Obstetric Subcommittee Minutes 3.17.20

Obstetric Anesthesia Subcommittee Minutes

March 17, 2020

12:00-1:00pm EST

Webex

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

David Swastek, St. Joseph Mercy Ann

Arbor

Brandon Togioka, Oregon Health Science

University

Eric Davies, St. Joseph Mercy Oakland

Joshua Younger, Henry Ford, Detroit

Ghislaine Echevarria, NYU Langone

Marie-Louise Meng, Duke

Ronald George, University of California-

San Francisco

Ashraf Habib, Duke

Jenifer Henderson, St. Joseph Oakland

Nirav Shah, MPOG Associate Director

Rachel Kacmar, University of Colorado

Katie Buehler, MPOG Clinical Program Manager

Joanna Kountanis, Michigan Medicine

Meridith Bailey, MPOG QI Coordinator

Carlos Delgado Upegui, University of

Washington

Brooke Szymanski, MPOG QI Coordinator

Stephanie Lim, University of California-

San Francisco

Jessica Wren, Henry Ford Macomb/Wyandotte

ACQR

Michelle Lucier, Henry Ford Detroit/WB

ACQR

1. OB Anesthesia Subcommittee Leadership

a. Seeking one of you or your obstetric anesthesia colleagues to lead or co-lead this

committee

b. Work with MPOG team (faculty/programmers/nurses) to create measures

c. Need someone practicing OB anesthesia to advise on measures and future directions

d. Contact Nirav (nirshah@med.umich.edu) or Kate (kjbucrek@med.umich.edu

) if

interested

2. 12/2019 Meeting Recap

a. Reviewed Call for Measure Survey Results

i. #1: Prolonged hypotension before cesarean delivery: 4.38/5.00

ii. #2: General Anesthesia Rate for Cesarean Delivery: 3.63/5.00

iii. #3: Non-opioid adjunct used for post cesarean delivery pain: 3.38/5.00

iv. #4: Antibiotic Timing for cesarean delivery: 3.25/5.00

1. Opted to add Antibiotic Selection Measure to assess azithromycin use

v. #5: First temperature in PACU for cesarean delivery: 3.13/5.00

vi. #6: PONV in PACU for cesarean delivery: 3.13/5.00

b. Coordinating Center to create ‘phenotype’ to identify labor epidural cases that

converted to cesarean delivery: done

c. Coordinating Center to assess the use of ICD 9/10 codes for capturing outcomes,

specifically SSIs: In progress

d. 2020 Selected Measures for Cesarean Delivery

i. Antibiotic Timing

ii. Antibiotic Selection

iii. Prolonged Hypotension

3. OB_ABX 01: Antibiotic Timing for Cesarean Delivery Specification Review

a. Description: Percentage of cesarean deliveries with documentation of antibiotic

administration initiated within one hour before surgical incision

b. Measure Time Period: 60 minutes prior to Surgical Incision through Surgical Incision

c. Inclusions:

i. Elective, urgent, or emergent cesarean delivery*

1. Dan Biggs, University of Oklahoma- should we include emergent

cesarean deliveries in this measure? It is not unusual to have a baby out

within 10 minutes of the initial decision to convert to cesarean delivery

a. Currently, this measure includes emergency cases but allows for

antibiotic to be delivered any time between anes start and end

rather than 60 minutes before incision- committee determines

this to be acceptable

ii. Patients undergoing cesarean section with hysterectomy (CPT: 01969)

*MPOG has created a ‘phenotype’ to sort cases based on procedure text, CPT codes,

and note documentation to identify cesarean delivery cases. CPT codes alone do not

seem to be reliable in determining case type.

iii. Case Type Categories:

1. Labor Epidural

2. Cesarean Delivery

3. Labor Epidural converted to Cesarean

4. Unable to determine

iv. All cases with actual or predicted CPT codes 01961, 01967, and/or 01968 will be

processed through the algorithm to determine denominator for cesarean

delivery measures

v. Algorithm

1. Begins with concepts such as anesthesia start, anesthesia end,

documentation of anesthetic agents, flows, procedure start and finish,

muscle relaxants

2. Determines if a case is surgical or non-surgical

3. Looks at other documentation if provided to further refine output

a. Neonate delivered

b. Duration of anesthetic

4. 94-96% accurate

5. Will be foundational for all OB measures in order to determine case

type (labor epidural, c-section, conversion to c-section)

