best interest of their patients.

How low could we go?
Many of our CRNAs were already below the national average, so why not see how low we could go. Ours was a two-pronged attack:

• Education. We hung a large black bulletin board outside our pharmacy. On the bottom of the board, we attached 4 or 5 evidence-based review articles. We cut out the key points from the articles and re-typed them in bold print on white paper, then placed each blurb on brightly colored paper. Every pass in the hall provided an opportunity to reinforce the information.

Each month, we focused on a different facet, such as anti-emetics, NSAIDs, ketamine, opioids, TIVA (total intravenous anesthesia) and fluid volume. The board for anti-emetics showed simple graphs and pictures of the receptors and discussed physiology. It listed the anti-emetics available and likelihood of success. We gave dosing strategies for TIVA using propofol, esmolol and sufenta. The ketamine board recommended using 0.5mg/kg right after induction, especially for orthopedic cases with a follow-up dosing regimen of 0.25mg/kg q30 minutes. Long-time CRNAs were more likely to remember this strategy from early introduction of ketamine in short gynecology cases. Newer anesthetists thought it was "cool." It worked for many patients in conjunction with NSAIDs and local anesthetic given by the surgeon for short cases.

• Defining the new protocol. We decided not to dictate specific drugs or techniques. The evidence-based literature gave several strategies. Besides, we were trying to improve patient comfort — not do a research project presented to the International Review Board. On top of all that, CRNAs don't particularly like being told how to do their jobs. We wanted to allow as much latitude as possible. Our sole protocol was to request that practitioners give 2 anti-emetics up front. Then, at least 20 minutes before the end of the case, give a third anti-emetic plus a long-acting pain medication such as dilaudid. We also asked that each anti-emetic be from a different class so that we hit all of the different PONV pathways. Practitioners concerned about giving such longer-acting pain medicine as morphine or dilaudid at the end of a case diluted the drugs until they learned how to time it so that the patient is awake and comfortable at the end of the procedure.

We requested regional blocks as supplements to general anesthesia whenever possible. The timing came from the evidence-based research. We didn't coerce anyone to use a particular technique or specific drug regimen, merely to choose from those available and to administer these at the designated times.

Persistence pays off
Just a few short months after we launched our program, our group rate for 24-hour post-op PONV had stabilized at 12%. I was thrilled to see individual rates decline to as low as 1.5%. "Of course they dropped," one of our CRNAs said with a laugh. "We heard about it ad nauseam." No pun intended!

A practitioner who prefers morphine for breast surgery used our strategy for anti-emetic and pain control timing, and her patients did not require rescue. More patients received regional anesthesia and adjuncts to opioids. Perhaps the surest sign that we had changed our ways was this: The amount of pain/nausea meds PACU nurses give has fallen dramatically.