Pediatric Subcommittee Minutes 10.6.20

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Pediatric Subgroup Meeting Minutes – October 6, 2020

Attendees: P=Present

Alina Bodas, Cleveland Clinic

Liem Pham, NYU Langone

Allan Simpao, Children’s Hospital of Philadelphia

Lisa Chan, Arkansas Children’s

Amber Franz, Seattle Children’s

Lisa Vitale, Michigan Medicine

Anna Clebone, University of Chicago

Lucy Everett, Mass General Hospital

Anna Swenson, University of Minnesota

Lori Reigger, Michigan Medicine

Anastasia Grivoyannis, Weill-Cornell

Luis Tollinche, Memorial Sloan Kettering

Anshuman Sharma, Washington University

Marco Silvestrini, US Anesthesia Partners

Ashka Shah, University of Utah

Morgan Brown, Boston Children’s

Bishr Haydar, Michigan Medicine

Olga Eydlin, NYU Langone

Bob Brustowicz, Boston Children’s

Paul Reynolds, Michigan Medicine

Brad Taicher, Duke University

Phillip Yun, OHSU

Carrie Menser, Vanderbilt

Priti Dalal, Penn State University

Charles Schrock, Washington University

Red Starks, US Anesthesia Partners

Cheryl Gooden, Yale University

R.J. Ramamurthi, Stanford

Christy Crockett, Vanderbilt

Robert Bryskin, US Anesthesia Partners

Claudia Benkwitz, UCSF

Robert Christensen, Michigan Medicine

Dan Roke, St. Louis Children’s

Ronak Patel, University of Virginia

David Buck, Cincinnati Children’s

Ruchika Gupta, Michigan Medicine

Elizabeth Elliot, Children’s Hospital of Philadelphia

Ryan Bradstreet, Bronson Healthcare Group

Germaine Cuff, NYU Langone

Shannon Grap, Penn State Children’s

Gina Whitney, University of Colorado

Shobha Malviya, Michigan Medicine

Hamid Vahabzadeh-Monshie, University of Oklahoma

Sean Wickers, University of Colorado (Med

Student)

Imelda Tjia, Texas Children’s

Stephanie Kahntroff, University of Maryland

Jacob Tiegs, NYU Langone

Steve Zgleszewski, Boston Children’s

James Xie, Stanford (Lucile Packard Children’s)

Tetsu Uejima, DuPont Children’s

Jennifer Dagen, US Anesthesia Partners

Tyler Morrissey, Colorado Children’s

Jessica Cronin, John Hopkins Children’s

Uma Parekh, Penn State Children’s

Jim Fehr, Stanford (Lucile Packard Children’s)

Vikas O’Reilly-Shah, University of Washington

Jina Sinskey, UCSF

Vivian Onyewuche, Henry Ford-Detroit

Joe Cravero, Boston Children’s

Wenyu Bai, Michigan Medicine

Jonathan Halem, Penn State Children’s

Wilson Chimbira, Michigan Medicine

Jorge Galvez, Children’s Hospital of Philadelphia

Nirav Shah, MPOG Associate Director

Julianna Mendoza, Stanford University

Kate Buehler, MPOG Clinical Program Manager

Jacques Scharoun, Weill-Cornell

Meridith Bailey, MPOG QI Coordinator

Jurgen de Graaff, Erasmus MC-Netherlands

Brooke Szymanski, MPOG QI Coordinator

Lora Gibbs, Michigan Medicine

Jackie Goatley, Michigan Medicine

Laura Downey, Emory University

Mike Mathis, MPOG

Lianne Stephenson, University of Wisconsin

Agenda & Notes

I. July 2020 Meeting Summary

a. Meeting Minutes from July 2020 have been posted to the website

b. Pediatric Measure Performance Review

i. TEMP-04

ii. Opioid Equivalency - Tonsil & Adenoidectomy (pediatric)

c. Non-Opioid Adjunct Measure Discussion (PAIN-01)

i. Initial measure proposal and discussion of non-opioid adjuncts to include

II. Announcements

a. Annual MPOG Retreat held virtually last Friday 10/2. All presentations available on our

website

i. CMS perspectives on Quality Improvement

ii. Best of MPOG Abstracts

iii. MPOG Subcommittee updates

iv. Is Equity, Diversity and Inclusion important for perioperative outcomes?

