Measure ID
PONV-05
Domain
Postoperative Nausea and Vomiting
Description

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

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.

Measure Type
Process
Rationale

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

Threshold
90%
Measure Time Period

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 (Cesarean conversion cases are determined using the Obstetric Anesthesia Type phenotype value codes 1, 7, 8)

Inclusions
  • All patients who meet one of the following criteria:
    • 18 years of age or older having a procedure requiring general anesthesia between Anesthesia Start and Anesthesia End, 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

PONV Risk Factors:

  • Female gender 
  • 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 < 50 years old 
Exclusions
Success Criteria

Administration of combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes for patients identified with risk factors for PONV: 

  • For patients with 1 or 2 risk factor(s), administration of at least two prophylactic pharmacologic antiemetic agents of different classes administered preoperatively or intraoperatively.
  • For patients with 3 or 4 risk factor(s), documented administration of three or more prophylactic pharmacologic antiemetic agents from different classes preoperatively or intraoperatively. 
  • For cesarean delivery patients (with or without general anesthesia), documented administration of two or more prophylactic pharmacologic antiemetic agents from different classes preoperatively or intraoperatively.
Other Measure Details
  • If smoking status is not documented, the patient is assumed to be a non-smoker and therefore is assigned at least one risk factor. 
  • 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. 
  • Patients undergoing cesarean delivery are identified using the ‘MPOG Obstetric Anesthesia Type’ phenotype results (value codes: 1, 2, 4, 7, or 8).
  • Except for cesarean deliveries, only patients receiving general anesthesia will be included for the measure. General anesthesia is defined by the ‘MPOG Anesthesia Technique: General’ phenotype.
  • 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.

Surgery Duration is Surgery End - Surgery Start date/time.

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
Risk Adjustment

Not applicable.

Provider Attribution

Provider(s) signed in at Induction End. 

Method for determining Responsible Provider: 

  1. Provider signed in at Anesthesia Induction End. If a provider is not signed in at induction end or induction end time not available then, 
  2. Provider signed in at Anesthesia Induction Begin. If provider is not signed in at induction begin or induction begin time not available then, 
  3. Provider signed in at Procedure Start. If provider is not signed in at procedure start or procedure start time not available then, 
  4. Provider signed in at Patient in Room. If provider is not signed in at patient in room or patient in room time not available then, 
  5. Provider signed in Anesthesia Start. 
MPOG Concept Used

Antiemetic (by class)

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

  • 10335 Ondansetron
  • 10208 Granisetron
  • 10711 Palonosetron

Anticholinergics

  • 10400 Scopolamine Patch
  • 10399 Scopolamine
  • 11040 Butylscopolamine

Antihistamines

  • 10257 Dimenhydrinate
  • 10160 Diphenhydramine
  • 10635 Meclizine

Antidopaminergics

  • 10169 Droperidol
  • 10210 Haloperidol
  • 10297 Metoclopramide
  • 10820 Amisulpride

Neurokinin-1 Receptor Agonists

  • 10035 Aprepitant
  • 10719 Fosaprepitant

Phenothiazines

  • 10374 Promethazine
  • 10373 Prochlorperazine

Glucocorticoids

  • 10147 Dexamethasone
  • 10296 Methylprednisolone

Other

  • 10377 Propofol (Infusion only)
  • 10378 Propofol w/ Remifentanil 10 mg/ml + 5 mcg/ml (Infusion only)
  • 10453 Propofol w/ Ketamine 10 mg/ml + 1 mg/ml (Infusion only)
  • 10572 Propofol w/ Ketamine 10 mg/ml + Unspecified ketamine (Infusion only)
  • 10577 Propofol w/ Ketamine 10 mg/ml + 0.5 mg/ml (Infusion only)
  • 10578 Propofol w/ Ketamine 10 mg/ml + 1.5 mg/ml (Infusion only)
  • 10579 Propofol w/ Ketamine 10 mg/ml + 2 mg/ml (Infusion only)
  • 10597 Propofol w/ Alfentanil 10 mg/ml + 50 mcg/ml (Infusion only)
  • 10639 Propofol w/ Remifentanil 10 mg/ml + 10 mcg/ml (Infusion only)
  • 10649 Propofol w/ Remifentanil 10 mg/ml + 20 mcg/ml (Infusion only)
  • 10651 Propofol w/ Remifentanil 10 mg/ml + 40 mcg/ml (Infusion only)

PONV Risk Factor- Smoking Status 

  • 70128 History - Social History- Tobacco
  • 70160 History - Social History - Tobacco (Current Smoker)
  • 70161 History - Social History - Tobacco (Former Smoker)
  • 70162 History - Social History - Tobacco (Non Smoker)
  • 71100 History - Social History- Tobacco Details Pack Years
  • 71110 History - Social History- Tobacco Details Current vs Past

Refer to Tobacco Smoking Classification phenotype for more details.

PONV Risk Factor- History of PONV/Motion Sickness

  • 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- Postoperative Opioid

Intravenous or Oral Medications

  • 10020 Alfentanil
  • 10186 Fentanyl
  • 10187 Fentanyl / Midazolam 40mcg/mL / 200mcg/mL
  • 10219 Hydromorphone
  • 10279 Meperidine
  • 10290 Methadone
  • 10306 Morphine
  • 10341 Oxycodone
  • 10414 Sufentanil
  • 10481 Oxycodone / Acetaminophen 5 mg / 325 mg
  • 10482 Hydrocodone / Acetaminophen 5 mg / 325 mg
  • 10483 Hydrocodone / Acetaminophen 7.5 mg / 500 mg
  • 10597 Propofol w/ Alfentanil 10 mg/mL + 50 mcg/mL

Local anesthetics with opioids

  • 10008 Bupivacaine w/ Hydromorphone 0.1% / Unspecified
  • 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
  • 10258 Bupivacaine w/ Hydromorphone 0.05% / 3 mcg/mL
  • 10408 Bupivacaine w/ Fentanyl 0.0625% / 5 mcg/mL
  • 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
  • 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
  • 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
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, 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.
Measure Reviewer(s)
Next Review: 2024
 Date Reviewed  Reviewer  Institution  Summary  QC Vote

 NA

 NA  NA  NA NA
Version
Published Date: 01/2022
 Date  Criteria  Revision
04/11/2023  Exclusion  Case duration updated to use Surgery Duration algorithm
03/16/2023  Exclusion  Replaced Non-Operative phenotype with Intubation Only as exclusion