Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)
Pediatric Subgroup Meeting Minutes – April 21, 2020
Attendees: P=Present; A=Absent; X=Expected Absence
A
Alina Bodas, Cleveland Clinic
A
Lisa Chan, Arkansas Children’s
A
Allan Simpao, Children’s Hospital of Philadelphia
P
Lisa Vitale, Michigan Medicine
P
Amber Franz, Seattle Children’s
A
Lucy Everett, Mass General Hospital
A
Anna Clebone, University of Chicago
X
Lori Reigger, Michigan Medicine
A
Anna Swenson, University of Minnesota
A
Luis Tollinche, Memorial Sloan Kettering
A
Anastasia Grivoyannis, Weill-Cornell
A
Marco Silvestrini, US Anesthesia Partners
P
Anshuman Sharma, Washington University
P
Morgan Brown, Boston Children’s
P
Bishr Haydar, Michigan Medicine
P
Olga Eydlin, NYU Langone
P
Bob Brustowicz, Boston Children’s
P
Paul Reynolds, Michigan Medicine
P
Brad Taicher, Duke University
A
Phillip Collier, Beaumont Royal Oak
A
Carrie Menser, Vanderbilt
A
Phillip Yun, OHSU
P
Charles Schrock, Washington University
P
Priti Dalal, Penn State University
P
Cheryl Gooden, Yale University
X
Red Starks, US Anesthesia Partners
A
Christy Crockett, Vanderbilt
P
R.J. Ramamurthi, Stanford
P
Claudia Benkwitz, UCSF
A
Robert Christensen, Michigan Medicine
P
Dan Roke, St. Louis Children’s
A
Ronak Patel, University of Virginia
A
David Buck, Cincinnati Children’s
P
Ruchika Gupta, Michigan Medicine
A
Elizabeth Elliot, Children’s Hospital of Philadelphia
P
Ryan Bradstreet, Bronson Healthcare Group
P
Germaine Cuff, NYU Langone
A
Shannon Grap, Penn State Children’s
A
Gina Whitney, University of Colorado
P
Shobha Malviya, Michigan Medicine
A
Hamid Vahabzadeh-Monshie, University of Oklahoma
A
Stephanie Kahntroff, University of Maryland
P
Imelda Tjia, Texas Children’s
P
Steve Zgleszewski, Boston Children’s
A
Jacob Tiegs, NYU Langone
A
Tetsu Uejima, DuPont Children’s
A
Jessica Cronin, John Hopkins Children’s
P
Uma Parekh, Penn State Children’s
P
Jina Sinskey, UCSF
P
Vikas O’Reilly-Shah, University of Washington
P
Joe Cravero, Boston Children’s
A
Vivian Onyewuche, Henry Ford-Detroit
A
Jorge Galvez, Children’s Hospital of Philadelphia
A
Wenyu Bai, Michigan Medicine
A
Julianna Mendoza, Stanford University
A
Wilson Chimbira, Michigan Medicine
A
Jacques Scharoun, Weill-Cornell
P
Nirav Shah, MPOG Associate Director
P
Jurgen de Graaff, Erasmus MC-Netherlands
P
Kate Buehler, MPOG Clinical Program Manager
P
Laura Downey, Emory University
P
Meridith Bailey, MPOG QI Coordinator
A
Lianne Stephenson, University of Wisconsin
P
Brooke Szymanski, MPOG QI Coordinator
Agenda & Notes
1) Roll Call
2) Thank you to all those who have joined this committee and continue to assist in moving this work
forward! Special thanks to Brad Taicher (Duke), Vikas O’Reilly-Shah (University of Washington), Bishr
Haydar (Michigan Medicine), Shobha Malviya (Michigan Medicine), Lisa Vitale (Michigan Medicine)
for helping lead this initiative.
3) Upcoming Events/Announcements
a) MPOG Pediatric Subcommittee Meetings
i) July 2020: Webex meeting
ii) October 2020: In-person meeting (hopefully) at ASA
iii) December 2020: Webex meeting
b) MPOG Quality Committee Meetings
i) April 27
th
10am EST Webex
ii) June 22
nd
10am EST Webex
iii) August 24
th
10am EST Webex
iv) October 26
th
10am EST Webex
c) MPOG Annual Retreat: October 2
nd
, ASA Washington D.C.
