Measure Abbreviation
PONV-01
Data Collection Method

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.

Measure Type
Process
Description

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. 

Measure Time Period

Preop through Recovery Room In

Inclusions
  • 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.
Exclusions
  • 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, 01968, 01969, 01990, 01991, 01992, 01996, 01999
  • Labor Epidurals (CPT: 01967)
  • Obstetric Non-Operative Procedures with procedure text: “Labor Epidural”
Success

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.

Other Measure Build Details
  • 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.
Responsible Provider

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.
Threshold
90%
MPOG Concept IDs Required

General Inhalational Anesthetic MPOG Concept IDs

3297

Enflurane Exp %

3298

Enflurane Insp %

3006

Isoflurane actual consumption (ml)

3007

Desflurane actual consumption (ml)

3260

Isoflurane Exp %

3265

Isoflurane Insp%

3280

Desflurane Exp %

3285

Desflurane Insp %

50420

Cardiopulmonary bypass – Isoflurane vaporizer turned on

3008

Sevoflurane actual consumption (ml)

3270

Sevoflurane Exp %

3275

Sevoflurane Insp %

3503

Sevoflurane (mmHg)

3250

Nitrous Insp %

3255

Nitrous Exp %

Antiemetic MPOG Concept IDs (by class)

Class: 5-Hydroxytryptamine (5-HT3) Receptor Antagonists

10335

Ondansetron

10164

Dolasetron

10208

Granisetron

10711

Palonosetron

Anticholinergics

10400

Scopolamine Patch

10399

Scopolamine

11040

Butylscopolamine

Antiemetic MPOG Concept IDs (by class)- Continued

Antihistamines

10257

Dimenhydrinate

10160

Diphenhydramine

10635 Meclizine

Butyrophenones

10169

Droperidol

10210

Haloperidol

Neurokinin-1 Receptor Agonists

10035

Aprepitant

10719

Fosaprepitant

Phenothiazines

10374

Promethazine

10373

Prochlorperazine

Steroids

10147

Dexamethasone

10296

Methylprednisolone

Prokinetic

10297

Metoclopramide

Other

10377

Propofol (Infusion only)

PONV Medical Reason Exclusion MPOG Concept ID

50046

Medical Performance Exclusion- PONV

PONV Risk Factor- Smoking Status MPOG Concept IDs:

70128

History- Social History- Tobacco

71100

History- Social History- Tobacco Details Pack Years

71110

History- Social History- Tobacco details Current vs Past

PONV Risk Factor- History of PONV/Motion Sickness MPOG Concept IDs:

70225

Assessment and Plan - Comments

70302

Assessment and Plan- Anesthetic Consideration

70338

General- PONV Risk Factors

70339

General- PONV Risk Total Score

70080

General- Previous Anesthetic Problem

70102

Misc- Motion Sickness

PONV Risk Factor- Intended Administration of Opioids for Postop Analgesia MPOG Concept IDs:

70234

Assessment and Plan – Postop Pain Management

10008

Bupivacaine w/ Hydromorphone 0.1% / Unspecified

10020

Alfentanil

10077

Bupivacaine w/ Fentanyl 0.0625% / 3 mcg/mL

10079

Bupivacaine w/ Fentanyl 0.08% / 2 mcg/mL

10080

Bupivacaine w/ Fentanyl 0.125% / 2 mcg/mL

10081

Bupivacaine w/ Fentanyl 0.125% / 3 mcg/mL

10082

Bupivacaine w/ Hydromorphone 0.0625% / 5 mcg/mL

10083

Bupivacaine w/ Hydromorphone 0.0625% / 10 mcg/mL

10103

Bupivacaine w/ Fentanyl 0.125% / 5 mcg/mL

10186

Fentanyl

10187

Fentanyl / Midazolam 40mcg/mL / 200mcg/mL

10219

Hydromorphone

10258

Bupivacaine w/ Hydromorphone 0.05% / 3 mcg/mL

10279

 Meperidine

10290

Methadone

10306

Morphine

10341

Oxycodone

10408

Bupivacaine w/ Fentanyl 0.0625% / 5 mcg/mL

10414

Sufentanil

10439

Bupivacaine w/ Sufentanil w/ Epinephrine 100 mg / 100 mcg / 0.42 mg

10475

Bupivacaine w/ Hydromorphone 0.125% / 5 mcg/mL

10476

Bupivacaine w/ Hydromorphone 0.125% / 10 mcg/mL

10478

Lidocaine w/ Hydromorphone 2% / 10 mcg/mL

10479

Lidocaine w/ Fentanyl w/ Epinephrine w/ Bicarbonate 2% / 5 mcg/mL / 1:200,000

10481

Oxycodone / Acetaminophen 5 mg / 325 mg

10482

Hydrocodone / Acetaminophen 5 mg / 325 mg

10483

Hydrocodone / Acetaminophen 7.5 mg / 500 mg

10486

Bupivacaine w/ Fentanyl 0.5% / 3 mcg/mL

10488

Bupivacaine w/ Fentanyl 0.5% / 10 mcg/mL

10518

Bupivacaine w/ Hydromorphone 0.5% / 10 mcg/mL

10519

Bupivacaine w/ Fentanyl 0.05% / 3 mcg/mL

10522

Bupivacaine w/ Morphine 0.75% / 0.2 mg

10534

Bupivacaine w/ Fentanyl 0.0625% / 2 mcg/mL

10536

Bupivacaine w/ Fentanyl 0.0625% / 10 mcg/mL

10554

Bupivacaine w/ Fentanyl 0.1% / 2 mcg/mL

10583

Bupivacaine w/ Fentanyl 0.0625% / 4 mcg/mL

10584

Bupivacaine w/ Fentanyl 0.0625% / 10 mcg/mL

10585

Bupivacaine w/ Fentanyl 0.125% / 4 mcg/mL

10597

Propofol w/ Alfentanil 10 mg/mL + 50 mcg/mL

10603

Bupivacaine w/ Hydromorphone 0.05% / 10 mcg/mL

10611

Bupivacaine w/ Fentanyl w/ Epinephrine 37.5 mg / 750 mcg / 0.125 mg

10620

Bupivacaine w/ Fentanyl 0.125% / 10 mcg/mL

10633

Ropivacaine w/ Fentanyl 0.125% 2 mcg/mL

10642

Bupivacaine w/ Fentanyl 0.01% / 4 mcg/mL

10643

Bupivacaine w/ Fentanyl 0.25% / 4 mcg/mL

10644

Bupivacaine w/ Fentanyl 0.25% / 2 mcg/mL

10646

Bupivacaine w/ Hydromorphone 0.125% / 20 mcg/mL

10648

Bupivacaine w/ Hydromorphone 0.1% / 20 mcg/mL

10654

Bupivacaine w/ Fentanyl 0.167% / 16.67 mcg/mL

10669

Bupivacaine w/ Fentanyl 0.25% / 10 mcg/mL

11120

Bupivacaine w/ Fentanyl 0.05% / 5 mcg/mL

11130

Bupivacaine w/ Fentanyl 0.25% / 2.5 mcg/mL

11140

Bupivacaine w/ Fentanyl 0.05% / 2 mcg/mL

Data Diagnostics Affected
  • 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
Rationale

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

References
  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.