Multifaceted approaches and PONV: A critical appraisal

Abstract

We read with interest the recent publication by Pym and Ben-Menachem regarding their use of a multifaceted reduction strategy in an effort to reduce the rates of postoperative nausea and vomiting (PONV). The efforts of the authors to implement a quality improvement project in their hospital is admirable, and highlight a growing awareness for the continuous need to re-evaluate and improve upon current practices based on a cycle of feedback and appraisal of evidence, as highlighted by the recent guidelines published by the College. In their discussion, the authors debated the lack of significant increase in prophylaxis prescribing, and a seemingly scant uptake of a promoted guideline on PONV prophylaxis, despite their use of a multifaceted reduction strategy. We would like to focus on this issue by commenting on the design of the study and offering some suggestions for further exploration. Reviews of multifaceted approaches in quality improvement literature reveal only modest to moderate success in improvement of professional behaviour and health outcomes. It is thus not surprising that, despite a statistically significant improvement in delays to discharge from the postoperative anaesthetic care unit (PACU), there was only a modest increase in adherence to the PONV guidelines, from 9% to 19%. Having said that, it is important to note that active strategies such as auditing and feedback (which were employed in this study) were likely to have a more significant effect on healthcare outcomes compared with the passive strategies of simply disseminating information. Damschroder et al.’s Consolidated Framework for Implementation Research (CFIR) is frequently employed to appraise quality improvement studies. By applying the five domains of the CFIR onto this study, it becomes clear from the onset that the intervention carried the advantages of having high trialability, low complexity, being rooted in evidence-based medicine and in a healthcare centre receptive to improvement. However, the challenges may lie in what Damschroder terms the ‘Tension for Change’ and the ‘Relative Priority’ — to put it simply, the perception for urgency of change as well as the prioritisation of change, which may be difficult to appreciate in the operating theatre of a tertiary health care centre, where there are many competing interests and benchmarks for quality improvement other than PONV. These factors, perhaps, could explain the low uptake rate of the guideline. Some suggestions for future exploration of this study may include a potential change in implementation. Damschroder et al. mention the appointing of ‘internal implementation leaders’ and ‘clinical champions’ — which may come in the form of departmental heads, or quality improvement leaders — as key factors for success. Another possible method is the utilisation of comparative performance reports, where the performance of individual anaesthetists is reviewed alongside the performance of the department as a whole. A recent paper by Collyer et al. trialled these reports and had success in both reducing PONV rates and increasing receptiveness amongst the staff members of their department. In summary, we believe that the strengths of this study lie within the evidence of low PONV prophylaxis compliance rates, as well as a further demonstration of the effect of a multifaceted approach towards quality improvement. Quality improvement is a challenging field, especially in anaesthesia, where superstition, dogma and science are often intertwined, and we hope that the authors will continue to persevere in their mission to improve outcomes in their health care centre.