Obstetric Subcommittee Minutes 12.11.2019

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Obstetric Subgroup Meeting Minutes – December 11, 2019

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

Sharon Abramovitz, Weill Cornell

Angel Martino, Sparrow Health System

Ami Attali, Henry Ford- Detroit

Arvind Palanisamy, Washington University

Melissa Bauer, Michigan Medicine

Carlo Pancaro, Michigan Medicine

Dan Biggs, University of Oklahoma

Mohamed Tiouririne, University of Virginia

Traci Coffman, St. Joseph Mercy Ann Arbor

Brandon Togioka, OHSU

Eric Davies, St. Joseph Mercy Oakland

Joshua Younger, Henry Ford, Detroit

Ghislaine Echevarria, NYU Langone

Marie-Louise Meng, Duke

Ronald George, UCSF

Nirav Shah, MPOG Associate Director

Jenifer Henderson, St. Joseph Oakland

Kate Buehler, MPOG Clinical Program Manager

Rachel Kacmar, University of Colorado

Meridith Bailey, MPOG QI Coordinator

Joanna Kountanis, Michigan Medicine

Brooke Szymanski, MPOG QI Coordinator

Germaine Cuff, NYU

Ashraf Habib, Duke

Agenda & Notes

1. Roll Call, Introductions & Background of ASPIRE measures

2. Review Minutes from last meeting in September 2017- Posted to the website for review:

https://mpog.org/files/Obstetrics%20Sub%20Group%20Meeting%20Minutes%209-20-

2017.pdf)

o Reviewed existing MPOG measures for applicability to obstetric anesthesia

o Modified exclusion criteria for TRAN 01/02; Exclude cases with:

 ICD 10 codes indicating postpartum hemorrhage

 VS Changes (HR>110, BP≤85/45, O2 sat<95%) or EBL ≥1500cc for patients

undergoing caesarean section (CPT: 01961, 01968, 019262, 01963, 01969)

 Labor epidural cases.

 In the future, account for ≥ 15% change in vital signs from baseline (MPOG still

does not capture baseline VS reliably.)

o Modified success criteria for TEMP 01 to include fluid warming as an acceptable means

warming for patients undergoing Caesarean Delivery.

o Did not add exclusion criteria for AKI 01 to exclude patients diagnosed with

preeclampsia or eclampsia using ICD 10 codes: cases flagged for provider review

3. ASPIRE Measures including Cesarean Delivery Cases (but excluding labor epidurals)

AKI 01

PONV 02 (with inhalational GA only)

BP 01

PUL 01 (with GA-ETT only)

BP 02

PUL 02 (with GA-ETT only)

BP 03

PUL 03 (with GA-ETT only)

CARD 02

SUS 01 (with inhalational GA only)

CARD 03

TEMP 01

GLU 01

TEMP 02 (with GA only)

GLU 02

TOC 01

NMB 01 (with GA only)

TOC 03

NMB 02 (with GA only)

TRAN 01

PONV 01 (with inhalational GA only)

TRAN 02

See MPOG website for measure specifications: https://mpog.org/quality/our-measures/

4. ASPIRE Measures including both Labor Epidurals & Cesarean Deliveries

• Med 01

• FLUID 01-NC

• PONV 03

5. ASPIRE Measures excluding all obstetric cases

• TEMP 03

i. Josh Younger, MD – Henry Ford Detroit: Is active warming required if patients’

temp is less than 36.0 degrees Celsius intraop? Yes- as part of the TEMP 01

measure. Cesarean deliveries are included for TEMP 01 but also allow for fluid

warming as active warming. Cesarean deliveries and labor epidural cases are

excluded from TEMP 03.

• TOC 02

• FLUID 01-C

6. Current Cesarean Delivery Data in MPOG

• 260,062 cesarean deliveries in MPOG database

• 1/22/2004-11/30/2019

• 52 Institutions represented

• Identified using anesthesia CPT codes: Most reliable way to identify procedures

1. 01961: Anesthesia for cesarean delivery only

2. 01968: Anesthesia for cesarean delivery following neuraxial labor

analgesia/anesthesia

• Approximately 40,000 cases/year in the MPOG registry using 01961 and 01968. 35 sites

currently submitting cesarean delivery data

• Plans to create a phenotype to identify labor epidural cases that converted to c-section.

Likely missing many conversion cases in this analysis.

7. Future Measure Build Discussion

• Call for Measures: Survey Results (8 responses) – Top 3 measures that were the most

popular among providers and considers data elements that MPOG can capture.

