Preventing Postoperative Nausea and Vomiting During an Ondansetron Shortage

Postoperative nausea and vomiting (PONV) degrades patient experience and increases healthcare costs. Estimates of PONV range from 10% to 80%. The Apfel Simplified Score is an evidence-based instrument for determining individual risk of PONV. Scoring enables anesthesia providers to match antiemetic strategies with the calculated risk of PONV. Data were collected across 3 times. After the Apfel scoring system was automated into the electronic medical record, providers were more likely to increase PONV prophylaxis for patients at highest risk and reduce prophylaxis for patients at lowest risk. Rates of PONV remained similar at baseline (34.7%) and in the early postimplementation period (38.8%); a modest reduction was observed in the final period (26.5%). Intravenous ondansetron, the most common antiemetic at baseline, was not available in the early postimplementation period, which may partially explain the initial increase in PONV. While ondansetron was unavailable, providers began using 3 other antiemetics, a practice that persisted once intravenous ondansetron returned. The Apfel score is an evidence-based tool that providers can use to reduce the risk of PONV. This electronic tool and the reminder cards have been shared across the US Military Health System, fostering an organizational culture that values targeted prophylaxis for PONV.