1. Nathalia Jimenez, MD (Seattle Children’s)

v. Integrating MPOG Data with Surgical Registries

b. SPA Quality & Safety Meeting this Friday 10/9

i. Update on the work of MPOG pediatric subcommittee will be presented

c. Upcoming meetings

i. Pediatric Subcommittee Meetings  December 2020- specific date TBD

ii. 2021 Schedule

1. February 17

2. May 19

3. August 18

4. October 9 (In person @ SPA)

5. December 15

iii. MPOG Annual Retreat 2021  October 8 (San Diego, CA)

d. New! Pediatric QI Dashboard

i. Similar to regular MPOG Dashboard except only for the measures that are

relevant to pediatric patients. Not all measures are specific to peds however,

automatic filter applied to view only patients <18yo.

ii. Includes two peds specific measures

1. PONV 02

2. TEMP 04

iii. Additional filters

1. Patient gender

2. Patient race

3. Provider type

iv. Measure summary pages

1. Overall score

2. Different result reasons

3. Breakdown by location – new!

a. Useful for institutions with larger campuses with multiple

locations

4. Performance trend graphs

a. See performance over time as well as comparison between sites

b. Easier to see own site vs others

5. Measure case list view

a. Allows user to review individual cases

b. Search filter

i. Case ID

ii. Attending

c. Dropdown for each case

i. Shows why the case got the result that it did

v. Hope to add in another functionality soon where sites can choose which subset

of measures they are interested in following and have those “favorites” be the

default view

III. MPOG Research Process Overview: From Real-World Data to Actionable

Knowledge

i. Michael Mathis, MD- Assistant Professor of Anesthesiology, Associate Research

Director, MPOG

ii. Shelly Vaughn, MPH- Depart of Anesthesiology, Lead Research Facilitator, MPOG

b. Types of Research Studies Leveraging MPOG

i. Descriptive Studies

ii. Operational Analysis

iii. Outcomes Studies

1. MPOG Data

2. MPOG + Surgical Registries (STS and NSQIP)

iv. Clinical Trials Network

c. Data Direct: “Democratizing” Data Access

i. When pursuing MPOG research, MPOG provides a wide array of tools to push

through the inertia of developing a research question and identifying a cohort of

MPOG patients which may serve to answer the question

ii. Our goal at MPOG central is to enable researchers to access perioperative EHR

data without needing to be an expert programmer, or a first-degree relative of

your hospital’s CMIO

iii. What DataDirect seeks to do, is democratize Data Access through implementing

an intuitive, user-friendly tool which makes a simple assumption that

anesthesiologists aren’t all software engineers

1.  Enables users to create a simple cohort of patients within minutes, to 
understand if a project is feasible. 
iv.  For more information on how to use MPOG DataDirect, please refer to the 
“Data Direct User Guide and Demonstration Talk” also available on our website. 
v.  For more information on the approach MPOG takes to ensure secure data 
analyses on a high-performance central server, please refer to the talk on “Big 
Data Management”. 
d.  Phenotypes: Structured Inferences from messy data 
i.  Another obstacle to doing high-quality observational research that MPOG has 
taken on, is the obstacle of wrangling messy, raw data derived from routine 
clinical care, and transforming this into a reproducible, clinically meaningful 
format. 
ii.  MPOG has developed a tool – the MPOG phenotype browser which rapidly 
transforms a combination of raw EHR data inputs, into a high-level, clinically 
meaningful, structured inference known as an MPOG phenotype. 
iii.  Phenotypes are validated, published, and made publicly available on the MPOG 
website 
iv.  For more details on this process, please refer to the “MPOG Phenotypes” talk 
given by Dr. Michael Burns 
e.  Developing a Research Study 
i.  At the MPOG coordinating center, we recognize that multicenter observational 
research using routinely collected, messy EHR data can often be a daunting 
process 
ii.  To break this down into digestible chunks for MPOG researchers to follow, we 
have a step-by-step playbook on our MPOG website, explicitly outlined in high 
detail, governed by the MPOG Perioperative Clinical Research Committee (or 
PCRC). 
iii.  These tried-and-true steps are designed to help researchers map out a research 
proposal from start to finish, beginning with reviewing these lectures and 
consulting your sites local MPOG research PI, and ending with a high-impact 
journal publication. 
iv.  For more information on this process, please visit the MPOG Research website 
f.  PCRC Community of Peers 
i.  The PCRC is a group of research collaborators across all MPOG centers, 
committed to the success of its peers through providing feedback over email at 
monthly web meetings, and at annual professional anesthesiology research 
forums  
ii.  For more information of the step-by-step process of presenting a research 
proposal through PCRC, please refer to the talk provided by Dr. Allison Janda, 
“Developing a PCRC Presentation” 
g.  Data Visualization and Curation 

