Obstetric Subcommittee Slides 7.15.20

ASPIRE Obstetric Anesthesia Subcommittee Meeting

July 15, 2020

Agenda

• Announcements

• March 2020 meeting recap

• AKI 01: Pre-eclampsia exclusions

• Review ABX 01- Antibiotic Timing for Cesarean Delivery

• BP 04: Prolonged Hypotension for Cesarean Delivery

• Next Measure?

Roll Call

Sharon

Abramovitz, Weill Cornell

Angel Martino, Sparrow Health System

Ami Attali, Henry Ford

- Detroit

Arvind

Palanisamy, Washington University

Dan Biggs, University of Oklahoma

Carlo Pancaro, Michigan Medicine

David Swastek, St. Joseph Mercy Ann Arbor

Mohamed Tiouririne, University of Virginia

Eric Davies,

Henry Ford Allegiance Health

Brandon Togioka, Oregon Health Science University

Ghislaine Echevarria, NYU

Langone

Joshua Younger, Henry Ford, Detroit

Ronald George, University of California

- San

Francisco

Marie

-Louise Meng, Duke

Jenifer Henderson, St. Joseph Oakland

Ashraf Habib, Duke

Rachel Kacmar, University of Colorado

Nirav Shah, MPOG Associate Director

Joanna Kountanis, Michigan Medicine

Kate

Buehler, MPOG Clinical Program Manager

Carlos Delgado

Upegui, University of Washington

Meridith

Bailey, MPOG QI Coordinator

Tom Klumpner, Michigan Medicine

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.

Thank you!

• Thank you to Dr. Rachel Kacmar (University of Colorado) and Dr. Dan Biggs (University of

Oklahoma) for serving as leaders of the OB Anesthesia subcommittee!

March 2020 Meeting Recap

• ABX 01-OB: Antibiotic Timing for Cesarean Delivery Specification Review

– Committee agreed on including emergent cases, but with a more forgiving timeframe for passing

– Committee agreed on adjusting appropriate timeframe for azithromycin (60 min before incision through anes

end) and clindamycin (within 60 minutes before surgical incision). All other antibiotics must be administered

‘within 60 minutes before incision’ (except vanco, which is 120 minutes) to ‘pass’ the measure

• Antibiotic selection measure

– Determined to be lower priority, may be useful to develop later in collaboration with surgical colleagues

• Prolonged Hypotension Measure Specification Review

– Discussed timeframe and applicable BP cutoffs for specific populations

– Committee agreed on lack of standardization, this measure will remain informational only

– Committee agreed on separate measures for pre-eclampsia and non pre-eclampsia patients

AKI Toolkit

• MPOG is happy to announce the release of its 4

toolkit: Avoiding Kidney Injury. This

toolkit reviews the pathophysiology and definitions of kidney injury as well as

recommendations for perioperative care.

• This toolkit includes a one-pager summary and slide presentations

– Overview, Pathophysiology & Definitions of Kidney injury

– Recommendations to prevent Kidney injury: Adult Surgical Patients

– Pediatrics

– Cardiac

– Obstetrics

• https://mpog.org/akitoolkit/

New OB Concepts Available for Mapping

• Fetal heart rate- Decelerations (50238)

• Fetal heart rate – Accelerations (50239)

• Fetal heart rate category (3166)

Epic OB Variables

• Baby A Delivery Time

• Baby B Delivery Time

• Baby C Delivery Time

• Baby Delivered

• Birth 1

• Birth 2

• Born by Cesarean section

• Born by vaginal delivery

• Cord Clamp Removed

• C-section

• C-Section Priority

• C-Section-59515/01961

• Delivery Date - Baby A

• Delivery Date - Baby B

• Delivery of Placenta Date

• Delivery of Placenta Time

• Delivery Time - Baby A

• Delivery Time - Baby B

• Epidural to C-section

• Epidural to emergent C-Section

• Epidural/Vaginal Delivery-62319/01967

• Forceps Assisted Delivery

• Incision

• Labor

• Labor Analgesia is Transferred to C-Section

• Labor Epidural to C-Section

• Placenta

• Placenta Delivered

• Placenta delivery method

• Placenta Out

• Post Delivery Procedure End

• Procedure Start

• Procedure Start Time

• Regional block to C-Section

• Repeat C-section

• Surgical Incision

• Surgical/Procedure Incision

• Umbilical cord

• Umbilical Cord, Infant

• Unscheduled C-Section Decision Date

• Unscheduled C-Section Decision Time

• Uterine Contractions

• Uterine Incision

• Uterine Incision Time (C/Section)

• Vaginal Delivery (Time)

• Vaginal Delivery in OR-59409/01960

• MPOG is working with Epic to include the following variables in the MPOG extract if used at

your site

AKI 01

• AKI 01 measures the percentage of cases where the baseline creatinine does not increase

more than 1.5 times within 7 postoperative days or the baseline creatinine level does not

increase by = 0.3 mg/dL within 48 hours postoperatively.

