ASPIRE Pediatric Subcommittee Meeting
December 17, 2019
Agenda
• Introductions & Background of MPOG/ASPIRE
• Current Status of Pediatric Data/Measures
• 2020 Plans
– Measure Goals
– Call for Measure Survey Results
• Subcommittee Membership and Meeting Schedule
Introductions
• ASPIRE Quality Team
– Nirav Shah, MD – MPOG Director of Quality
– Kate Buehler, MSN – Clinical Program Manager
– Meridith Bailey, MSN – QI Coordinator
– Brooke Szymanski, MSN – QI Coordinator
• Pediatric Representatives joining us from around
the US and Netherlands!
• Roll Call
Arkansas Children's
Beaumont Royal Oak*
Bronson Healthcare Group*
Children's Hospital of Philadelphia
Cincinnati Children's
Cleveland Clinic*
Colorado Children's
Duke University*
Erasmus MC
- Netherlands
Henry Ford
-Detroit*
Mass General Hospital*
Memorial Sloan Kettering*
NYU
Langone*
OHSU*
Oklahoma University*
Penn State Children's
Stanford (Lucile Packard Children's)*
UCLA*
UCSF*
University of Chicago
University of Maryland
University of Michigan*
University of Virginia*
Seattle Children's
Hospital
University of Wisconsin
Weill
-Cornell*
Yale
- New Haven Children's*
*Indicates participating MPOG site
What is MPOG?
• Formed in 2008
• Academic and community hospital
consortium. Includes over 40 hospitals
across the country (and 2 in the
Netherlands)
• Aggregates data
• Dual mission of research and quality
improvement
What we have achieved so far
• Demographic Information
• Preoperative H&P
• Medications / Infusions / Fluids / Outputs
• Physiologic values/ Laboratory values
• Intraop events
• IV Access
• Staff in / out
• Professional fee CPT codes
• Discharge ICD 9/10 codes
• Outcome record / Outcome registry
49 institutions, 5 EHR vendors
~12 million cases extracted,
mapped, de-identified, and
available for QI and research
~75 million medication doses
24 billion physiologic
observations
Reporting Dashboard
Individual Performance E-mail
ASPIRE Pediatrics – Current State
• 8% of total cases in MPOG
Registry
• 1 Pediatric Specific Measure
(PONV 02)
• 0 Sites contributing NSQIP-peds or
CCAS-STS registry data
• SPA and Wake up Safe Discussions
Date Range
Case Count
Total
1,430,738
1/2014
- 9/2019 (recent 5
years)
907,077
2018
– 2019 (last year)
118,617
Top 10 Sites Contributing Pediatric Data
Institution
Age < 18
Vanderbilt University Medical Center
250,430
University of Michigan Health System
218,740
University of Oklahoma Health Sciences Center
105,648
Washington University School of Medicine
87,700
University Medical Center
- Utrecht
68,266
Oregon Health and Science University
67,276
Cleveland Clinic
52,834
NYU
Langone Medical Center
48,854
University of Vermont
- Fletcher Allen Health Care
40,254
Pediatric Subcommittee (2017): Where we left off…
• Set pediatric measure exclusion to patients <
12yo. Still relevant? Interest in more specific
age exclusion?
– Neonate: < 1 mo , Infant: 1 mo – 1y
– Toddler: 1-3y , Child: 4-7y
– Adolescent: 8-11y , Pre-teen: 12-17y
• Additional exclusions for measures added
after 2017?
