Implementation of a Postoperative Aromatherapy Pilot Project

Introduction

Every year, hundreds of millions of people receive surgical care to address a physical health issue (Hall, Schwartzman, Zhang, & Liu, 2017), with some estimates as high as 230 million a year worldwide (“Anesthesia death rates”, 2012). Many millions of these surgical patients require the use of anesthesia, of which a common side-effect is postoperative nausea and vomiting (PONV). PONV can complicate postoperative healthcare, reduce hospital efficiency, and increase healthcare costs. However, there is a low-cost method for reducing PONV that can significantly enhance healthcare and hospital outcomes: postoperative aromatherapy.

Rationale and Significance

As a practicing post-anesthesia care nurse (PACU) registered nurse (RN), the author of this paper has observed first-hand the nausea and vomiting that often result from anesthesia. Approximately 20 to 40 percent of all surgical patients suffer from PONV (Stoicea et al., 2015). Women are at higher risk from developing PONV; other risk factors include the use of nitrous oxide; a health history of PONV and/or motion sickness; surgeries involving the abdomen, breast, ear, nose, or throat; postoperative opioid use; and age (with younger patients being more likely to suffer from PONV rather than older patients (PONV) (Stoicea et al., 2015).

While postoperative nausea (PON) can increase patient anxiety and lead to greater patient dissatisfaction with the process, postoperative vomiting (POV) can have more significant healthcare implications (Stoicea et al., 2015). POV can lead to “hematoma, dehydration, aspiration, and esophageal damage” (Stoicea et al., 2015, para 1); in cases of maxillofacial surgery, vomiting can lead to excessive bleeding and ruptures of the wound along the surgical incision (wound dehiscence). Further, PONV can delay the discharge process, and by extension, the treatment of other patients (Stoicea et al., 2015).

With proper implementation and resource support, the author anticipates that this pilot project would provide efficient and effective alleviative care to adult patients in post-surgical care who have received anesthesia medication. It would also improve patient satisfaction with the surgical process, and prevent, reduce, or eliminate healthcare complications stemming from PONY using a low-cost, low labor solution. If expanded to all postoperative wards across the author’s employer facility, the author expects that the use of postoperative aromatherapy could help reduce hospital-wide postoperative discharge transitions to nonacute care settings; reduce postoperative healthcare complications and medical costs; reduce reported instances of PONV; and increase surgical patient satisfaction. 

Literature Review

While the author’s choice of this project was rooted in firsthand observation, the incorporation of aromatherapy into post-surgical care and in other forms of alleviative care has been explored in other facilities and in published research. Stoicea et al.’s 2015 study examined the effectiveness of a range of alternative medicines, including CBD oil, in reducing or elimination PONV, including music therapy, acupuncture, and electro-acupuncture (2015). The use of isopropyl alcohol and peppermint were also examined; while Stoicea et al. noted some studies that showed evidence that the placebo effect might be responsible for aromatherapy’s benefits, it also cited others that showed effectiveness in alleviating PONV (2015). Of these, Mamaril, Windle, and Burkhard’s 2012 study showed some nausea reduction (Mamaril et al., 2012). Hinds et al. also completed a study in 2009 that showed that aromatherapy provided some reduction of PONV (Hines, Steels, Chang, & Gilshenan, 2009). Another study showed that postoperative pain could be alleviated by the provision of lavender treatments (Olapour et al., 2013). This study was limited to a small sample size of 60 women, however. Jun et al. (2013) also found some alleviative effects on PONV on knee replacement patients who took anesthesia medication. Given the mixed evidence in existing academic research of the effectiveness of this intervention, this pilot project will serve both as further validation of evidence-based practices as well as both a new protocol. 

