Percentage of patients who had a procedure requiring general anesthesia OR cesarean delivery and received appropriate prophylaxis for postoperative nausea and vomiting.  

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 surgery.¹ Effective management of PONV leads to optimal patient outcomes and comfort during the postoperative period.^2-3 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 In patients undergoing cesarean delivery, the Society for Obstetric Anesthesia and Perinatology recommends the use of at least 2 antiemetic agents from different classes to reduce the incidence of PONV.⁸

4 hours before Preop Start to PACU Start

*For cesarean delivery cases converted from labor epidural: 4 hours before cesarean delivery start time to PACU Start 

All patients who meet one of the following criteria:

• Age> 18 years requiring general anesthesia (determined by Anesthesia Technique: General value codes >0) and have one or more risk factors for PONV (see risk factors below)
• Cesarean delivery, with or without general anesthesia (risk factors not considered), all ages included (determined by Obstetric Anesthesia Type value codes: 1, 2, 4, 7, 8)

PONV Risk Factors:

• Age< 50 years
• Sex: Female 
• History of PONV or motion sickness (equates to one risk factor even if history of both)
• Non-smoker
• Opioid use for postoperative pain (Includes use of opioids given intraoperatively and whose effects extend into the post anesthesia care unit (PACU) or postoperative period or opioids given in the PACU. 
• Duration of inhalational anesthesia greater than 1 hour 
• Selected procedures (uses actual CPT codes only, not predicted):
  • Cholecystectomy 
    • Anesthesia CPT codes: 00790 
    • Surgical CPT codes: 47562, 47563, 47564, 47600, 47605, 47610, 47612, 47620
  • Laparoscopy 
    • Anesthesia CPT codes: 00790, 00792, 00794, 00796, 00797, 00840, 00842, 00844, 00846, 00848, 00851, 00860
    • Surgical CPT codes: 43644, 43645, 43647, 43648, 43651, 43652, 43653, 43659, 45395, 45397, 45400, 45402, 45499, 49320, 49321, 49322, 49323, 49324, 49325, 49326, 49329, 49650, 49651, 49652, 49653, 49654, 49655, 49656, 49657, 49659, 50541, 50542, 50543, 50544, 50545, 50546, 50547, 50548, 50549, 50945, 50947, 50948, 50949, 55866, 58541, 58542, 58543, 58544, 58545, 58546, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58578, 58660, 58661, 58662, 58670, 58671, 58672, 58673, 58679, 59150, 59151, 59898, 60650, 60659 
  • Gynecologic 
    • Anesthesia CPT codes: 00840, 00848, 00940, 00944
    • Surgical CPT codes: 11004, 11305, 11306, 11307, 11308, 11420, 11421, 11422, 11423, 11424, 11426, 11620, 11621, 11622, 11623, 11624, 11626, 12001, 12002, 12004, 12005, 12006, 12007, 12020, 12021, 12041, 12042, 12044, 12045, 12046, 12047, 13131, 13132, 13160, 14040, 14041, 15115, 15120, 15135, 15155, 15175, 15240, 15320, 15335, 15340, 15365, 15420, 15574, 15620, 15650, 15740, 15750, 15756, 15757, 15839, 15850, 15851, 15852, 17000, 17004, 17106, 17107, 17108, 17110, 17111, 17250, 17270, 17271, 17272, 17273, 17274, 17276, 17311, 20000, 20005, 20500, 20501, 58550, 58552, 58553, 58554, 58555, 58558, 58559, 58560, 58561, 58562, 58563, 58565, 58570, 58571, 58572, 58573, 58578, 58579, 58600, 58605, 58611, 58615, 58660, 58661, 58662, 58670, 58671, 58672, 58673, 58679, 58700, 58720, 58740, 58750, 58752, 58760, 58770, 58800, 58805, 58820, 58822, 58823, 58825, 58900, 58920, 58925, 58940, 58943, 58950, 58951, 58952, 58953, 58954, 58956, 58957, 58958, 58960, 58970, 58974, 58976, 58999, 59000, 59001, 59012, 59015, 59070, 59072, 59074, 59076, 59100, 59120, 59121, 59130, 59135, 59136, 59140, 59150, 59151, 59160, 59200, 59300, 59320, 59325, 59350, 59400

• Age < 18 years of age (exception: cesarean delivery - any age) 
• ASA 5 & 6 including Organ Procurement (CPT: 01990)
• Patients transferred directly to the ICU 
• Procedures:
  • Bronchoscopy (only) procedures
  • Diagnostic Imaging (only) cases
  • Electroconvulsive Therapy cases
  • Endoscopy (only) procedures 
  • Intubation Only cases
  • Labor Epidurals (determined by Obstetric Anesthesia Type value codes: 3, 5, & 6 including obstetric non-operative procedures - CPT: 01958) 
  • TEE/Cardioversion
• Surgery Duration ≤ 30 minutes (does not apply to cesarean delivery cases)

For patients ≥18 years old undergoing general anesthesia:

1. At least two prophylactic pharmacologic antiemetic agents of different classes administered preoperatively or intraoperatively for patients with one or two risk factors

2. At least three prophylactic pharmacologic antiemetic agents from different classes preoperatively or intraoperatively for patients with three or more risk factors 

For Cesarean Delivery Cases only (with or without general anesthesia, any age):

At least two prophylactic pharmacologic antiemetic agents from different classes preoperatively or intraoperatively.

• If smoking status is not documented, the patient is assumed to be a non-smoker and therefore is assigned at least one risk factor. 
• Patients undergoing cesarean delivery are determined by Obstetric Anesthesia Type value codes: 1, 2, 4, 7, or 8.
• Cesarean conversion cases are determined by Obstetric Anesthesia Type value codes: 1, 7, 8.
• Except for cesarean deliveries, only patients receiving general anesthesia will be included for the measure. General anesthesia is determined by Anesthesia Technique: General value codes >0
• 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 
  • Antidopaminergics
  • Antihistamines 
  • Anticholinergics

• The recommended pharmacologic anti-emetics for PONV prophylaxis for cesarean delivery include: 
  • 5-Hydroxytryptamine (5-HT3) Receptor Antagonists 
  • Glucocorticoids 
  • Antidopaminergics

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 healthcare 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.

Algorithm for Determining Surgery Duration for 30-minute Exclusion:

Surgery Start

• Surgery Start. If not available, then
• Induction End. If not available, then
• Patient In Room. If not available, then
• Anesthesia Start

Surgery End

• Surgery End. If not available, then
• Patient out of Room. If not available, then
• Anesthesia End

*This measure will include valid MPOG cases defined by the Is Valid Case phenotype.

Not applicable.

Provider(s) signed in at Induction End.

Method for determining Responsible Provider:

1. Provider signed in at Anesthesia Induction End. If no provider signed it at that time then,
2. Provider signed in at Anesthesia Induction Start. If no provider signed in at that time then,
3. Provider signed in at Surgery Start. If no provider signed in at that time then,
4. Provider signed in at Patient in Room. If no provider signed in at that time 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, Belani KG, Bergese S, et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesthesia and analgesia. 2020;131(2):411-448.
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.
7. Mascha EJ, Gan TJ, Vetter TR. Quality Improvement Interventions Associated With Improved Postoperative Nausea and Vomiting: Separating the Signal From the Noise. Anesthesia and analgesia. 2019;128(5):847-849.
8. Bollag L, Lim G, Sultan P, et al. Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean. Anesthesia and analgesia. 2021;132(5):1362-1377.