4) December 2019 Meeting Recap
a) Meeting minutes and slides have been posted to the website
b) 23 pediatric anesthesiologists in attendance
c) 2020 Plans: Build 2-3 pediatric specific measures
i) Temperature Management
ii) Postoperative respiratory complications
iii) Add tonsillectomy and adenoidectomy + spine procedures to the morphine equivalency
dashboard
iv) Intraoperative hypotension (informational measure)- tabled to future discussion
5) SPA Quality and Safety Measure Workgroup
a) Brad Taicher MD, PhD (Duke) presented an intro to MPOG at SPA Q&S meeting in February
b) Proposed the formation of a metric workgroup within SPA Q&S to help inform the MPOG
subcommittee of best practices in pediatric anesthesia.
c) First in person workgroup meeting planned for October at ASA
d) All members of the SPA Q&S committee are welcome to join, regardless of involvement with
MPOG
i) Priti Dalal (Penn State)- Question regarding who the leader from SPA Q&S leading this
initiative/collaboration with MPOG; who should primary contact be?
(1) Brad Taicher (Duke) and Vikas O’Reilly-Shah (University of Washington) to take this
liaison role on for now but are open to others helping; will be an open collaboration,
goal is to be inclusive
e) Contact Meridith (Meridith@med.umich.edu) if interested in joining
6) Improved MPOG QI Dashboard: Scheduled for May 2020 release
7) Pediatric Measure Specification Review (Bishr Haydar- Michigan Medicine)
a) Temperature Management (TEMP-04-Peds)
i) Overview of temperature measure discussion to date
(1) Examine hypothermia, hyperthermia, or both?
(a) Focusing on hypothermia only more frequent among pediatric cases & poses
greatest risk to patients (Committee reached consensus that this is the appropriate
place to start: hypothermia should be the focus.)
(2) Low median temperature value (<36.0 degrees Celsius) will flag cases for review
(a) Consecutive temperature: difficult from a technical perspective.
(b) Average temperature not utilized since it can be impacted by over-warming a
patient at the end of a case.
(3) Nadir temp < 35C will also flag cases for review
(a) Seamon et al (2012) determined that a single intraoperative temperature
measurement less than 35C increased surgical site infection risk by 221% per degree
below 35C (p=0.007)
(4) Time Period: Intraoperative
(a) Many patients are hypothermic for a significant duration of the procedure despite
having a temperature > 36C postop.
(b) Baseline temperature and the first temp value postop will be listed for each case as
information only to assist in case review.
ii) Measure Specification: Intraoperative Temperature Management (TEMP 04-Peds)
(1) Description: Percentage of patients < 18 years old who undergo any procedure greater
than 30 minutes who have a median core/near core body temperature < 36
o
C (96.8
o
F)
or nadir temp < 35
o
C (95
o
F)
(a) Vikas O’Reilly-Shah (University of Washington): Comment that grouping these two
populations together (nadir and median groups) could lead to issues if this measure
was used for research purposes.
(i) Nirav Shah (MPOG): MPOG will be able to break these into separate groups on
the measure build side
(2) Measure Time Period: Patient in Room to Patient Out of Room
(3) Algorithm for determining Measure Start/End Times
(a) Measure Start Time
(i) Patient In Room. If not then,
(ii) Induction End. If not then,
(iii) Procedure Start. if not then,
(iv) Anesthesia Start
(b) Measure End Time
(i) Patient Out of Room. If not then,
(ii) Procedure End. If not then,
(iii) Anesthesia End
(4) Core or Near Core Temperature Monitoring Includes:
(a) Pulmonary Artery, Distal Esophageal, Nasopharyngeal, Temporal, Tympanic,
Bladder, Rectal Temperature, Axillary Temperature (arm must be at patient side) or
Oral Temperature (Skin temperatures would be excluded.)
(b) Claudia Benkwitz (UCSF): Raised concern regarding capturing temperature routes
with the actual temperature values since temperatures can be very different
between routes.
(i) Bishr Haydar (Michigan Medicine): Expressed that routes will be available upon
case review and ultimately want to know if a patient was hypothermic from any
of the core or near-core routes.
(c) RJ Ramamurthi (Stanford): Is mode more appropriate compared to median for this
measurement?
