Standardizing Documentation

for Postoperative Nausea

and Vomiting in the Electronic
Health Record
CONNI DeBLIECK, DNP, RN; ANNE FISHMAN LaFLAMME, BSN, RN; MARY JANE RIVARD, BSN, RN;
KAREN A. MONSEN, PhD, RN, FAAN

ABSTRACT
Postoperative nausea and vomiting (PONV) remains a common postoperative com-
plication that causes patient discomfort and increases health care costs. Clinicians use
the American Society of PeriAnesthesia Nurses (ASPAN) guideline to help prevent
and treat PONV. However, the lack of standardized terminology in the electronic
health record (EHR) and the lack of clinical decision support tools make it difficult for
clinicians to document guideline implementation and to determine the effects of
nursing care on PONV. To address this, we created a concept map of the Perioperative
Nursing Data Set (PNDS) that illustrates the relationship between elements of this
standardized nursing terminology and the ASPAN guideline, using the Systematized
Nomenclature of MedicinedClinical Terms multidisciplinary terminology to fill any
gaps. This mapping results in a standardized dataset specific to PONV for use in an
EHR, which links nursing care to nursing diagnoses, interventions, and outcomes. The
mapping and documentation in the EHR also allows standardized data collection for
research, evaluation, and benchmarking, which makes perioperative nursing care of
patients who are at risk for or experiencing PONV measureable and visible.
Distributing this information to perioperative and perianesthesia nursing personnel, in
addition to implementing risk assessment tools for PONV and clinical support alerts
in electronic documentation systems, will help support implementation of the PONV
clinical practice guideline in the EHR. AORN J 98 (October 2013) 370-380.
AORN,
Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2012.12.021

Key words: postoperative nausea and vomiting, PONV, Perioperative Nursing Data
Set, PNDS, standardized nursing terminology, electronic health record, EHR,
postoperative nursing.

unpleasant side effects of anesthesia.1 The Amer-

P
ostoperative nausea and vomiting (PONV)
and postdischarge nausea and vomiting ican Society of PeriAnesthesia Nurses (ASPAN)
(PDNV) are two of the most common and evidence-based Clinical Practice Guideline for the

http://dx.doi.org/10.1016/j.aorn.2012.12.021
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AORN, Inc, 2013
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Prevention and/or Management of PONV/PDNV1 because of a lack of standardized terminology in

guides anesthesia professionals and perianesthesia electronic documentation (eg, individual data el-
nurses in preventing and treating these side effects. ements, care interventions, patient outcomes) as
Coupling this clinical practice guideline with the well as a lack of clinical decision support tools.
clinical decision support mechanisms available in To help resolve this challenge, we developed a
electronic health records (EHRs) supports evidence- concept map (Figure 1) of the Perioperative Nursing
based care. However, it is difficult for clinicians Data Set2 (PNDS) that illustrates the relationship
to appropriately document the implementation of between elements of this standardized nursing ter-
the guideline recommendations at the point of care minology and maps it to the PONV portion of the

Figure 1. A concept map demonstrates how a standardized terminology documents nursing care. SNOMED
CT is a registered trademark of the International Health Terminology Standards Development Organisation,
Copenhagen, Denmark.

