Pediatric Subcommittee Minutes 12.17.2019

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Pediatric Subgroup Meeting Minutes – December 17, 2019

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

Alina Bodas, Cleveland Clinic

Luis Tollinche, Memorial Sloan Kettering

Allan Simpao, Children’s Hospital of Philadelphia

Marco Silvestrini, US Anesthesia Partners

Anna Clebone, University of Chicago

Michelle Lucier, Henry Ford- Detroit

Anshuman Sharma, Washington University

Paul Stricker, Children’s Hospital of Philadelphia

Bishr Haydar, University of Michigan

Paul Reynolds, University of Michigan

Brad Taicher, Duke University

Phillip Collier, Beaumont Royal Oak

Charles Schrock, Washington University

Phillip Yun, OHSU

Cheryl Gooden, Yale University

Prita Dalal, Penn State University

Claudia Benkwitz, University of California San

Francisco

Red Starks, US Anesthesia Partners

Elizabeth Elliot, Children’s Hospital of Philadelphia

Robert Christensen, University of Michigan

Gary Loyd, Henry Ford- Detroit

Ronak Patel, University of Virginia

Germaine Cuff, NYU Langone

Ryan Bradstreet, Bronson Healthcare Group

Gina Whitney, University of Colorado

Shobha Malviya, University of Michigan

Hamid Vahabzadeh-Monshie, University of

Oklahoma

Stephanie Kahntroff, University of Maryland

Jacques Scharoun, Weill Cornell

Tetsu Uejima, DuPont Children’s

Jacob Tiegs, NYU Langone

Vikas O’Reilly-Shah, University of Washington

Jina Sinskey, University of California San Francisco

Vivian Onyewuche, Henry Ford-Detroit

Jorge Galvez, Children’s Hospital of Philadelphia

Wenyu Bai, University of Michigan

Julianna Mendoza, Stanford University

Wilson Chimbira, University of Michigan

Jurgen de Graaff, Erasmus MC-Netherlands

Nirav Shah, MPOG Associate Director

Laura Gibbs, Michigan Medicine

Katie Buehler, MPOG Clinical Program Manager

Lianne Stephenson, University of Wisconsin

Meridith Bailey, MPOG QI Coordinator

Lisa Chan, Arkansas Children’s

Brooke Szymanski, MPOG QI Coordinator

Lucy Everett, Mass General Hospital

Agenda & Notes

1) Roll Call, Introductions

2) Background of MPOG/ASPIRE

a) Formed in 2008

b) Academic and community hospital consortium; includes over 40 hospitals across the country (2

in Netherlands)

c) Dual mission of research and quality improvement

d) Collect data from 49 institutions and 5 EHR Vendors

e) Over 12 million cases extracted & de-identified

f) Includes demographic, medication/fluid administration, physiologic, billing, and staff data

g) ASPIRE is the quality improvement arm of MPOG

h) ASPIRE dashboard and provided feedback emails available to participating sites

3) Current Status of Pediatric Data/Measures

a) 8% of total cases in MPOG Central

b) 1 Pediatric Specific Measure (PONV 02)

c) 0 Sites contributing NSQIP-peds or CCAS-STS registry data

d) SPA and Wake up Safe Discussions

e) Top 10 sites contributing data: see slide 10.

f) Current Age Exclusion for ASPIRE measures

i) Set at <12yo- is this still appropriate?

(1) Neonate: < 1 mo , Infant: 1 mo – 1y

(2) Toddler: 1-3y , Child: 4-7y

(3) Adolescent: 8-11y , Pre-teen: 12-17y

ii) Claudia Benkwitz, UCSF- consider excluding pediatric cardiac cases or at least examine them

separately as the parameters will be different.

iii) Vikas O’Reilly Shah, University of Washington- Consider evaluating patients who revisit the

health system frequently to assess their outcome measures differently or separately.

iv) Nirav Shah, MPOG Coordinating Center- Can list patient comorbidities as part of the

measure details in the analysis but would recommend still including patients with these

additional comorbidities in the measure rather than excluding them so providers can still

review performance and determine if any opportunity is present. Trying to adopt the

philosophy of flagged vs. failed cases.

