Quality Committee Meeting Minutes 8.27.2018

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Quality Committee Meeting Notes – Monday, August 27, 2018

Attendees: P=Present; A=Absent; X=Expected Absence

Applefield, Daniel (St. Joseph Oakland)

LaGorio, John (Mercy Muskegon)

Angel, Alan (Bronson Battle Creek)

Lins, Steve (Bronson Battle Creek)

Aziz, Mike (Oregon)

Louzon, Kathryn (Beaumont Royal Oak/Troy)

Bailey, Meridith (Michigan)

Lucier, Michelle (Henry Ford)

Bhavsar, Shreyas (MD Anderson)

Mathis, Mike

Biggs, Dan (Oklahoma)

Malenfant, Tiffany (Beaumont Trenton/Wayne)

Bledsoe, Amber (Utah)

Mathis, Mike (Michigan)

Bonello, Laura (Beaumont)

McKinney, Mary (Beaumont Dearborn/Taylor)

Burns, Mike (Michigan)

Nachamie, Anna (Weill Cornell)

Chiao, Sunny (Virginia)

Nanamori, Masakatsu (Henry Ford Detroit)

Collins, Kathleen (St. Mary)

Obembe, Samson (Cornell)

Coons, Denise (Bronson)

Paganelli, William (Vermont)

Crawford, Joan (Mercy Muskegon)

Pardo, Nichole (Beaumont Grosse Pointe)

Cuff, Germaine (NYU Langone)

Poindexter, Amy (Holland)

Harwood, Tim (Wake Forest)

Poterek, Carol (Beaumont)

Haus, Jason (Beaumont Troy)

Quinn, Cheryl (St. Joes Oakland)

Hightower, William (Henry Ford W. Bloomfield)

Rensch, Robert (Bronson Kalamazoo)

Heiter, Jerri (St. Joseph A2)

Schonberger, Rob (Yale)

Hitti, Nicole (Weill Cornell)

Shah, Nirav (Michigan)

Horton, Brandy (A4)

Smith, Susan (Beaumont)

Jameson, Leslie (Colorado)

Tollinche, Luis (Memorial Sloan Kettering)

Kaye, Toni (

Tyler, Pam (Beaumont Farmington Hills)

Lacca, Tory (Michigan)

Vaughn, Shelley (Michigan)

Ladd, Chris (Michigan)

Wood, Aaron (Beaumont Farmington Hills)

Agenda & Notes

1. Minutes from June 25, 2018 meeting approved- posted on the website for review. Recording

available as well.

2. Roll Call: Will contact QI Champions and ACQRs directly to inquire about participation status

if missing. Other participants can review meeting minutes and contact Coordinating Center if

missing from attendance record.

3. Upcoming Events:

a. October 12 – MPOG Retreat/ASA Conference – San Francisco

i. Registration is open! https://mpog.org/events-news/mpogretreat2018/

ii. Featured Speakers

1. Dr. Robert Wachter (UCSF)

2. Dr. Thomas Insel (Mindstrong)

3. Dr. Elizabeth Whitlock (UCSF)

iii. QI Stories

1. Dr. Timur Dubovoy (University of Michigan)

4. Survey results from ASPIRE Collaborative meeting on 7/20

a. Overall very positive feedback

b. Many were inspired by Dr. Bagian and agreed he gave a phenomenal talk.

c. Thank you to those who presented site QI stories.

5. Welcome New Sites!

a. Beaumont Trenton, Dr. Ashvin Patel

b. Beaumont Wayne. Dr. Marina Dyment

c. Tiffany Malenfant, MSN is the ACQR for both sites

6. QI Story – Dr. Steven Lins (Bronson Battle Creek)

a. Pain management for hip fracture patients: switched from femoral nerve blocks with low

dose spinal anesthetics to continuous fascia iliaca blocks

i. Problem: Patients continued to receive high doses of narcotics between ED and

surgery with frequent delirium on arrival to surgery where many could not sign

their own consent.

ii. QI initiative: placed continuous fascia iliaca blocks upon arrival to ED and

continued for up to three days post-op. Avoided narcotics which reduced opioid

consumption and post op delirium.