• Currently includes pre-eclampsia patients who undergo cesarean delivery

– AKI 01 excludes non-operative procedures including labor epidurals currently

– Cesarean deliveries with pre-eclampsia are included

• Should AKI 01 exclude pre-eclampsia patients?

• References:

– Van Hook JW: Acute kidney injury during pregnancy. Clin Obstet Gynecol 2014; 57:851–61

– Huang C, Chen S: Acute kidney injury during pregnancy and puerperium: a retrospective study in a single

center. BMC Nephrol 2017; 18:146

– Arulkumaran N, Lightstone L: Severe pre-eclampsia and hypertensive crises. Best Pract Res Clin Obstet

Gynaecol 2013; 27:877–84

ABX 01-OB: Percentage of cesarean deliveries with documentation of antibiotic administration

initiated within one hour before surgical incision

BP 04-OB: Hypotension During Cesarean Delivery Spec Review

Current Draft

• Description: Total cumulative minutes

of hypotension after spinal placement

for patients with and without pre-

eclampsia.

Discussion

• Should this be displayed as mean or

median minutes of hypotension?

• Or display as ‘cases below a cumulative

minute threshold?’ What should this

threshold be?

BP 04-OB Spec Review

Current Draft

• Total cumulative minutes of

hypotension will be resulted for two

time periods: spinal placement to

delivery and delivery through

anesthesia end.

– For patients with pre-eclampsia,

hypotension is defined as >20% decline from

baseline systolic blood pressure.

– For patients without pre-eclampsia,

hypotension is defined as SBP<90mmHg.

Discussion

• Based on prelim data from 7/1/19-

4/30-20

– 37,739 Total C-sections (scheduled or

conversion from vaginal delivery)

– 3,800 (1%) of the total c-sections were

identified as having pre-eclampsia using our

phenotype

– 914 (24%) have a baseline BP in MPOG.

– Given the low # of pts identified to have

preeclampsia and the low % with baseline

BP, should preeclampsia patients be

excluded from this measure? Or included

but noted to have pre-eclampsia?

BP 04-OB Spec Review

• Exclusions:

– Cesarean delivery patients undergoing general

anesthesia- determined using Anesthesia Technique-

Neuraxial MPOG phenotype

– Patients undergoing cesarean section with

hysterectomy (CPT: 01969)

– Emergency cesarean delivery with diagnosis of

placental abruption (ICD-10: O45*)

– Rupture of uterus (spontaneous) before onset of

labor (ICD-10: O71.0)

– Newborn affected by intrauterine blood loss from

ruptured cord (ICD-10: P50.1)

– Abnormal uterine or vaginal bleeding, unspecified

(ICD-10: N93.9)

– Placenta previa with hemorrhage, third trimester

(ICD-10: O44.13)

– Hemorrhage from placenta previa, antepartum

condition or complication (ICD-10: 641.13)

– Hemorrhage from placenta previa, delivered, with or

without mention of antepartum condition (ICD-10:

641.11)

– HELLP syndrome, unspecified trimester (ICD-10:

O14.20)

– HELLP syndrome, second trimester (ICD-10: O14.22)

– HELLP syndrome, third trimester (ICD-10: O14.23)

– HELLP syndrome, complicating childbirth (ICD-10:

O14.24)

– HELLP syndrome, complicating the puerperium (ICD-

10: O14.25)**

• Inclusions: All cesarean deliveries (as determined using the MPOG Obstetric Anesthesia Type phenotype)

with neuraxial anesthesia only (as determined by the Anesthesia Technique-Neuraxial MPOG Phenotype)

**Should patients with HELLP syndrome be excluded or treated as

pre-eclampsia patients?