• Measure #1: Prolonged hypotension before cesarean delivery

1. Measure Time Period:

o Spinal placement time to delivery of neonate OR

o Spinal placement time to procedure start (incision)

2. Hypotension Definition:

o SBP < 90mmHg or <100mmHg; >20% decrease for pre-eclampsia patients

3. Prolonged: 5 or 10 minutes?

4. Inclusions: Patients undergoing anesthesia for cesarean section (CPT: 01968 &

01961); includes epidural, spinal, combined spinal epidural, & general anesthesia

cases for cesarean section delivery

5. Exclusions: Emergency c-sections with diagnosis of placental abruption (O45*),

Rupture of uterus (spontaneous) before onset of labor (O71.0), Newborn

affected by intrauterine blood loss from ruptured cord (P50.1), Abnormal uterine

or vaginal bleeding, unspecified (N93.9), Placenta previa with hemorrhage, third

trimester (O44.13), Hemorrhage from placenta previa, antepartum condition or

complication (641.13), Hemorrhage from placenta previa, delivered, with or

without mention of antepartum condition (641.11)

6. Provider Attribution- Anesthesia providers signed in at:

o Neuraxial- Spinal performed (50680), if not available then

o AACD Procedure Start Date/Time (50006), if not available then

o Obstetrics- Uterine Incision (50357), if not available then

o Obstetrics- Delivery of Neonate (50358).

7. Discussion:

o Marie-Louise Meng – Duke: How was decision made to use SBP vs. MAP?

Interested in considering a MAP value in addition to SBP as it has become

common practice to ignore DBP and is not necessarily best practice.

Considerations are different in women with pre-eclampsia vs. non-

hypertensive women.

o Joanna Kountanis – Michigan Medicine– Standardized blood

pressure target is not well defined in obstetrics. A Cochrane

review revealed numerous ways to define hypotension but the

majority of studies refer to SBP- see Table 1:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.C

D002251.pub3/full

o Marie-Louise Meng – Duke: Is there a way to look at hypotension that

was treated?

o Nirav Shah, Michigan Medicine – MPOG can look at the total

vasopressor treatment dose (bolus and infusion). Also able to

compile a list of interventions that if documented would flag as

hypotension treatment. Need to identify a way to delineate labor

epidural portion of the case from the cesarean section for

conversion cases. This will be important for determining duration

to ensure hypotension is measured intraoperatively and not in a

labor room.

o Brandon Togioku, OHSU – Comment on using medication administration

to flag cases are intraop since it is rare to give 2% lidocaine,

chlorprocaine, or heavy bupivacaine etc. in a labor room except for a few

circumstances (i.e. forcep utilization) however this may be an alternate

marker that patient is in the OR and not a definitive marker.

o Kate Buehler, Michigan Medicine – Coordinating has discussed

this and may use documentation of these medications as one

way to determine conversion to cesarean delivery

o Ronald George, UCSF – We do most of forceps in labor rooms

using these same medications- not necessarily indicative of a

cesarean delivery unfortunately.

• Measure #2: General Anesthesia Rate for Cesarean Delivery

1. Percentage of cesarean delivery procedures converted to general anesthesia

2. Measure Time Period: Neuraxial Start to Neonate Delivery

3. Inclusions: Elective or Urgent C-Sections (CPT: 01961 & 01968) with neuraxial

anesthesia (epidural, spinal, or CSE) with documentation of intubation, volatile

gas, or NMB (indicating conversion to GA)

4. Exclusions:

o Patients undergoing emergency cesarean section

o Patients undergoing cesarean section with hysterectomy (CPT: 01969)?

o Contraindications to regional anesthesia including…?

o Documentation of patient request for general anesthesia?

5. Proposal: Informational only measure? No threshold/target

6. Provider Attribution: Anesthesia attending signed in at time of conversion to

general anesthesia

7. Algorithm to determine responsible provider:

o Placement of endotracheal tube, or supraglottic airway (LMA), if not

available

o Anesthesia Induction Start, if not available

o Administration of first NMB dose, if not available,

o Initiation of volatile gas

8. Alternative: Refrain from assigning attribution; institution rate only

• Discussion:

1. Is it possible to utilize the macro as a timestamp to when we transfer from

epidural to c-section? This should indicate that we stopped the epidural and

converted to the OR portion of the case.

o Nirav Shah, Michigan Medicine – MPOG has a concept that Epic sites can

map to. If a uterine incision is not documented or the ‘conversion to c-

section’ concept is not used- difficult to indicate whether the patient was

transferred to the operating room for delivery vs. c-section.

o Kate Buehler, Michigan Medicine - MPOG is currently working on a

phenotype to trigger the time epidurals are converted to c-section

2. Dan Biggs, University of Oklahoma – Institutions may see different rates of this

depending on the number of high risk patients in their population.

o Nirav Shah, Michigan Medicine – Agree. This measure could allow

institutions to track their epidural conversion rates over time and

compare such rates across all institutions within MPOG.

