<p><strong>BACKGROUND: </strong>Postoperative nausea vomiting (PONV) after elective outpatient surgery can complicate discharge and increase patient suffering. Within our hospital system, there was variability in the use of PONV prophylaxis for patients undergoing anterior cruciate ligament (ACL) reconstruction, which resulted in variable outcomes. To address this variability, we designed and implemented a standardized PONV prophylaxis guideline for the care of this surgical population.</p>

<p><strong>AIM: </strong>We sought to develop and implement a standardized PONV prophylaxis guideline for all patients presenting for elective ambulatory ACL reconstruction with the goal of reducing the rate of emesis to less than or equal to 5%.</p>

<p><strong>METHODS: </strong>We convened a multidisciplinary team to develop a PONV prophylaxis guideline which included administration of dexamethasone, ondansetron, and a low-dose propofol infusion in addition to a femoral and sciatic nerve block and routine ketorolac administration for pain control. Our primary outcome, emesis rate, was tracked using a P-chart. Process measures included use of guideline medications and balancing measures included opioid administration, pain scores, and emergence time.</p>

<p><strong>RESULTS: </strong>We analyzed PONV outcomes for 817 patients from January 1, 2014, to December 31, 2018. The baseline postoperative emesis rate for all anesthetizing locations was 17%. Following, guideline implementation, the emesis rate decreased to 5%. Opioid administration was decreased following guideline implementation. The percentage of patients managed without any perioperative opioids increased from 16% in the baseline group to 38% following guideline implementation. The P-chart suggests that the observed reduction in emesis rate represents special cause variation and this reduction was sustained over a two-year period.</p>

<p><strong>CONCLUSIONS: </strong>Implementation of standard PONV guidelines for adolescents undergoing outpatient ACL reconstruction was associated with lower emesis rates. This reduction in emesis rate may have been due to the concurrent reduction in opioids we observed following guideline implementation.</p>