Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively. 

The purpose of this process of care measure is to reduce the incidence of postoperative nausea and vomiting in adult surgical patients. 

Postoperative nausea and vomiting (PONV) is a common and unpleasant outcome of anesthesia care that can lead to other complications, lengthening the patient’s recovery period after surgery¹. Effective management of PONV leads to optimal patient outcomes and comfort during the postoperative period.² The Apfel score is one of the most common risk predictors for PONV and is based on 4 variables: female gender, nonsmoking status, history of PONV or motion sickness and postoperative opioid administration. The presence of each additional risk factor increases a patients risk of PONV by twenty percent.³ Although including a prophylactic anti-emetic administration protocol that considers such risk factors has shown to reduce the incidence of PONV, there is high variability in this outcome.^4-7

4 hours before Anesthesia Start to PACU start

• All patients, 18 years and older, who undergo any procedure and meet BOTH of the following conditions:

1. Recieve an inhalational anesthetic (Halogenated or Nitrous)
2. Have three or more risk factors for PONV
   • Female gender
   • History of PONV
   • History of motion sickness
   • Non-smoker
   • Opioids administered intraoperatively

• Antiemetic medical exception (Concept ID:50046)
• Labor Epidurals (as determined by the MPOG 'Obstetric Anesthesia Type' Phenotype results 'Labor Epidural' and 'Conversion (Labor Epidural Portion)')
• Patients age < 18 years
• Patients transferred directly to the ICU
• Procedures:
  • Obstetric Non-Operative Procedures (CPT: 01958)
  • Open Cardiac Procedures
  • Procedure Type: Liver Transplant 
  • Procedure Type: Lung Transplant
  • Procedures (by CPT): 00452, 00622, 00634, 01916, 01920, 01922, 01953, 01958, 01960, 01967, 01990, 01991, 01992, 01996, 01999

*Cases where the 'Measure End Time' precedes 'Measure Start Time' will be excluded and marked invalid.

Patient receives combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively

Anti-emetic therapy: The recommended first- and second-line classes of pharmacologic anti-emetics for PONV prophylaxis in patients at moderate to severe risk of PONV include (but are not limited to):

• NK-1 Receptor Antagonists
• 5-Hydroxytryptamine (5-HT3) Receptor Antagonists
• Glucocorticoids
• Phenothiazines
• Phenylethylamines
• Butyrophenones
• Antihistamines
• Anticholinergics

Note: In addition, propofol infusion is accepted as one of the antiemetic options for this measure. The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications.

• Values for flows and gases will be assessed and considered artifact if less than the following ranges and the patient did not receive any other inhalational general anesthetics greater than these ranges:
  • Nitrous Oxide Flows: <0.2 L/min
  • Isoflurane Insp %: <0.3%
  • Sevoflurane Insp %: <0.4%
  • Desflurane Insp %: <1.2%
  • Nitrous Oxide Insp % <20%
• If smoking status is not documented, patient is assumed to be a non-smoker and therefore is assigned at least one risk factor.
• Risk factor for opioid administration includes those given intraoperatively and whose effects extend into the PACU. *See MPOG Concepts used section
• Algorithm for determining Measure End Time:
  • Recovery Room In Date/Time. If not available then,
  • Phase I Recovery Room In Date/Time. If not available then,
  • Phase II Recovery Room In Date/Time. If not available then,
  • Patient out of Room. If not available then,
  • Data Capture End. If not available then,
  • Anesthesia End.

Provider(s) signed in at Induction End.

Method for determining Responsible Provider:

1. Provider signed in at Anesthesia Induction End. If not available then,
2. Provider signed in at Anesthesia Induction Start. If not available then,
3. Provider signed in at Procedure Start. If not available then,
4. Provider signed in at Patient in Room. If not available then,
5. Provider signed in Anesthesia Start.

1. Gillmann HJ, Wasilenko S, Zuger J, et al. Standardised electronic algorithms for monitoring prophylaxis of postoperative nausea and vomiting. Archives of medical science : AMS. 2019;15(2):408-415.
2. Collins AS. Postoperative nausea and vomiting in adults: implications for critical care. Critical care nurse. 2011;31(6):36-45.
3. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesthesia and analgesia. 2014;118(1):85-113.
4. Schraag S, Pradelli L, Alsaleh AJO, et al. Propofol vs. inhalational agents to maintain general anaesthesia in ambulatory and in-patient surgery: a systematic review and meta-analysis. BMC anesthesiology. 2018;18(1):162.
5. Gan TJ, Ginsberg B, Grant AP, Glass PS. Double-blind, randomized comparison of ondansetron and intraoperative propofol to prevent postoperative nausea and vomiting. Anesthesiology. 1996;85(5):1036-1042.
6. De Oliveira GS, Jr., Castro-Alves LJ, Chang R, Yaghmour E, McCarthy RJ. Systemic metoclopramide to prevent postoperative nausea and vomiting: a meta-analysis without Fujii's studies. British journal of anaesthesia. 2012;109(5):688-697.