(i) Vikas O’Reilly-Shah (University of Washington): Should we try to capture the
time below threshold rather than a single value?
1. Nirav Shah (MPOG): Median is easiest to understand for providers and easy
to calculate.
2. Bishr Haydar (Michigan Medicine): If focusing on how to improve provider
behavior, median may be more straightforward for providers to understand.
(ii) Anshuman Sharma (WashU): Is there a way to filter out the noise/inaccurate
values?
1. Nirav Shah (MPOG): Artifact code in place to address the jumps in
temperature that occur when the probe is initially trying to calibrate
(iii) Anshuman Sharma (WashU): This measure would assist in improving
organizational practices but also allow institutions to compare to national
performance to bring back to our sites to drive improvement. In favor of this
measure. Do we want to address the end of case temperature as a separate
measure? Does this align with the MIPS measure for reporting?
1. Nirav Shah (MPOG): This measure does not align with the MIPS measure
exactly - MIPS measure is more closely aligned with ASPIRE measure: TEMP
03 although this new pediatric measure as well as the TEMP 03 measure use
36 degrees Celsius as the cutoff rather than 35.5. Will plan to include the
end of case temperature as additional information for the cases flagged by
the measure so providers can compare median values to end of case
temperatures.
(iv) Claudia Benkwitz (UCSF): How will cases be excluded, specifically cardiac cases?
Do we not submit those cases to MPOG?
1. Nirav Shah (MPOG): MPOG will apply the measure exclusions within the
measure code, will use anesthesia CPT codes to exclude
(v) Bishr Haydar (Michigan Medicine): What routes are most appropriate to include
for core or near-core temperatures?
1. Brad Taicher (Duke): Do most sites on the adult site document a
temperature monitoring location?
a. Nirav Shah (MPOG): Most do now, since MPOG implemented the TEMP
02 core temperature monitoring measure
2. Claudia Benkwitz (UCSF) & Priti Dalal (Penn State)- Axillary probes can easily
become dislodged and temperatures may not be accurate
a. Shobha Malviya (Michigan Medicine): Many cases only use axillary
cases, do we want to exclude all those cases?
b. Amber Franz (Seattle Children’s): Does arm at patient side need to be
documented to use the axillary temp? Are sites documenting this? For
small children, their arm easily falls away from the side.
i. Nirav Shah (MPOG): We have focused on this for adults so many
sites are documented ‘at the patient side’ but may not be feasible in
the pediatric population.
c. Nirav Shah (MPOG): Would encourage including those cases as review
can help identify process issues - If you exclude all axillary cases, less
likely to review and as Shobha mentioned, this can be a high volume of
cases
3. Ruchika Gupta (Michigan Medicine): Should MAC cases be excluded?
a. Committee agrees to exclude MAC cases- downstream impact or risk of
SSI is low for MRI & other common MAC cases.
(5) Case Exclusions:
(a) ASA 5 and 6
(b) Cases < 30 minutes duration
(c) Unlisted Anesthesia procedure (CPT: 01999)
(d) Organ Harvest (CPT: 01990)
(e) Obstetric Non-Operative Procedures (CPT: 01958, 01960, 01967)
(f) Cardiac Surgery (CPT: 00561, 00562, 00563, 00566, 00567, 00580)
(g) Add MAC cases as additional exclusion
(h) Exclude cases without a temperature or core/near-core temperature route
documented
(6) Responsible Provider: Provider present for the longest duration of the case per staff
role.
(a) Provider Attribution: Committee agrees to attribute the provider signed in for the
longest duration of the case per staff role.
(7) Success Criteria: The median temperature intraoperatively is ≥ 36 C (96.8F) or is the
nadir ≥ 35 C (95F).
(a) We will “clean” temperature values using the following artifact algorithm:
(b) Less than 32.0˚C (89.6F)
(c) Greater than 40.0˚C (104.0F)
(d) Any minute-to-minute jumps > 0.5˚C equivalent.
(e) Will account for initial warm up of probe placement
(8) Feedback requested: In addition to baseline temp and first postop temp, what other
data (if any) should be displayed as a “case detail”?
8) Next Steps
a) Publish temperature management measures- will send notes to this committee to summarize
discussion and consensus
b) Finalize specification for opioid equivalency – send to group and publish measure
c) Send out specifications for proposed measures
Meeting adjourned at: 1203
