This measure is calculated based on data extracted from the electronic medical record combined with administrative data sources such as professional fee and discharge diagnoses data. This measure is explicitly not based on provider self-attestation.

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. 

Preop Start to PACU start

• All patients, aged 18 years and older, who undergo any procedure including surgical, therapeutic, or diagnostic under an inhalational general anesthetic between Anesthesia Start and Anesthesia End, AND who have three or more risk factors for PONV.
  • PONV Risk Factors:
    • Female gender
    • History of PONV
    • History of motion sickness
    • Non-smoker
    • Intended administration of opioids for post-operative analgesia. This includes use of opioids given intraoperatively and whose effects extend into the post anesthesia care unit (PACU) or post-operative period, or opioids given in the PACU, or opioids given after discharge from the PACU.

• Patients <18 years old.
• Patients transferred directly to the ICU
• Liver Transplants (see ProcedureTypeTransplantLiver phenotype)
• Lung Transplants (see ProcedureTypeTransplantLung phenotype)
• Procedures (by CPT): 00452, 00561, 00562, 00563, 00567, 00622, 00634, 01916, 01920, 01922, 01953, 01958, 01960, 01990, 01991, 01992, 01996, 01999
• Obstetric Non-Operative Procedures (CPT: 01958)
• Labor Epidurals (as determined by the MPOG 'Obstetric Anesthesia Type' Phenotype results 'Labor Epidural' and 'Conversion (Labor Epidural Portion)')
• Invalid cases where Measure End results prior to Measure Start

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 %: <0.2%
  • Sevoflurane Insp %: <0.5%
  • Desflurane Insp %: <0.5%
  • Nitrous Oxide Insp % <15%

• If smoking status is not documented, patient is assumed to be a non-smoker and therefore is assigned at least one risk factor.
• This measure requires CPT codes to be transferred to the MPOG database for cases to be included. Those sites participating with this measure must have current pro fee procedure data in the MPOG Central database- refer to the flow diagram on page 10 of this specification for more details.
• 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 Begin. 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.

• Percentage of Cases with Professional Fee Procedure Codes
• Percentage of Cases with Antiemetic Medications
• Percentage of Cases in which the Patient has a known Gender
• Percentage of Intraoperative Notes with a Meaningful Note Mapping
• Percentage of Preoperative Notes with a Meaningful Type Mapping

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

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.