BP 04-OB Spec Review

Current Spec Draft

• Measure Time Periods (2):

– 1. Spinal placement time to delivery of

neonate

– 2. Delivery of neonate to anesthesia end

Discussion

• When ‘neonate delivered’ is not

documented

– Will only result one time period

– Option: Spinal placement to anesthesia end?

BP 04-OB Spec Review

• Measure time period 1 Details

– Start Time:

– Scheduled cesarean delivery cases -determined using ‘Obstetric neuraxial start time phenotype’

-Considers a large subset of neuraxial related concepts (such as ‘Labor epidural start’ and ‘Neuraxial- Spinal

needle approach’) as well as medications given via the intrathecal route and gives the earliest of the associated

times as the ‘Neuraxial start’ time

– Conversion from labor epidural cases - determined using the ‘Cesarean Delivery Start Time for

Conversions’ phenotype

1. ’Patient in Room’ if within 60 minutes before ‘Procedure Start’, if not available then

2. The earliest of concept Obstetrics-Labor Continued as C-Section and ‘Procedure Start’, if not available then

3. Time of Peinduction-Patient transported to OR by anesthesia team’

– End Time:

– Delivery of Neonate 2, if not available then Delivery of Neonate

BP 04-OB Spec Review

Measure Reporting Groups

• Patients will further be categorized as scheduled cesarean delivery or labor epidural converted to

cesarean delivery- results will be separated for each of these groups:

– Scheduled Cesarean Delivery

– Pre-eclampsia Patients: >20% decline from baseline systolic blood pressure

– Cumulative minutes of hypotension from spinal placement to delivery

– Cumulative minutes of hypotension from delivery to anesthesia end

– Non pre-eclampsia Patients: SBP<90mmHg

– Cumulative minutes of hypotension from spinal placement to delivery

– Cumulative minutes of hypotension from delivery to anesthesia end

– Labor epidural converted to Cesarean Delivery

– Pre-eclampsia Patients: >20% decline from baseline systolic blood pressure

– Cumulative minutes of hypotension from cesarean delivery start time to delivery (see algorithm above for how cesarean

delivery start time is determined)

– Cumulative minutes of hypotension from delivery to anesthesia end

– Non pre-eclampsia Patients: SBP<90mmHg

– Cumulative minutes of hypotension from cesarean delivery start time to delivery (see algorithm above for how cesarean

delivery start time is determined)

– Cumulative minutes of hypotension from delivery to anesthesia end

BP 04-OB Spec Review

Measure Reporting Groups – Discussion

• Currently breaking out scheduled cesarean deliveries from labor epidurals converted to

cesarean deliveries

• Of the 37,739 cesarean deliveries in the prelim data, 8,092 were identified as conversions

(21.4%)

– Phenotype limitation: only identifies cases where the labor epidural and cesarean are part of the same case

– Will not find cases where the labor epidural portion was stopped and a new case started for cesarean

deliveries

• Should scheduled and conversion cases be treated the same for BP 04?

BP 04-OB Spec Review

• Success: Not applicable- informational measure only

• Responsible Provider: Not applicable- informational measure only

• Threshold: Not applicable- informational measure only

BP 04-OB Spec Review

• Multiple blood pressures: Instances where there are two blood pressure monitoring methods, the

higher MAP will be used to determine measure compliance.

• Artifact: Artifact readings will be identified and removed from final measurement calculation. Artifact

processing: if systolic and diastolic blood pressures are present, the values must be at least 5 mmHg

apart; otherwise the values will be excluded. MAP values less than 10 are excluded.

• Each incidence of hypotension will count for a max of 5 minutes if there is a gap in blood pressure

measurement

• Average cumulative minutes of hypotension from spinal placement to delivery of the last neonate (if

more than one) will be resulted as one number for the institution. Individual cases will show the total

cumulative minutes of hypotension for this time period.

• Average cumulative minutes of hypotension from delivery to anesthesia end will be resulted as a

second number for the institution. Individual cases will show the total cumulative minutes of

hypotension for this time period.

Call for Measure Survey Results

• Review 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

• Next measure: General Anesthesia Rate for Cesarean Delivery?

THANK YOU!

Brooke Szymanski, MSN, RN, CPN

MPOG QI Coordinator

bmiszy@med.umich.edu

Nirav Shah, MD

MPOG Associate Director

nirshah@med.umich.edu