i. Following the acceptance of a research proposal by the PCRC committee, MPOG

recognizes that additional data inspection, visualization, and cleaning are usually

necessary to ensure rigorous research

ii. To learn more about the access and use of MPOG Data Explorer, please refer to

the talk by Dr. Nicholas Douville, “Inspecting and Curating MPOG Data”.

h. MPOG Pediatric Research

1. 007 - Schonberger: PCRC Accepted Prevalence and trends of high body

mass index in a multi-institution pediatric surgical population: A Report

From the Multicenter Perioperative Outcomes Group (MPOG) (Yale)

2. 018 – De Graaf: Published Ansthesiology 2018

3. 038 – Lichtor: Submission to Journal of Pediatrics Anesthesia practice

for pyloromyotomy: A retrospective analysis of care patterns from a

national cohort (Yale)

4. 046 – Riegger: Published Anesthesia & Analgesia 2020

5. 068 – Rosenbloom: Presented to PCRC 9/17/18 Racial differences in

induction times in pediatric anesthesia practice: A retrospective cohort

study from the Multicenter Perioperative Outcomes Group Research

Consortium (Massachusetts General Hospital)

6. 090 – Montana: TBD Risk Factors for Persistent Severe Intraoperative

Hypoxemia Among Pediatric Patients undergoing Non-cardiac Surgery

(Washington University - St. Louis Children’s)

7. 092 – Rosenbloom: PCRC Accepted The effect of induction time on

intraoperative hypoxemia for pediatric patients undergoing anesthesia:

a retrospective cohort analysis (Massachusetts General Hospital)

8. 118 – Puglia: TBD Associations between the COVID pandemic and

adherence to ASPIRE Quality Measures - Pediatric (Michigan Medicine)

9. 124 - Legrand (PCRC 0102 Sub-analysis): Practice Patterns for Albumin

Use in Pediatric Liver Transplantation (UCSF)

10. 128 – Pryor/Tangel: TBD External validation of a Perioperative Risk

Score to Predict Mortality after Pediatric Surgery (Weill-Cornell)

i. Tips and tricks, along with videos, available https://mpog.org/tipsandtricks/

IV. Pediatric Measure Performance Review

a. Opioid Equivalency – spine (pediatrics)

i. Anesthesia Start → Anesthesia End

ii. Case Cohort – Patients < 18yo

1. Procedures on cervical spine and cord

a. not otherwise specified (CPT: 00600)

b. patient in sitting position (CPT: 00604)

2. Procedures on thoracic spine and cord

a. not otherwise specified (CPT: 00620)

b. via an anterior transthoracic approach; not utilizing 1 lung

ventilation (CPT: 00625); utilizing 1 lung ventilation (CPT: 00626)

