Obstetric Subcommittee Slides 3.17.20

ASPIRE Obstetric Anesthesia Subcommittee Meeting

March 17, 2020

Agenda

Roll Call

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

Will post slides to the MPOG website for those who could not attend.

Opportunity!

• Seeking one of you or your obstetric anesthesia colleagues to help lead this committee

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

• Need someone practicing OB anesthesia to advise on measures and future direction

• Contact Nirav (nirshah@med.umich.edu) or Kate (kjbucrek@med.umich.edu) if interested!

December 2019 Meeting Recap

• Reviewed Call for Measure Survey Results

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

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

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

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

- Opted to add Antibiotic Selection Measure to assess azithromycin use

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

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

• Coordinating Center to create ‘phenotype’ to identify labor epidural cases that converted to cesarean

delivery: done

• Coordinating Center to assess the use of ICD 9/10 codes for capturing outcomes, specifically SSIs: In

progress

OB_ABX 01: Antibiotic Timing for Cesarean Delivery

Description: Percentage of cesarean deliveries with documentation of antibiotic

administration initiated within one hour before surgical incision

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

Inclusions:

• Elective, urgent, or emergent cesarean delivery*

• 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.

Obstetric Anesthesia Algorithm for determining Case Type

• Case Type Categories:

– Labor Epidural

– Cesarean Delivery

– Labor Epidural converted to Cesarean

– Unable to determine

• 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

• Antibiotic Timing measure also includes

cesarean delivery with hysterectomy

(CPT: 01969)

Obstetric Anesthesia Algorithm for determining Case Type

Obstetric Anesthesia Algorithm for determining Case Type: Part 2

Obstetric Anesthesia Algorithm for determining Case Type: Part 3

Antibiotic Timing for Cesarean Delivery – Measure Specification

Exclusions:

• Obstetric Non-Operative Procedures*

• Cesarean delivery with documentation of infection prior to incision and mapped to

one of the following MPOG concepts*

– 50181 Compliance- Prophylactic Antibiotic Variance Note

– 50182 Compliance- Prophylactic Antibiotic Variance Note Detail

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

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

*Determined using MPOG Obstetric Anesthesia phenotype

Antibiotic Timing for Cesarean Delivery – Measure Specification

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

procedure start)

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

Date/Time (50006)

**For cases without a documented surgical incision time or procedure start time, the case will be

flagged for review.

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.

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.

Exceptions:

• If not ordered/not indicated - flag/fail

• If ‘Prophylactic antibiotic administered (not documented on MAR)’ – flag/fail

Antibiotic Timing for Cesarean Delivery – Measure Specification

• For emergency cases, success is determined by documentation of any of the following

antibiotics initiated between anesthesia start and anesthesia end.

• Any of these antibiotics administered within the timeframe will result in success for this

measure focused on antibiotic timing, rather than selection.

Acceptable Antibiotics/Timing:

Antibiotic MPOG Concept Appropriate Start Time

Azithromycin 10048 Between Anesthesia Start and 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

Gentamicin 10202 Within 60 minutes before incision

Vancomycin 10444 Within 120 minutes before incision

Antibiotic Selection for Cesarean Delivery

• Institutional level measure (no attribution)

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

anesthesia-specific measure

• Feedback:

– OB can order without anesthesia input

– Required to administer as ordered, but can give suggestions

– Each surgical site infection is already reviewed at each institution, including abx choice and timing

• Does this group wish to focus on this?

Specification Draft

Cefazolin

Cefazolin &

Azithromycin

Ceftriaxone

Ceftriaxone &

Azithromycin

Cefoxitin

Cefoxitin &

Azithromycin

Cefuroxime

Cefuroxime &

Azithromycin

Only

75.01% 9.01% 0.08% 0.01% 1.15% 0.20% 0.00% 0.00% 1.04%

Prolonged Hypotension before Cesarean Delivery

Measure Time Period:

• Spinal placement time to delivery of neonate

Hypotension Definition:

• SBP <80% baseline (>20% decrease from baseline) OR

• SBP < 90mmHg or <100mmHg

• 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.

– 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

• Assess if hypotension that was treated instead/also?

Definition of Hypotension: SBP <80% baseline seems supported in literature

Prolonged Hypotension before Cesarean Delivery

• Prolonged:

– 5 or 10 minutes?

• Inclusions:

– Elective, urgent, or emergent cesarean delivery*

– Patients undergoing cesarean section with hysterectomy (CPT: 01969)

Note: Includes epidural, spinal, combined spinal epidural, & general anesthesia cases for cesarean section delivery

*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.

• 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)

• Provider Attribution- Anesthesia providers signed in at:

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

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

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

4. Obstetrics- Delivery of Neonate (50358).

THANK YOU!

Kate Buehler, MS, RN, CPPS

MPOG Clinical Program Manager

kjbucrek@med.umich.edu

Nirav Shah, MD

MPOG Associate Director

nirshah@med.umich.edu