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ASPAN guideline1; when there was no PNDS term for implementing specific preventive and rescue
that adequately matched the PONV guideline, we measures.1
mapped it to the Systematized Nomenclature of Perioperative providers who do not use a PONV
MedicinedClinical Terms (SNOMED CT), a risk assessment tool do not have the basic foun-
multidisciplinary terminology. This mapping re- dation of risk classification on which the ASPAN
sulted in a standardized dataset using SNOMED evidence-based guidelines rely.1 The preventive
CT and mapping with the ASPAN algorithm that recommendations in the guideline include anes-
was specific to PONV for use in an EHR. thesia interventions (eg, total IV anesthesia, re-
gional blocks, non-steroidal anti-inflammatory
GUIDELINE DESCRIPTION AND RATIONALE agents) and pharmacological interventions (eg,
According to ASPAN, PONV is defined as the onset dexamethasone, 5-HT3 receptor antagonists, an-
of nausea or vomiting in the first 24 hours after tihistamines, scopolamine patches, droperidol).
surgery.1 The ASPAN guideline takes into account Therapeutic interventions include ensuring ade-
the entire range of perioperative care from pre- quate hydration and the multi-modal treatment of
admission to post-discharge. It includes preventive pain. Acupressure and aromatherapy also are cited
and treatment interventions, as well as pharmaco- as complementary interventions for PONV1 and
logical, therapeutic, and complementary interven- can be provided by nurses.
tions for the adult patient undergoing surgery or Not completing a PONV risk assessment can
an invasive procedure that requires anesthesia or result in a substandard level of care for the patient.
sedation.1 The guideline ranks the recommenda- Often, individual elements of a PONV risk as-
tions for each perioperative phase of care based sessment are scattered throughout the clinical re-
on the amount of benefit and risk to the patient cord, which makes it difficult for the perioperative
and the graded level of evidence available to sup- or postanesthesia care unit (PACU) clinicians to
port the recommendation.1 score the patient’s risk and develop a plan of care.
In the guideline, ASPAN also emphasizes the Therefore, the anesthesia professional cannot order
importance of using a risk assessment tool to ac- the appropriate interventions as supported by the
curately determine the patient’s risk of PONV, such ASPAN guideline, and the nurse cannot administer
as the testing tools from Apfel et al3 and Koivur- the most appropriate medications. Another risk
anta et al.4 Data elements collected in a PONV risk if the baseline assessment is not completed is
assessment3,4 include the patient’s that the patient may receive an inappropriate
level of intervention, which may result in side
n gender,
effects from unnecessary treatments or a failure to
n history of PONV and motion sickness, and
prevent PONV.5
n smoking status.
The lack of standardized data elements to doc-
Scoring is based on the “American College of ument PONV assessment and intervention makes
Cardiology/American Heart Association classifica- it impossible to quantify the outcomes of the rec-
tion which address the risk/benefit ratio and amount ommended evidence-based care guidelines or report
and quality of the evidence supporting the recom- current trends in PONV.5 In addition, benchmarking
mendation.”1(p231) Furthermore, the patient “classes quality of care related to PONV between facilities
are ranked and based on clinical indication of re- cannot be completed without collecting these data.
commendation and consideration of the risk versus In today’s health care culture, it is increasingly im-
benefit.”1(p231) The higher the resulting score, the portant to use clinical data to quantify the quality
greater the risk that the patient will experience of care for reimbursement and accreditation and to
nausea or vomiting and the greater the evidence improve current clinical care guidelines. Therefore,

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it is important to be able to integrate the ASPAN significant changes in practice, according to a 2008
guideline into the EHR to support best practices for study by Kooij et al.9 This research showed a sub-
the patient and maintain high standards of care. stantial difference in patient improvement between
support methods. Individuals who identified with
IMPLEMENTING THE CLINICAL PRACTICE three of the four risk factors were “prescribed
GUIDELINE PONV prophylaxis that consisted of dexametha-
Research supports the implementation of the sone 8 mg IV given on induction of general anes-
ASPAN clinical practice guideline to assist peri- thesia and granisetron 1 mg IV administered shortly
operative practitioners in preventing PONV for before awakening.”9(p894)
surgical patients. For example, using a risk as- There is a small amount of research describing
sessment tool and integrating clinical decision the implementation and effectiveness of clinical
support reminders into the EHR can be helpful. decision support tools for PONV in EHR docu-
By using these tools to prevent PONV, perioper- mentation. In one such study by Kooij et al,9 73%
ative personnel can both offset and prevent patient of high-risk patients, who were identified as such
discomfort and the costs related to PONV. because they met three out of four risk factors in
The use of a risk assessment tool is supported in the Apfel et al3 PONV risk assessment, were pre-
the literature to reduce the risk of giving unneces- scribed prophylactic antiemetics after clinicians
sary interventions to low-risk patients who may not implemented a patient-specific clinical decision
experience the same degree of benefit from them.3-6 support reminder in the electronic anesthetic re-
As tested, the simplified risk assessment tools from cord and not in the nursing EHR. In this study,
Apfel et al3 and Koivuranta et al4 are better suited the researchers compared prophylactic antiemetic
for this than more complicated tools such as the one prescription rates after the reminder was imple-
from Sinclair et al.6 A comparison of six available mented and discovered a 38% pre-intervention
risk assessment methods showed Apfel et al3 and increase in prophylaxis. After the reminder was
Koivuranta et al4 “have the best discrimination and discontinued, there was a decrease of 41% in pre-
calibration”7(p238) and have identified four common scribing prophylactic antiemetics.10 As a follow-up,
risk factors for PONV: Kooij et al10 re-implemented the guidelines; in
the pre-admission testing phase of care, when
n female gender,
patients were determined to need intraoperative
n nonsmoker,
PONV prophylaxis, adherence to prescribing
n a history of PONV, and
3,4 guidelines increased from 37% to 79%. This re-
n a history of motion sickness.
search supports the integration of individualized
The simple models3,4 are unique in that they dem- clinical decision support tools into electronic sys-
onstrate generalization to different practice envi- tems as a reminder for perioperative staff members
ronments,7 and their simplicity makes them easy to order antiemetic medications based on the pa-
to implement with little cost and minimal education. tient’s level of risk.
Shojania et al8 completed a systematic review Furthermore, when implementing evidence-
of 28 studies obtained from the Cochrane database based practices, clinicians must consider the pa-
and found that EHR clinical decision support re- tient’s perspective on treatment. According to
minders about interventions that are provided to the ASPAN, “PONV is the most commonly reported
patient improved adherence to PONV guideline patient fear before elective surgery, and it is rated
processes by 4.2%. More research is needed to by patients as being more debilitating than post-
identify the characteristics of clinical reminders operative pain or the surgery itself.”1(p232) The
that encourage clinicians to make statistically reported incidence of PONV averages 38.3% in