1. Increased communication with ER physicians before they give narcotics

so anesthesiology could do a baseline assessment and perform block in

the ED.

iii. Results: Patients do much better with block placed in ED, decrease length of stay

after surgery, greater patient/family satisfaction and decreased narcotic use.

b. Discussion

i. Buy in obtained with smaller anesthesia staff. Providers were able to see the

results of pain scores first hand while placing the block.

ii. Currently documenting blocks in Epic. MPOG interesting in capturing this data.

7. Updates

a. Opioid Equivalency

i. OME dashboard is now available. Informational metric only.

ii. Results are grouped by case groupings through CPT codes.

1. May break out into specific groups in the future based on feedback.

iii. Comparisons across institutions and within specific institutions as well

1. Trending graphs available comparing your institution to all ASPIRE

institutions.

2. Provider specific comparisons available

iv. Ability to filter average administration and case length times by month, day or

case. Flags cases that received Remi and/or an unknown dose.

v. Discussion

1. It would be useful to know if patient is already on chronic opioid use.

2. Epic workgroup definition of common opioid equivalency is in the works

b. Dashboard Improvement

i. Case details – moving from dashboard to case viewer

ii. Data lookback will be increased from 1 to 2 years

iii. Improved dashboard performance

c. CPT Prediction

i. Measures that need CPT codes for inclusion and exclusion will now use CPT

prediction code until actual pro fee billing information is submitted. Once the

actual billing codes are submitted they will be swapped in for the earlier

predicted codes.

d. Pulmonary 02 – Tidal volume less than 8cc/kg IBW

i. Had same exclusion list as PUL 01.

ii. A lot more variation seen in PUL 02. 40-80% range of compliance across all

institutions

1. Potential area to focus on as a collaborative next year as a bundled

measure or on its own.

2. Working to refine the exclusion criteria.

a. Mike Aziz (OHSU) suggests bundle PUL 02 with PEEP measures

and exclude intracranial cases.

b. Kathleen Collins (St. Joes, Livonia) consider excluding bariatric

cases.

e. TRAN 02 - Identifies blood transfusion cases when the hematocrit was <30% or

hemoglobin was <10g/dL post-transfusion

i. Current Success: Hematocrit value documented as less than or equal to 30%

and/or hemoglobin value documented as less than or equal 10g/dL OR if no

hematocrit or hemoglobin checked within 6 hours of anesthesia end

ii. Proposed change: If no hemoglobin value within the immediate postop period,

should be excluded rather than marked as a success.

1. Will look into how many cases this will effect and move forward with this

update.

8. Coming Up

a. PEEP (PUL-03): an informational measure that analyzes PEEP usage across patients

undergoing mechanical ventilation during anesthesia. PUL 03 will determine if any PEEP

was administered (as defined by median PEEP >2) and also analyzes the level of PEEP

administration

1. No PEEP (<2 cm H20)

2. Low PEEP (2-4 cm H20)

3. Moderate PEEP (>4 to <8 cm H20)

4. High PEEP (>8 cm H20)

ii. Trending towards a bundle lung protective measure and PUL 03 would be

included in this.

b. CARD 03 - Myocardial Injury for High risk Patients

i. Plan to release in Q4 after ASA

ii. Outcome measure that identifies high cardiac risk patients that have severely

elevated troponin levels (Troponin I >.60 mcg/L) within 72 hours postoperatively

iii. Inclusions

1. All high risk surgeries* OR

2. All anesthetic cases performed on patients with history of ischemic heart

disease, congestive heart failure, cerebrovascular disease, diabetes

requiring preop insulin, or chronic kidney disease

3. *High-risk surgeries include intraperitoneal, intrathoracic, or

suprainguinal vascular procedures, as adapted from the Revised Cardiac

Risk Index (RCRI) and identified by Anesthesia CPT codes.

a. Definition of high risk patients is based on comorbidities not

current medications.

Meeting concluded at 11:02am