6. Will first use the phenotype for the antibiotic timing measure but

anticipate using for all OB specific measures

7. Will go back to other measures that include/exclude labor epidurals or

c-sections and will use the algorithm to properly exclude cases rather

than CPT codes alone

8. Dan Biggs, University of Oklahoma- Could duramorph be used to further

refine algorithm? Only used for labor epidurals

9. Mohamed Tiouririne, University of Virginia- Using duramorph more for

vaginal tears

10. MPOG will look into this and if needed, will add to the algorithm to

improve accuracy

d. Exclusions:

i. Obstetric Non-Operative Procedures- determined using OB anesthesia type

algorithm

ii. Cesarean delivery with documentation of infection prior to incision and mapped

to one of the following MPOG concepts*

1. 50181 Compliance- Prophylactic Antibiotic Variance Note

2. 50182 Compliance- Prophylactic Antibiotic Variance Note Detail

* Will only check for one of these notes if an antibiotic is not administered.

iii. If ‘Patient on scheduled antibiotic/documented infection’ - exclude

e. Measure Start Time: 60 minutes before procedure start (For Vancomycin, 120 minutes

before procedure start)

f. Measure End Time: Surgical Incision Time (50235), if not available then AACD Procedure

Start Date/Time (50006)

i. **For cases without a documented surgical incision time or procedure start

time, the case will be flagged for review.

g. Success: Documentation of at least one antibiotic administration within one hour of

surgical incision. See ‘Other Measure Build Details’ for emergency cases and antibiotic

timing exceptions.

i. Will not count “check box” field “prophylactic antibiotic administered”- must be

documented in the medication administration record (MAR) with antibiotic

administered with dose & time

ii. Documentation of “Not ordered” or “not indicated” will be flagged as well for

review, unless feedback received that these cases should be excluded

h. Responsible Provider: All anesthesia providers signed in at the time of incision. If

surgical incision time is not documented, then providers signed in at the procedure start

time will be attributed.

i. Other Measure Build Details:

i. For emergency cases, success is determined by documentation of any of the

following antibiotics initiated between anesthesia start and anesthesia end.

1. Should emergency cases be excluded? Or should the measure look at

whether or not an antibiotic was given at any point between anesthesia

start and end?

2. Brandon Togioka, Oregon Health Science University - It would be

appropriate to look to see whether or not one was given, is beneficial to

give at some point

ii. Any of these antibiotics administered within the timeframe will result in success

for this measure focused on antibiotic timing, rather than selection.

Antibiotic

MPOG Concept

Appropriate Start Time

Azithromycin

10048

Between Anesthesia Start and Anesthesia End

Change to 60 minutes before incision through Anesthesia End

Cefazolin

10107

Within 60 minutes before incision

Cefepime

10108

Within 60 minutes before incision

Cefotaxime

10109

Within 60 minutes before incision

Cefotetan

10110

Within 60 minutes before incision

Cefoxitin

10111

Within 60 minutes before incision

Ceftriaxone

10114

Within 60 minutes before incision

Cefuroxime

10115

Within 60 minutes before incision

Clindamycin

10131

After delivery of neonate before anesthesia end

Change to ‘Within 60 minutes before surgical incision’

Gentamicin

10202

Within 60 minutes before incision

Vancomycin

10444

Within 120 minutes before incision

Acceptable Antibiotics/Timing:

j. Mohamed Tiouririne, University of Virginia – appropriate time frame for azithromycin,

others seem ok

k. Brandon Togioka, Oregon Health Science University - Why is clindamycin timeframe

different? Clindamycin should be the same timeframe as the other ABX

i. Understanding based on forum that it should be given after cord clamping

ii. We don’t capture cord clamping, defer to neonate delivered

iii. Rachel Kacmar, University of Colorado – our institution gives before incision

iv. Ronald George, University of California- San Francisco - clindamycin give like

cefazolin, azithro before cord clamp

v. Lack of standardization on azithromycin timeframe- some before and after cord

clamping

l. Committee agrees that clindamycin should be changed to be given within 60 minutes

before surgical incision

m. Committee also agrees that azithromycin should be initiated within 60 minutes before

surgical incision through anesthesia end

n. MPOG will start to review cases at this point and will reach out via forum if we have

more questions- Will push to dashboard soon after case review

4. Antibiotic Selection Measure, proceed?

a. MPOG can build this measure- could be institution level (no attribution)

b. Surgeon orders antimicrobial prophylaxis – may be helpful for organization but not an

anesthesia-specific measure

c. Feedback:

i. OB can order without anesthesia input

ii. Required to administer as ordered, but can give suggestions

iii. Each surgical site infection is already reviewed at each institution, including abx

choice and timing

d. Does this group wish to focus on this?

i. Dan Biggs, University of Oklahoma – Anesthesia has zero input on abx selection

at his institution, surgeon orders. Anesthesia only administers what is ordered

ii. Mohamed Tiouririne, University of Virginia – At UVa, anesthesia only changes

the antibiotic order if we see a discrepancy in the orders.

iii. Would this be helpful to your institutions to share this data?