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the PACU7 and more than 50% after discharge amount of nitrous oxide during induction. The pa-
to home.4 The literature cites evidence in support tient undergoes surgery lasting 190 minutes in a
of implementing the PONV clinical guidelines to supine position. She has sequential compression
reduce PONV effects for patients.1,11 devices on both legs, and a forced-air warming
In addition to patient discomfort, the costs of blanket is used to maintain normothermia. The
PONV and PDNV also may include the treatment patient tolerates the procedure well.
of adverse effects caused by vomiting (eg, wound The patient arrives in the PACU without inci-
dehiscence, aspiration), which can lead to increased dent. Her vital signs are within normal limits and
lengths of stay; unplanned inpatient stays after sur- she voices no initial symptoms of nausea. During
gery; an increase in home recovery periods; and lost the 15-minute postoperative evaluation, however,
work time.12 Wender states, “As [the] most common the patient reports moderate nausea, which she
of postsurgical complications, [PONV] and [PDNV] states is a level 6 on a 10-item verbal descriptor
affect approximately 25 million patients worldwide scale. She soon begins vomiting small amounts
yearly, with an estimated annual financial impact of fluid consistent with the presence of bile in the
of several million dollars.”11(S3) stomach. The PACU nurse notifies the anesthesia
There is supporting evidence that the cost- professional per facility policy while implemen-
effective use of interventions for PONV begins ting the PONV protocol according to the ASPAN
by using the simplified risk assessment tool to guideline. The patient’s hydration status and blood
determine the appropriate interventions on a per- pressure are adequate, and the PACU nurse admin-
patient basis.11-14 Therefore, to offset and prevent isters the droperidol as ordered by the anesthesia
patient discomfort and related costs from PONV, professional. As a complementary therapy, the
it is important to implement the ASPAN guideline PACU nurse offers the patient aromatherapy, but
within the EHR. It is helpful to view this in regard she refuses. After 15 minutes, the patient reports her
to a clinical patient’s experience (Figure 2). nausea score is a 4 out of 10. The nurse continues
to assess the patient until her discharge from the
Case Study PACU subsequent to continued improvement.
A 46-year-old woman is scheduled for a total ab-
dominal hysterectomy. She does not have a history TRANSLATION PROCESS
of smoking or alcohol use. She has a history of We began the translation process (ie, matching data
motion sickness and previous PONV. In addition, across multiple elements) by identifying various data
she is terrified of the PACU because of her previous elements in the EHR that comprise risk assessment
experience with PONV. In the preoperative area, and parts of the ASPAN guideline algorithm. We
the anesthesia professional receives a clinical de- matched PNDS concepts with data elements such
cision support alert with the patient’s PONV risk as code type, identifiers, domains, and description
score, which suggests the prophylactic administra- and then chose data elements that corresponded
tion of an antiemetic and the avoidance of certain with the PNDS and SNOMED CT. We chose
anesthetic medications such as nitrous oxide, potent SNOMED CT because PNDS concepts already
inhaled agents, and opioids.15 have been mapped to SNOMED CT concepts.16
The anesthesia professional administers ondan-
setron, a 5-HT3 receptor antagonist, to the patient Selecting the Appropriate Terminology
on arrival to the OR. The anesthesia professional Selecting the appropriate terminology is critical
avoids using volatile anesthetic agents, such des- when mapping an evidence-based guideline to a
flurane or sevoflurane,15 but does use a nominal recognized nursing terminology in an EHR. In

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Figure 2. A flow diagram demonstrating how a case study is integrated with the concept map.

a review of selected EHRs, we found a lack of specific to PONV/PDNV. Therefore, we proposed

standardized documentation and clinical decision the use of AORN’s PNDS revised second edition2 as
support related to the PONV/PDNV guidelines and the interface terminology for the ASPAN PONV/
a lack of measurable interventions and outcomes PDNV clinical guideline.