4) 2020 Plans

a) Measure Goals: Build 2-3 pediatric specific measures in 2020

i) Extending Glucose measures to preop and PACU. Separating treatment vs. glucose lab

recheck

(1) Glucose < 60 mg/dL treated or re-checked within 90 minutes

(2) Preoperative glucose check on diabetes patients or high-risk cases

(a) Claudia Benkwitz, UCSF- preop glucose is not often checked in pediatric patients-

this measure may not apply.

ii) Move forward with measure suggestion from 2017

(1) Hypotension informational measure displaying the lowest, highest and average MAP

values per age group

(a) < 1 mo

(b) 1 mo – 1 yo

(d) 4-7 yo

(e) 8-11 yo

(f) 12-17 yo

(g) Measure Time Period: Intraoperative

(h) Inclusions: All patients requiring general anesthesia or monitored anesthesia care

(MAC)

(i) Exclusions:

(i) Patients > 18 years old

(ii) ASA 5 and 6 cases

(iii) Organ Harvest, liver transplant, lung transplant and Cardiac surgeries

iii) Prioritize 2 additional measures that exclude patients > 18yo

(1) % of cases with sustained postoperative hypothermia (4.08/5)

(2) % of cases where the patient is re-intubated in PACU (4.04/5)

(3) % of cases where non-opioid adjunct was used (3.79/5)

(i) Nirav Shah, MPOG Coordinating Center- We capture all medication

administration data and can report the results of adjunct pain administrations

with high confidence

(4) Other Medication Dosing (3.75/5)

b) Call for Measure Survey Results

i) 24 Providers completed the survey – Thank You!

ii) No overwhelming consensus on one measure focus

(1) % of cases with sustained postoperative hypothermia (75%)

(2) % of cases where the patient is re-intubated in PACU (75%)

(3) % of cases with ≥ 2 intubation attempts (65%)

(a) Claudia Benkwitz, UCSF- Look at provider roles to determine if there is any

correlation in number of attempts; also examine comorbidities. Interested in cardiac

specific measures for pediatrics.

(4) % of cases where non-opioid adjunct was used (65%)

(5) Other Medication Dosing (80%)

iii) MPOG data capture - measure limitations

(1) 4 Hours before Anesthesia Start  6 hours after Anesthesia End

iv) Temperature Management

(1) Proposal 1: % of cases where patient’s temperature was < 36 C during immediate

postoperative period

(a) Time bounds: patient out of OR, patient in recovery room, PACU discharge, 6 hours

after Anesthesia End

(b) Inclusion criteria: All patients regardless of postop disposition

(2) Proposal 2: Informational Measure: temperature < 36 C at specific times

(a) Patient In Room, Induction End, Procedure Start, Procedure End, PACU Arrival

(i) Julianna Mendoza, Stanford- Currently working on this at our institution- in

favor or maintaining a specific temperature intraoperatively. Looking at

temperatures between induction and procedure start.

(ii) Tetsu Uejima, DuPont Children’s- Our institution has focused on normothermia

targeted at specific case types or age range (NICU patients)

v) Airway Management

(1) Reintubation rates in PACU

(a) Proposal: % of cases where the patient is intubated between patient out of room

and PACU discharge.

(i) Inclusions: All patients (general, MAC, Sedation)

(ii) Exclusions: ICU direct transports

(2) Very Interested (75%): % of cases where the patient is re-intubated in PACU

(3) Shoba Malviya, Michigan Medicine: Respiratory complications in PACU may be a better

metric as reintubations rarely occur in pediatric patients.

vi) Medication Dosing: medications of interest?

vii) Pain Management

(1) Proposal 1: % of cases with a postoperative pain score greater than ____

(a) Inverse Measure. Threshold?