1. Mohamed Tiouririne, University of Virginia - keep on table to discuss at

next meeting

2. Dan Biggs, University of Oklahoma - I think it is good information to

share with colleagues but not a priority

5. Prolonged Hypotension Measure Specification Review

a. Highest rated on the survey, but high variability in definition of hypotension

b. 12/2019 Discussion: Consider 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.

i. 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.CD002251.pub3

/full

c. Assess if hypotension that was treated instead/also?

d. Measure Time Period: Spinal placement time to delivery of neonate

e. Hypotension Definition:

i. For MPOG data, baseline BP means a BP taken either in preop or labor and

delivery

1. Ronald George, University of California- San Francisco – baseline doesn’t

work well in this setting, having an absolute value of SBP ≥ 90mmHg

sounds reasonable

2. Rachel Kacmar, University of Colorado - absolute value does not account

for patients with pre-eclampsia. They would need a different value for

baseline

3. Dan Biggs, University of Oklahoma - What is acceptable pressure for

someone who’s pressure starts at 220? Committee agrees – no clear

consensus in this area

4. Mohamed Tiouririne, University of Virginia - Don’t want to decrease BP

in preeclamptic patients by >20%

5. What should we use for baseline:

a. Mohamed Tiouririne, University of Virginia - first BP in OR is an

appropriate surrogate for baseline

b. Carlos Delgado Upegui, University of Washington - practice is to

look at first BP and titrate phenylephrine as appropriate to keep

around that value

c. Dan Biggs, University of Oklahoma - sometimes gradually bring

pressures down. Is 20% reasonable if someone’s pressure is

really high?

d. Mohamed Tiouririne, University of Virginia – Normally do not

want BP <140/90

6. Options:

a. Could exclude patients with pre-eclampsia from measure based

on discharge diagnosis information

b. Could provide more informational view for these patients on

the new dashboard: one informational measure for patients

with pre-eclampsia and a second informational measure for

patients without eclampsia

i. Use SBP <80% baseline (>20% decrease from baseline)

for patients with pre-eclampsia

ii. Use SBP < 90mmHg for patients without pre-eclampsia

f. Definition of ‘Prolonged:’

i. What is a reasonable duration?

ii. 5 or 10 minutes?

1. Mohamed Tiouririne, University of Virginia - Can MPOG look at two time

frames: (1) between spinal and birth and (2) after birth?

a. Yes- can assess cumulative minutes of hypotension through

delivery & total minutes of hypotension from spinal through

anes end

2. Rachel Kacmar, University of Colorado - there is often more tolerance

for hypotension after baby is out

g. Inclusions:

i. Elective, urgent, or emergent cesarean delivery*

ii. Patients undergoing cesarean section with hysterectomy (CPT: 01969)

iii. Note: Includes epidural, spinal, combined spinal epidural, & general anesthesia

cases for cesarean section delivery

iv. *MPOG has created a ‘phenotype’ to sort cases based on procedure text, CPT

codes, and note documentation to identify cesarean delivery cases. CPT codes

alone do not seem to be reliable in determining case type.

h. Exclusions:

i. Separate out preeclamptic patients in a separate measure- see above

ii. 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)

i. Prolonged Hypotension for Cesarean Delivery Discussion Conclusions:

i. Committee agrees there is a lack of literature and standardization in regards to

treating hypotension for cesarean delivery- will proceed with descriptive

measure that will help institutions understand variability and determine next

steps

ii. MPOG to build one informational measure for patients with pre-eclampsia using

SBP <80% baseline (>20% decrease from baseline) & assess cumulative minutes

below 80% baseline for two time periods before and after delivery

iii. MPOG to build a second informational measure for patients without pre-

eclampsia using SBP < 90mmHg as the threshold. Measure will assess

cumulative number of minutes below 90mmHg for two time periods: before and

after delivery.

iv. Will share institution comparison across MPOG sites

v. Provider Attribution- Committee agrees this measure will be

informational/descriptive only- no attribution

vi. Will send out more detailed spec on forum for further feedback

6. Meeting Conclusion

a. Forge ahead with antibiotic timing measure

b. Start working on a hypotension measure which accounts for variability in evidence and

preeclampsia patients as well

i. Will release to forum for review

c. Looking for obstetric anesthesiologist to lead subcommittee- contact Coordinating

Center if interested

Meeting adjourned at 1258