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The American Nurses Association recognized demonstrated successful concept mapping of the
the PNDS as an official nursing terminology in PNDS to the SNOMED CT reference terminology.
1999.17 The PNDS is an empirical, validated, and This is beneficial for future interoperability re-
standardized way of describing nursing care in the quirements for EHR documentation.19
perioperative area, and using it supports perioper- Mapping the PONV/PDNV clinical guideline
ative nursing to further evidence-based practice, with the PNDS fills the gap of nursing interventions
manage costs, and improve quality of care. Addi- and outcome measurements that are currently found
tionally, the PNDS provides consistent terms and in EHRs. Interventions and outcomes are identifi-
precise definitions for nursing diagnoses, interven- able at intervals throughout the perioperative phase
tions, and outcomes specific to the perioperative of care through direct patient assessment. Inserting
phases of care. AORN also has approved the PNDS the PNDS terminology within the ASPAN clinical
for use within various EHRs, specifically in OR guideline assists nurses in identifying patient needs,
information management systems.17 For these re- recommending appropriate interventions, and set-
asons, this interface terminology suits the EHR ting outcome goals throughout the care continuum.
because the “manner in which data is documented, The combination of guideline EHR documentation
captured, and mined is a critical factor for improving and PNDS interventions and outcomes documen-
health care.”2(pvii) tation in discrete fields facilitates reporting on these
The PNDS also is associated with the Peri- data and evaluating PONV/PDNV at the patient,
operative Patient-Focused Model as a conceptual department, facility, or population level. Imple-
framework for use in perioperative nursing prac- menting the PONV/PDNV guideline with links to
tice.18 This patient-centered model is divided into the PNDS also reinforces the association between
four domains: safety, physiological responses, be- the guideline interventions and nursing assessment,
havioral responses, and the health system.2 These interventions, and outcomes. This shifts the nurs-
domains relate to the three types of PONV/PDNV ing focus to prevention, rather than treating PONV
prevention and treatment intervention recommen- after it occurs.
dations (ie, pharmacological, therapeutic, comple- We developed a concept map of the PNDS using
mentary).1 A combination of the patient-focused the Institute for Human and Machine Cognition
model and the PONV/PDNV guideline can provide Cmap Tools20 software that demonstrates how a
a fit within guidelines using the PNDS data el- standardized terminology documents nursing care.
ements. These elements are clearly defined, are As a collage of words, the concept map described
relevant to PONV/PDNV clinical application, have in Figure 1 outlines the standardized terminology
the same common language for all procedures, and perspective and illustrates the relationships between
are consistent with guidelines.18 Furthermore, the each of its concepts. This mapping will assist cli-
PNDS coded terminology framework describing nicians in understanding the relationships, leading
patient care allows for a standardized nomenclature to desired outcomes.
and gathering of data for immediate patient use,
supports quality improvement, and provides reli- Strengths and Limitations
able and valid clinical data.18 Having the ASPAN PONV clinical practice
The combination of an improved framework and guideline incorporated into the EHR provides
standardization results in a standardized termi- evidence-based practices that support quality of
nology that functions across the continuum of care performed by perioperative nurses and anes-
perioperative patient care, and this infrastructure thesia professionals. The purpose of the guide-
in turn supports both human and technical com- line is to identify risk factors associated with
munication needs. Additionally, Westra et al16 PONV during the preoperative phase of care and

