PHASE 2: PREPARATION

FAME (Feasibility, appropriateness, meaningfulness effectiveness) criteria can be used to help select the intervention to be implemented. (Pearson et al., 2005).

Please see the FAME assessment of acupressure for PONV.

View FAME Assessment of Acupressure for PONV

The initial FAME analysis based on the literature indicates moderate to strong support for acupressure on each of the four criteria.  Acupressure is a feasible, appropriate, meaningful and effective intervention that should be implemented for PONV.

When acupuncture or acupressure is introduced depends on the purpose of the intervention. If acupuncture / acupressure is intended to prevent PONV, then the intervention needs to be applied prior to surgery or immediately after surgery. If it is designed to manage PONV, then it can be used after surgery when patients experience PONV. It is possible to use acupuncture for both purposes. In that case, acupuncture is applied both pre-operatively and post-operatively. Acupuncture is often provided 30 min prior to surgery due to the availability of staff. A recent study shows acupuncture provided about 12 to 24 hours prior to surgery is also effective in preventing PONV (Li et al., 2017).

The time of application and the form of acupuncture or acupressure are determined by the characteristics of the inner setting, including the availability of staff, patient scheduling, and surgical population. For high risk patients, prevention is essential.

Types of patients: One need to consider individual risks and patient preferences.

PONV management guidelines recommend that additional PONV prophylaxis be given to patients at higher risk (Gan et al., 2014). Recent analysis of 22 studies (n=95154) indicated that the most reliable patient predictors of PONV are female gender, history of PONV or motion sickness, non-smoker, and younger age (Apfel et al., 2012).

Patients at higher PONV risk may show greater benefit from the use of acupoint stimulation (Frey et al., 2009) and increased satisfaction with PONV prophylaxis  (Scuderi et al., 1999). Patient preference is also important as a high proportion of patients prefer additional non-drug therapy for PONV (Weeks et al., 2017). Pre-operative PONV rsik assessment is necessary. See here for a sample self-check PONV risk assessment sheet developed based on Apfel score (Apfel et al., 1999).

Type of surgery:  Surgery related predictors of PONV include duration of anaesthesia with volatile anaesthetics and postoperative opioids analgesia (Apfel et al., 2012).  The influence of surgery type is debated, but cholecystectomy, gynaecological and laparoscopic surgery have reported significantly higher incidences of PONV (Apfel et al., 2012), and are considered to place patients at higher risk (Gan et al., 2014).  Subgroup analysis of surgeries (caesarean section, gynaecological and other surgeries) has shown that acupressure effectively reduced nausea, vomiting and rescue antiemetic use for all these subgroups of patients (Shiao and Dune, 2006).

To enable the implementation and documentation of acupuncture / acupressure, hospital PONV guidelines and PONV documentation need to be revised or developed.

• Hospital PONV guidelines to be revised
• PONV checklist is needed
• Patient information about acupuncture / acupressure if needed
• Operative checklist to reflect the use of acupressure
• Ward notes
• Drug chart to reflect the use: if wristband is used

The limited literature shows that the four keys barriers to implementing acupuncture for PONV are

• B1: a lack of awareness of existing evidence;
• B2: a lack of capability;
• B3: a lack of equipment; and
• B4: a lack of time.

The enablers could be the interests of anaesthetists, nurses or surgeons in providing acupuncture or acupressure to patients or to receive education about this non-drug intervention.

Situation analysis is necessary based on the known and unknown barriers. See a sample situation analysis list and related actions for acupressure wristband as an example.