Measure Description Pediatric Exclusion
AKI 01 Postop AKI Not discussed
BP-01 MAP <55 Exclude < 12yo
BP-02 Monitoring Gap None
NMB-01 TOF checked None
NMB-02 Reversal administered None
GLU-01 Hyperglycemia Exclude < 12yo
GLU-02 Hypoglycemia None
PUL-01 Tidal Volume < 10 Exclude <12yo
FLUID-01 Colloids None
TRAN 01 Hgb/Hct checked Exclude CHD < 21yo
TRAN 02 Overtransfusion Exclude < 2yo
TEMP 01 Active Warming None
TEMP 02 Core Temp Monitoring None
CARD 01 Postop Troponin I > 1.0 None
MED 01 Overdose (opioid/benzo) Not discussed
PUL 02 TV < 8mL/kg Exclude <12yo
PUL 03 PEEP utilization Exclude <12yo
SUS 01 FGF > 3L/min None
TOC 01-03 Transfer of Care None
PONV 02 PONV Process None
PONV 03 PONV Outcomes None
CARD 02-03 Troponin I >0.6 None
TEMP 03 Hypothermia postop None
Measures Published
after 2017
ASPIRE Pediatrics - 2020 Tentative Plans
• Extending Glucose measures to preop and PACU. Measure preoperative glucose
checking.
• Peds hypotension measures (informational)
• Prioritize 2-3 additional measures that are peds focused
#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)
#4: Other Medication Dosing (3.75/5)
Glucose Management
• Extending hypoglycemia measure (GLU-02) to preop and
PACU
– Glucose < 60 mg/dL treated or re-checked within 90 minutes
• Preoperative glucose check on diabetes patients or high-
risk cases
• Treatment of Glucose > 200 mg/dL: limited evidence in
non-diabetic patients < 12yo
– Include Diabetic patients <12yo?
Blood Pressure Informational Measure
• Informational measure displaying the lowest, highest and average MAP values per age group
– < 1 mo
– 1 mo – 1 yo
– 1-3 yo
– 4-7 yo
– 8-11 yo
– 12-17 yo
• Measure Time Period
– Intraoperative
• Inclusions:
– All patients requiring general anesthesia or monitored anesthesia care (MAC)
• Exclusions:
– Patients > 18 years old
– ASA 5 and 6 cases
– Organ Harvest, liver transplant, lung transplant and Cardiac surgeries
Call for Measure Survey Results
• 24 Providers completed the survey – Thank You!
• Highest rated measures (no overwhelming consensus)
#1: % of cases with sustained postoperative hypothermia (75% of providers interested or very
interested)
#2: % of cases where the patient is re-intubated in PACU (75%)
#3: % of cases with ≥ 2 intubation attempts (65%)
#4: % of cases where non-opioid adjunct was used (65%)
#5: Other Medication Dosing (80%)
• FYI: MPOG data capture - measure limitations
– 4 Hours before Anesthesia Start  6 hours after Anesthesia End
– What can’t we do?
Temperature Management
• Proposal 1: % of cases where patient’s temperature was < 36 C during immediate
postoperative period
– Time bounds: patient out of OR, patient in recovery room, PACU discharge, 6 hours after
Anesthesia End
– Inclusion criteria: All patients regardless of postop disposition?
• Proposal 2: Informational Measure: temperature < 36 C at specific times
– Patient In Room, Induction End, Procedure Start, Procedure End, PACU Arrival
No Interest Mild Interest
Very Interested
% of cases with hypothermia at procedure start
21% 16% 63%
% of cases with intraoperative hyperthermia
30% 25% 45%
% of cases with sustained postoperative
hypothermia
8% 17% 75%
Airway Management
• Reintubation rates in PACU
– Proposal: % of cases where the patient is intubated between patient out of room and PACU
discharge.
– Inclusions: All patients (general, MAC, Sedation)
– Exclusions: ICU direct transports
No Interest Mild Interest
% of cases where the patient is re
-intubated in PACU 15% 10% 75%
% of cases with ≥ 2 intubation attempts
15% 20% 65%
Medication Dosing
• Other medication dosing of interest?
No Interest Mild Interest Very Interested
% of cases where
appropriate dosing of Sugammadex or
Neostigmine is given to patients who receive a paralytic
intraoperatively
25%
30%
45%
Other Medication Dosing
20%
10%
70%
Pain Management
• Proposal 1: % of cases with a postoperative pain score greater than ____
– Inverse Measure. Threshold?