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effectively prevent or treat PONV based on current of postoperative opioids, do not have a mapping
evidence. Clinical decision support guides clini- to either PNDS or SNOMED CT.
cians to standardize the treatment of patients who Limitations exist for implementing the guide-
are at risk for or are experiencing PONV with the line in an electronic format when personnel do not
intention of helping medical and nursing personnel readily accept changes embedded into the EHR into
proactively intervene according to the evidence- their practice. For instance, clinical decision support
based guideline. tools could be ignored by clinicians, resulting in
Mapping the PONV guideline to PNDS and minimal or no change in practice and patient out-
SNOMED CT in the EHR links nursing cared comes. Focused education, active staff involve-
represented by documentation of assessmentsdto ment, and post-implementation monitoring of
nursing diagnoses, interventions, and outcomes. clinicians’ responses to clinical decision support
It also allows standardized data collection for re- alerts, however, could overcome these limitations.
search, evaluation, and benchmarking of care. In Also, in the current market, clinical decision sup-
this way, perioperative nursing care of the patient port is mostly limited to vendor-supported systems
at risk for or experiencing PONV becomes mea- that require an expensive implementation in most
surable and therefore visible.21 facilities.
The PNDS alone does not support a comprehen- Another limitation is that this mapping was not
sive and accurate mapping of the ASPAN clinical completed with the most recent version of PNDS,
practice guideline to the nursing terminology and but was accomplished with the 20072 revised sec-
requires the use of SNOMED CT as well. For in- ond edition. The current version of PNDS is part of
stance, the recommended preventive and treatment the AORN Syntegrity Framework, an electronic
antiemetic medications and care guidelines for data model that incorporates PNDS data elements
patients who are female and have a history of with standardized perioperative documentation.18
motion sickness do not exist in the PNDS but do This is an important limitation, and the mapping
exist in SNOMED CT. Even when a PNDS concept discussed in this article needs to be updated to the
relates to the PONV risk assessment and algorithm most recent version of PNDS.2
elements, it is often not specific enough. As an
example, the assessment of PONV maps to PNDS
E.310, evaluation of gastrointestinal status.2 Al- SUGGESTED IMPLEMENTATION PLAN
though an evaluation of gastrointestinal status Successful dissemination of information requires
includes evaluating the patient for nausea and precise planning by project coordinators. There
vomiting, it is not exclusive to nausea and vom- are many facets to consider, such as what infor-
iting and results in an indirect map to this element mation to distribute and where and how to distrib-
in the PONV clinical practice guideline. Examples ute it to perioperative and perianesthesia personnel.
like this abound in the mapping and need to be Acute care facilities communicate information in
addressed, possibly by the introduction of more several ways, including the use of e-publications,
granular subconcepts (ie, narrower, more specific e-learning, unit meetings, e-mail, and printed post-
categories) under the broader concepts in the ers or presentations. To communicate and educate
PNDS to accurately map the guideline to the peri- personnel about this implementation, we suggest
operative nursing terminology. Likewise, the risk n using a learning module to explain the ASPAN
assessment results are very specific to the nausea guidelines and how to document a PONV risk
and vomiting risk assessment and do not map to assessment during the preoperative phase,
either terminology. Additional elements, such as n holding unit meetings to inform personnel of
surgery that lasts more than 60 minutes and the use upcoming changes in the EHR, and

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Figure 3. The ASPAN algorithm. Copyright ª2010-2012 American Society of PeriAnesthesia Nurses (ASPAN). All
rights reserved. Reprinted with permission.

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n providing staff members with pocket-sized practice guideline and including it in EHR docu-
laminated copies of the ASPAN algorithms mentation makes the assessment available to all
(Figure 3). clinicians, and clinical decision support models
can be constructed to increase adherence to the
These tactics help personnel recognize and treat
recommendations.
PONV according to the ASPAN guidelines.
Our suggested implementation plan includes Editor’s notes: The second edition of the Periop-
building clinical decision support mechanisms into erative Nursing Data Set (PNDS) was superseded by
the EHR to assist personnel with the practice change the third edition (PNDS 3) in 2011. The PNDS 3
processes. To do this, the risk factor assessment terminology is only distributed through AORN and
should be incorporated into existing documentation AORN Syntegrity licensed vendors. For questions
and a clinician should calculate the patient’s total about PNDS 3 implementation into the electronic
score to generate several risk factor alerts. This total health record and electronic perioperative record
score can be used to inform staff members and solutions, please contact the AORN Syntegrity team
anesthesia professionals of the patient’s potential via e-mail at [email protected]. AORN Syntegrity
PONV risk in the preoperative, intraoperative, and is a registered trademark of AORN, Inc, Denver,
PACU areas, and it encourages the use of recom- CO. SNOMED CT is a registered trademark of the
mended treatments based on the algorithm that is International Health Terminology Standards De-
programmed into the EHR. In addition, anesthesia velopment Organisation, Copenhagen, Denmark.
professionals should use the ASPAN algorithm
laminated pocket guide that provides suggested
treatment according to the patient’s level of risk. References
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