(b) Pain scales used; variation in documentation

between nursing documentation of postop pain score and the total dose of pain

medication administered in PACU (much like the study that was conducted for

adults)

(2) Proposal 2: % of cases where non-opioid adjunct was used

(a) Include or exclude patients with regional blocks?

(b) Case Types

(3) Anshuman Sharma, WashU – Large variance in using regional anesthesia- would be

helpful in guiding future practice.

viii) ASPIRE Opioid Dashboard

(1) Add Tonsillectomy/Adenoidectomy and Spine categories for patients < 18yo

(2) Morphine equivalents in the OR vs. PACU

(3) Anshuman Sharma, WashU- One of the benefits of MPOG is identifying variance

amongst organizations or providers in providing care- specifically for intraop opioid

administration. This could be beneficial for displaying practice patterns for opioid use in

the pediatric population.

ix) Other Suggestions

(1) Fluid Management (3.75/5)

(2) Antibiotic Stewardship (3.67/5)

(3) % of cases with hypoxemia (3.63/5)

(4) Transfusion Management in patients < 2yo (3.54/5)

(5) % of cases with emergence delirium

(6) % of cases with laryngospasm

(a) Vikas O’Reilly-Shah, University of Washington- Look for surrogates for laryngospasm

or bronchospasm rather than provider documentation of the event such as

succinylcholine administration or epinephrine administration

(7) % of cases where Succinylcholine was administered in PACU

(8) % of cases using FiO2 less than 30% with patients SpO2 > 92%

(9) % of cases where the patient was NPO liquids for < 2 hours without adverse outcomes

5) Subcommittee Membership & Meeting Schedule

a) Open to all pediatric anesthesiologists

i) Do not have to practice at an active MPOG institution

b) Basecamp forum: best format for communication between members

c) How often should this group meet?

i) Shobha Malviya, Michigan Medicine- Meet at least quarterly to keep everyone on task

ii) Vikas O’Reilly-Shah, University of Washington: Try to coordinate at least 2 of the meetings

with SPA Quality and Safety meetings

d) Need volunteers to assist with measure build questions

e) MPOG Collaborative Meetings 2020 (In-person)

i) March 27

, Schoolcraft College, Livonia, MI

ii) July 17

, Henry Center East Lansing, MI

iii) October 2

, ASA-Washington DC

6) Recommendation

a) Build 2-3 peds specific measure in 2020

i) Temperature management: postoperative hypothermia or intraoperative hypothermia at

defined intervals

ii) Intraoperative Hypotension – informational measures

iii) PACU re-intubation or utilization of respiratory therapy (if possible)

iv) Add tonsillectomy and spine to opioid equivalency dashboard

v) Non opioid adjuncts, including regional blocks

7) General Comments:

Anna Clebone, University of Chicago, SPA- Beneficial to highlight the pediatric specific measures that

are evidence based and, when possible, link back to outcome data to prove the process is effective

in improving outcomes

a) Nirav Shah, MPOG Coordinating Center- There seems to be limited pediatric anesthesia

literature that provides concrete evidence to inform measures; some of the initial measures

may be based on expert opinion and be focused on describing variance rather than hard

thresholds for pass/fail. Can use dashboards and provider feedback emails to provide this

information to Quality Champions and individual providers

b) Vikas O’Reilly Shah, University of Washington- If we are choosing process measures that have

been linked to improving outcomes in the literature, would be beneficial to provide feedback to

providers to focus on certain processes of care.

- Anna Clebone, University of Chicago, Vice Chair-SPA Quality and Patient Safety: SPA meeting is

usually on Saturday morning of the ASA. In addition, SPA is interested in building measures (ideally

evidence-based) focused in the following areas and would be interested in collaborating with MPOG

to obtain data for these metrics:

- Care for patients with high BMI at surgery centers

- Changing NPO guidelines to be < 1hour for fluids

Meeting adjourned at: 1104