3. Procedures in lumbar region; not otherwise specified (CPT: 00630)

4. Extensive spine and spinal cord procedures (CPT: 00670)

iii. Measure Specification

iv. Review comparison by site

v. Variation by provider and case count (past 12 months)

vi. Opioid Equivalency by case

1. Includes information on remifentanil admin and highest pain score per

case

b. Pain 01 – In development

i. Description: Percentage of patients < 18 years old who undergo a surgical or

therapeutic procedure and receive a non-opioid adjunct preoperatively and/or

intraoperatively.

ii. Success Criteria: At least one non-opioid adjunct medication was administered

to the patient during the preoperative or intraoperative period.

iii. Measure Time Period: Preop Start → Anesthesia End

iv. Exclusions

1. ASA 5 and 6; Patients transferred directly to ICU

2. Organ Harvest, Cardiac Surgery , Non-operative procedures and

Radiology procedures

3. Patients that were not extubated in the immediate postoperative

period.

4. Patients not given opioids or non-opioid adjuncts

v. Responsible Provider: No individual attribution

vi. New Since last meeting:

1. Patients extubated rather than ICU transfer

2. No responsible provider - cases flagged at departmental level

vii. Medications and Route Considered

1. Non-Opioid Adjuncts

a. Acetaminophen

b. Aspirin

c. Ibuprofen

d. Naproxen

e. Celecoxib

f. Ketorolac

g. Ketamine

h. Lidocaine (IV infusion only)

i. Dexmedetomidine

j. Gabapentin

k. Pregabalin

l. Clonidine

m. Esmolol

i. Data is lacking for peds, however subcommittee

decided that it would be valuable to include

n. Magnesium

o. Note: dexamethasone was not included as it is given so

commonly that we didn’t want success to be a low bar

2. Routes

a. Intravenous (bolus and infusion)

b. Intramuscular (*Ketorolac only)

c. Oral

d. Nasal

e. Enteric Tube

f. Note: Transdermal and rectal routes not considered

3. Additional information provided

a. Peripheral Nerve Block (Yes/No)

i. MPOG limitations for inclusion of regional anesthesia;

currently working on phenotype for PNB

b. Neuraxial (Yes/No)

c. Spinal (Yes/No)

d. Opioids Given in PACU

e. Highest Pain score in PACU

V. MPOG Quality Measure Review – Brad Taicher, MD

a. Background

i. Coordinating Center has created a review schedule for all measures

1. Quality measures should reflect the latest evidence or may be “topped

out” and worth retiring if no longer relevant for QI

ii. MPOG subcommittee members have tremendous experience and expertise that

should be leveraged to keep quality measures current and relevant to pediatrics

iii. Request MPOG Pediatric Champions collaborate in this review process with

other quality committee members

b. Plan

i. Reviewers will make one of the following recommendations (with supporting

evidence)

1. Continue measure as is

2. Modify measure

3. Retire measure

ii. Considerations

1. Reviewers will be de facto members of MPOG Quality Improvement

Measure Workgroup

2. Coordinating Center will not assign more than 2 measures per Quality

Champion

3. Coordinating Center team will assist reviewers as necessary to complete

review process

c. Measure Review Schedule: Pediatrics

i. 12/2020

1. AKI 01 - Acute Kidney Injury → (Bishr Haydar)

2. PUL 01 - Protective Tidal Volume, < 10mL/kg PBW → (Wes Templeton)

3. PUL 02 - Protective Tidal Volume, < 8mL/kg PBW → (Wes Templeton)

4. TEMP 03 - Postoperative Hypothermia → (Vikas O’Reilly-Shah)

ii. 03/2021

1. CARD 02 - Myocardial Infarction → (Peds Reviewer?)

2. PONV 02 - PONV Prophylaxis, Pediatrics → (Brad Taicher & Lisa Vitale)

iii. Full Schedule

VI. Next Steps

a. Publish PAIN 01

i. Requesting feedback regarding current plan for measure

b. Discuss 2021 Goals

i. Call for Measure Survey will be sent out later this month

ii. Feedback is greatly appreciated

c. Schedule meeting for December

d. Measure Build

i. Pediatric Temperature Management (TEMP 04)- COMPLETE!

ii. OME Pediatric Cohort #1- Tonsillectomy/Adenoidectomy- COMPLETE!