– Pain scales used; variation in documentation
• Proposal 2: % of cases where non-opioid adjunct was used
– Include or exclude patients with regional blocks?
– Case Types
No Interest Mild Interest Very Interested
% of cases where non
-opioid adjunct was used
8%
29%
63%
% of cases where opioid was not used
30%
20%
50%
% of cases where opioids were given in PACU
20%
30%
50%
% of cases with a postoperative pain score greater than ____
8%
25%
67%
Average opioid administration (using morphine equivalents) by case
type
5%
45%
50%
ASPIRE Opioid Dashboard
• Add Tonsillectomy/Adenoidectomy and Spine categories for patients < 18yo
• Morphine equivalents in the OR vs. PACU
Other Suggestions – What are we missing?
• Fluid Management (3.75/5)
• Antibiotic Stewardship (3.67/5)
• % of cases with hypoxemia (3.63/5)
• Transfusion Management in patients < 2yo (3.54/5)
• % of cases with emergence delirium
• % of cases with laryngospasm
• % of cases where Succinylcholine was administered in
PACU
• % of cases using FiO2 less than 30% with patients SpO2 >
92%
• % of cases where the patient was NPO liquids for < 2
hours without adverse outcomes
Recommendation
• Build 2-3 peds specific measure in 2020
– Temperature management: postoperative hypothermia
– Intraoperative Hypotension – informational measures
– PACU re-intubation (if possible)
– Add tonsillectomy and spine to opioid equivalency dashboard
• More discussion
– Pain management
– Glucose management
– Appropriate medication dosing – what medications?
– Other suggestions – need more consensus
Pediatric Subcommittee Membership
• Open to all pediatric anesthesiologists
– Do not have to practice at an active MPOG institution
• Basecamp forum: best format for communication
between members?
• How often should this group meet?
– Need help with measure build questions
– Approval Process
• How can we work with SPA (Wake Up Safe) or other
groups
• 2020 Existing Meetings
 Quality Committee Meetings (Webex)
• February 24
th
, April 27
th
, June 22
nd
, August 24
th
, October 26
th
 MPOG Collaborative Meetings (In-person)
• March 27
th
, Schoolcraft College, Livonia, MI
• July 17
th
, Henry Center East Lansing, MI
• October 2
nd
, ASA-Washington DC
THANK YOU!
Meridith Bailey, MSN, RN
MPOG Pediatric Program Lead
Meridith@med.umich.edu
Nirav Shah, MD
MPOG Associate Director
nirshah@med.umich.edu
ASPIRE Measures
• AKI 01 (Excludes Baseline Cr ≤ 0.2): Percentage of cases that baseline creatinine
increased more than 1.5 times within 7 postoperative days or the baseline creatinine
level increased by ≥ 0.3 mg/dL within 48 hours after anesthesia end.
• MED 01: Percentage of cases that required the use of naloxone or flumazenil for
medication overdose.
• BP 01 (Excludes < 18yo): Percentage of cases where intraoperative hypotension
(MAP < 55 mmHg) was sustained for less than 20 minutes.
• BP 02: Percentage of cases where gaps greater than 10 minutes in blood pressure
monitoring are avoided.
• BP 03 (Excludes < 18yo): Percentage of cases where intraoperative hypotension
(MAP < 65 mmHg) was sustained for less than 15 minutes
ASPIRE Measures
• CARD 02: Percentage of cases with elevated postoperative Troponin levels or
documentation of perioperative myocardial injury.
• CARD 03: Percentage of high cardiac risk cases with significantly elevated postoperative
troponin levels.
• FLUID 01-NC: Percentage of non-cardiac cases in which colloids were not administered
intraoperatively.
• GLU 01: Percentage of glucose labs with perioperative glucose > 200 mg/dL with
administration of insulin or glucose recheck within 90 minutes of original glucose
measurement.