Project Implementation

Upon approval, the author intends to work with the nurses in her postoperative care ward (the postoperative aromatherapy, or PA) team, the hospital’s care management/planning team and the information technology team to develop a postoperative aromatherapy working committee (PA-WC) for implementation. While consensus would be sought, it is assumed that success metrics would include the following: (1) lower levels of patient PONV (observed and reported); (2) lower rates of anti-nausea drugs being prescribed in the pilot project ward; (3) lower rates of post-operative complications reported; (4) cost-savings realized from reduction in prescription drug use; (5) higher levels of post-operative ward discharge satisfaction reported; and (6) higher levels of post-hospital discharge satisfaction. When outcomes were agreed to, the PA-WC would develop a screening mechanism for individuals at high risk for experiencing PONV. The author envisions an algorithm that searches for such patients, provides the author an electronic list of their names and cases for review, screening out those who have indicated sensitivities and/or allergies to natural fragrances, as well as respiratory difficulties. Upon review, the author will work with the care planning team to provide patients with information about the pilot program and obtain their informed consent. Upon obtaining informed consent, the PA team will provide patients with peppermint and/or lavender aroma inhalants while they are in the ward. The PA team will be asked to complete a brief observational form at the end of the aromatherapy treatment; similarly, patients in the pilot project will be asked to self-report their physiological symptoms after the conclusion of the treatment. The author will also work with the PA team, treating physicians, and the pharmacy to assess the frequency of anti-nausea drugs being prescribed to patients in this ward. Aggregated observational behavior data and discharge surveys, along with prescription drug data, will be assessed each month, and compared to data from wards not using aromatherapy treatments. 

Testing the efficacy of aromatherapy also requires testing the efficacy of the inhalant; an inhalant that does not disperse the fragrance effectively will impair the effectiveness of the project. Moreover, inhalants may not be the best form of aromatherapy to alleviate pain (existing literature is not clear on which methods are the most effective). Depending on the results of the inhalants, the PA-WC team may need to test the efficacy of aromatherapy swabs. The author proposes that after a month of the project, a second ward be engaged in a similar pilot to test the efficacy of aromatherapy swabs, with fragrances delivered directly to the surgical site.

Based on a cursory Google search, aromatherapy inhalants can be purchased for approximately $0.30 for orders between 1,000 and 10,000. With approximately 70 individuals coming through the ward per month, two to three inhalants necessary to obtain the intended effect per patient, and approximately 10 percent held in reserve to address potential human error in the pilot program, the author estimates that a single order of inhalants can accommodate the pilot project for three months. The budget for this project is accordingly approximately $500 (plus taxes and shipping), as it also includes aromatherapy swabs which can be purchased for an estimated $0.02 per swab at prevailing wholesale rates.

Potential Challenges

There are several potential challenges to this pilot, including the author not being able to obtain approval, inability to develop a rapid screening mechanism internally, inability of nurses to properly implement aromatherapy treatments properly, and inability to obtain enough patients who provide informed consent to obtain the desired internal validity for this effort. Assuming approval, the author will work assiduously to recruit effective team-members who are invested in the project, provide personal training in aromatherapy techniques to each PA team nurse, and provide personalized coaching to each PA team nurse about how to improve the chances of receiving informed consent from patients.

References

Anesthesia death rates improve over 50 years. (2012). CBC News. Retrieved from http://www.cbc.ca/news/health/anesthesia-death-rates-improve-over-50-years-1.1200837

Hall, M. J., Schwartzman, A., Zhang, J. and Liu, X. (2017). Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010. National Health Statistics Reports. Retrieved from https://www.cdc.gov/nchs/data/nhsr/nhsr102.pdf.

Hines, S., Steels, E., Chang, A., & Gilshenan, K. (2009). Aromatherapy for treatment of postoperative nausea and vomiting: A Cochrane systematic review. International Journal of Evidence-Based Healthcare, 7(3).

Jun, Y. S., Kang, P., Min, S. S., Lee, J.-M., Kim, H.-K., & Seol, G. H. (2013). Effect of eucalyptus oil inhalation on pain and inflammatory responses after total knee replacement: A randomized clinical trial. Evidence-Based Complementary and Alternative Medicine: eCAM, 2013, 502727. 

Mamaril, M. E., Windle, P. E. & Burkhard, J. F. (2006). Prevention and management of postoperative nausea and vomiting: A look at complementary techniques. Journal of Perianesthesiology Nursing, 21(6), 404-410. 

Olapour, A., Behaeen, K. Akhondzadeh, R., Soltani, F., al Sadat Razavi, F. & Bekhradi. R. (2013). The effect of inhalation of aromatherapy blend containing lavender essential oil on cesarean postoperative pain. Anesthesiology and Pain Medicine, 3(1), 203-207.

Stoicea, N., Gan, T. J., Joseph, N., Uribe, A., Pandya, J., … , & Bergese, S. D. (2015). Alternative Therapies for the prevention of postoperative nausea and vomiting. Frontiers in Medicine, 2, 87. http://doi.org/10.3389/fmed.2015.00087