iii. OME Pediatric Cohort #2- Spine- COMPLETE!

iv. Non-Opioid Adjunct (PAIN-01) – December 2020

e. Basecamp forum

i. Great place for us to keep track of feedback

ii. Please let us know if you do not have access

VII. Discussion

a. Meridith Bailey, MPOG Coordinating center – Main feedback on basecamp was

regarding whether or not we want to release PAIN 01 with the regional phenotype as a

cleaner way to see whether or not a block was given or release now with meds only and

regional as informational only. The phenotype is not quite ready yet. The adult MIPS

measure considers regional as a non-opioid adjunct. The current spec does not consider

regional as a non-opioid

b. Should regional anesthesia be counted as a non-opioid adjunct and be considered

passing for the measure?

1. Shobha Malviya, Michigan Medicine- Regional doesn’t always have to

be non-opioid because we do a lot of spinal opioids

2. Wilson Chimbira, Michigan Medicine-“thumbs up” (Zoom)

3. Bishr Haydar, Michigan Medicine- Use of spinal shouldn’t have massive

impact on immediate opioid consumption during the OR they wouldn’t

receive much by way of opioid so they should be excluded I would think

from the measure. For patients with regional, certainly they are going to

benefit from not receiving any immediate opioids and might have an

entirely opioid free course. So, I would think that they should be

included

4. Shobha Malviya, Michigan Medicine- Would we include the patients

getting spinal morphine for hernia repairs? I would not consider that a

non-opioid adjunct strictly speaking

5. Bishr Haydar, Michigan Medicine- I would agree with that. The use of

intrathecal opioids for postoperative analgesia shouldn’t impact the

adverse events associated with opioids

6. Carrie Menser, Vanderbilt – At a minimum you would want to count it as

a success if you used a regional technique that involved local anesthetic

in particular. I think you are dealing with a pretty small subset of

patients that are receiving intrathecal opioids only, that’s a pretty

defined population. Most of them are going to be utilized in conjunction

with a local anesthetic at which point it would be systemically opioid

sparing

7. Joe Cravero, Boston Children’s- I would agree. What we have done in

studies that we have looked at where we have used either epidurals or

spinals with opioids is we consider it different from systemic opioids

because the dosing is so hard to compare and it constitutes a regional

intervention. I think strictly speaking you are right it is the use of an

opioid but to us it is considered a different use of an opioid so it is

considered regional, not like a systemic opioid, knowing that some of it

does get systemic so it does get messy, but I would agree with the last

comment that it should be considered separately

8. Nirav Shah, MPOG Coordinating Center- should a regional with local

anesthetic be considered a non-opioid adjunct?

9. Joe Cravero, Boston Children’s- Absolutely

ii. Brad Taicher, Duke- I think non-opioid adjunct is tough phrasing, opioid sparing

is better. It is still opioid sparing from a parenteral perspective

iii. Meridith Bailey, MPOG Coordinating Center- The regional phenotype should be

ready in the next couple of weeks

1. Next steps would be to add it to the measure code and then review the

cases to validate that it is grabbing the cases accurately

iv. Wilson Chimbira, Michigan Medicine- In that case, I recommend we wait until its

ready. I think if we have it informationally only then we will be missing a lot of

opioid sparing adjuncts

v. Meridith Bailey, MPOG Coordinating Center- Will follow up via Basecamp with

progress and shoot for December deadline

c. OME Feedback

i. Nirav Shah, MPOG Coordinating Center- As you look at the OME data for spine

cases, as you do the case review would be interesting to get feedback regarding

if we are including the right cases or if there are cases that are slipping in there

that may not be appropriate. We are using anesthesia CPT codes and not

surgical CPT codes to define the cases which can contribute to the messiness. If

you start seeing something weird in the case list please let us know.

1. We are transitioning from the old dashboard to the new. OME is only

available in the old dashboard right now. Will be moved over, along

with provider dashboards, within the next 6-8 weeks. Then we will

retire the old dashboard.

Meeting adjourned at: 1456