• GLU 02 (Excludes <12yo): Percentage of glucose labs with perioperative glucose < 60 with
administration of dextrose containing solution or glucose recheck within 90 minutes of
original glucose measurement
ASPIRE Measures
• NMB 01: Percentage of cases with a documented Train of Four (TOF) after last dose of non-
depolarizing neuromuscular blocker.
• NMB 02: Administration of neostigmine, Sugammadex, and/or edrophonium before
extubation for cases with nondepolarizing neuromuscular blockade
• PONV 02 (Excludes < 3yo): Percentage of patients aged 3 through 17 years of age, who
undergo a procedure under general anesthesia in which an inhalational anesthetic is used for
maintenance AND who have two or more risk factors for post-operative vomiting (POV), who
receive combination therapy consisting of at least two prophylactic pharmacologic anti-
emetic agents of different classes preoperatively and/or intraoperatively.
• PONV 03: Percentage of patients, regardless of age, who undergo a procedure and have a
documented nausea/emesis occurrence postoperatively OR receive a rescue antiemetic in
the immediate postoperative period.
ASPIRE Measures
• PUL 01 (Excludes <12yo): % of cases with median tidal volumes less than 10ml/kg.
• PUL 02 (Excludes <12yo): % of cases with median tidal volumes less than 8ml/kg.
• PUL 03 (Excludes <12yo): % of cases in which Positive End Expiratory Pressure (PEEP) is used for
patients undergoing mechanical ventilation during anesthesia.
• SUS 01: % of cases with mean fresh gas flow (FGF) equal to, or less than 3L/min, during administration
of halogenated hydrocarbons and/or nitrous oxide.
• TEMP 01: % of cases that active warming was administered by the anesthesia provider- includes fluid
warming for c-sections
• TEMP 02: % of cases with increased risk of hypothermia that the anesthesia provider documented
core temperature.
• TEMP 03: % of patients, who undergo general or neuraxial anesthesia of ≥ 60 minutes for whom at
least one body temperature ≥ 36 degrees Celsius was recorded within 30 minutes before or 15
minutes after anesthesia end.
ASPIRE Measures
• TOC 01: Percentage of patients who undergo a procedure under anesthesia in which a
permanent intraoperative anesthesia staff change occurred, who have a documented use of
a checklist or protocol for the transfer of care from the responsible anesthesia practitioner
to the next responsible anesthesia practitioner.
• TOC 02: Percentage of patients who are under the care of an anesthesia practitioner and are
admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist
which includes the key transfer of care elements is utilized
• TOC 03: Percentage of patients who undergo a procedure under anesthesia and are
admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a
documented use of a checklist or protocol for the transfer of care from the responsible
anesthesia practitioner to the responsible ICU team or team member
ASPIRE Measures
• TRAN 01: Percentage of cases with a blood transfusion that have a hemoglobin or
hematocrit value documented prior to transfusion.
• TRAN 02: Percentage of cases with a post transfusion hemoglobin or hematocrit value less
than 10/30.
• Transfusion Measure Pediatric Exclusions
– Excludes Patients < 2yo
– Patients < 12yo undergoing cardiac surgery
– Patients < 12yo who were either transfused PRBC or had an EBL greater than 30cc/kg
ASPIRE MEASURE PERFORMANCE VARIATION
ADULTS VS. PEDIATRICS
2019
AKI 01 Performance All Ages (risk adjusted)
AKI 01 Performance < 12yo (risk adjusted)
NMB 01
TOF checked prior to extubation
NMB 02
NMB reversal given prior to extubation
TRAN 01
Hgb/Hct check prior to transfusion
TRAN 02
Hgb/Hct > 10/30 post transfusion
PONV 01 (>18 yo)
PONV 02 (<18 yo)
PONV 03
2 Anti-Emetics Administered Preop/Intraop PONV Reported and/or Rescue Anti-Emetic Administered Postop