3. Angel Martino, Sparrow Health System – Are labor epidural specific measures on

the agenda for measure build or are we choosing to only focus on cases in the

OR? Wet taps are of interest for labor epidural patients & would be important to

measure.

o Nirav Shah, Michigan Medicine – It is easier for MPOG to capture data

intraoperatively. Wet tap data is also highly variable in MPOG. We do not

capture data from labor rooms for most sites as this is nursing

documentation (most sites submit anesthesia record data)

o Angel Martino - There are diagnosis codes for women who deliver

vaginally- could possibly use those to identify labor epidural cases.

o MPOG Coordinating Center to review vaginal delivery diagnosis codes

• Measure #3: Antibiotic Timing for cesarean delivery

1. MPOG Registry Data: 39,654 cesarean delivery (Oct 2018-Nov 2019)

2. Antibiotic Timing: Percentage of cesarean deliveries with any antibiotic

administered within 60 minutes before procedure start: 81.95% (past 12 months)

3. Antibiotic Selection:

o Cefazolin (75%), Cefazolin & Azithromycin (9%), Cefoxitin (1.15%),

Azithromycin (1.04%), Cefoxitin & Azithromycin (0.20%), Ceftriaxone

(0.08%), Cefuroxime (0%), Cefuroxime & Azithromycin (0%)

4. Discussion

o Kate Buehler, MPOG Coordinating Center- Does it make sense to start

with antibiotic selection/timing measures as MPOG has this data and the

build should be straightforward?

o All - Interest in looking at administration rates of Azithroymycin in

combination with other antibiotics. Azithromycin is commonly

administered in addition to another antibiotic for epidural to C-section

conversion cases.

o Dan Biggs, University of Oklahoma – 100% of OB patients receive

azithromycin at OU.

o Angel Martino, Sparrow Health System – In favor of focusing on this

measure first since infection is one of the highest reasons for maternal

morbidity. Measure should consider both antibiotic selection and timing.

o Nirav Shah, Michigan Medicine – this measure may be somewhat

descriptive in terms of simply displaying practice variation across

sites.

o Angel Martino, Sparrow Health System - Can MPOG compare Surgical

Site Infection rates with antibiotic compliance?

o Nirav Shah, Michigan Medicine – MPOG receives discharge

diagnoses codes however, it is hard to separate out if it was a

pre-existing code or a new code that is specific to that

encounter. The coordinating center needs to do some work to

determine how relevant/accurate these codes are in identifying

new SSI. Tying outcomes to these cases will most likely be a

phase two component of this measure build.

• Continue to Investigate other measures?

1. Non-opioid adjunct used for post cesarean delivery pain: 3.38/5.00

2. First temperature in PACU for cesarean delivery: 3.13/5.00

3. PONV in PACU for cesarean delivery: 3.13/5.00

• Other suggested topics from survey

1. Rate of dural puncture during epidural placement

2. Adjunctive azithromycin for non-elective cesarean deliveries (C/SOAP trial)

3. TXA administration when EBL > specified amount (TBD)

4. Transfusion rates

5. Intraoperative Core Temperature Monitoring

6. Intraoperative Active Warming

7. Intraoperative sedation medication administration for cesarean delivery

8. Rate of emergency c-sections after CSE with intrathecal opioids

9. Rate of anemia prior to elective cesarean delivery

10. Rate of success in neuraxial anesthesia in spinal fusion patients

• SOAP Centers of Excellence Criteria

1. Generated by expert consensus & incorporate evidence-based recommendations

2. Topics:

o Personnel & Staffing: MPOG does not capture

o Equipment, protocols, & policies: MPOG does not capture

o Cesarean delivery management

o Routine utilization of a pencil-point needle, 25 gauge or less for the

provision of spinal anesthesia

o Multimodal analgesia protocols (Non-opioid adjunct used for post

cesarean section pain)

o Strategies to prevent intraop maternal and fetal hypothermia (TEMP 01)

o Appropriate antibiotic prophylaxis

o Spinal hypotension prophylaxis and treatment

o Nausea & Vomiting prophylaxis and treatment

3. Labor Analgesia

o Use of low-concentration local anesthetic solutions with neuraxial

opioids

4. MPOG does not capture

o Recommendations & Guidelines implementation:

o QA & Patient Follow-up

8. 2020 Goals

• Measure focus for 2020: No consensus on one measure of focus

1. Brandon Togioka, OHSU– in favor of hypotension. OHSU does almost no GA

conversion cases and focus more on early interventions to prevent this.

2. Joanna Kountanis, Michigan Medicine – In favor of hypotension measure

3. Angel Martino, Sparrow Health System – In favor of Antibiotic measure

• Collaboration with other OB anesthesia groups (SOAP, ASA Task Force for Obstetric

Anesthesia) – Didn’t have enough time to discuss on call

• Measure Build: Prioritize & determine ‘ownership’

1. Need volunteers to assist with measure build questions

o Dan Biggs, University of Oklahoma

o Ron George, UCSF

2. Approval process

• Potential Toolkit Topics? – Didn’t have time to address during call.

9. Subcommittee Membership and Meeting Schedule

• How often should this group meet?

• Create Basecamp forum?

1. All in agreement on this form of communication. MPOG to create Basecamp

Forum in invite all members of subcommittee.

2. MPOG interested in hosting an in person meeting to go over a few additional

topics – potentially at one of the SOAP meetings.

• 2020 Existing Meetings:

1. Quality Committee Meetings (Webex)

o February 24

o April 27

o June 22

o August 24

o October 26

2. MPOG Collaborative Meetings (In-person)

o March 27, Schoolcraft College, Livonia, MI

o July 17, Henry Center East Lansing, MI

o October 2, ASA-Washington DC

Meeting concluded at 3:00pm