ASPIRE Pediatric Subcommittee Meeting
July 21, 2020
Agenda
• April 2020 Meeting Recap
• Announcements
• Measure Performance Review
• Temperature Management (TEMP-04)
• Opioid Equivalency: Tonsil and Adenoidectomy
• Non-Opioid Adjunct Measure (PAIN-01)
April 2020 Meeting Recap
• Meeting Minutes from April 2020 have been posted to the website
• Established SPA Quality and Safety Measure Workgroup
• Dr. Vikas O'Reilly-Shah and Dr. Brad Taicher to serve as MPOG liaisons
• TEMP-04 Measure Discussion
• Reached consensus on measuring hypothermia intraoperatively
• Addressed temperature artifact algorithm
• Exclude MAC/Sedation cases and those without documentation of a core temperature route
2020 MPOG Meetings
(Virtual)
• Pediatric Subcommittee Meetings
- October (Before or After SPA?)
- December
• MPOG Quality Committee Meetings
- August 24
th
- October 26
th
• MPOG Annual Retreat 2020
Acute Kidney Injury Toolkit
• Avoiding Kidney Injury is the 4
th
toolkit released by MPOG
• Toolkit Components :
– Recommendations for Perioperative Care: Pediatrics
– AKI Reference Guide
• MPOG Measure: AKI-01
– Patients ≤ 18 years old
– KDIGO Criterion used
– Exclusion criteria: baseline creatinine < 0.2mg/dL
– Success criteria:
– The creatinine level does not go above 1.5x the baseline creatinine within 7 days post-op or does
not increase by ≥ 0.3 mg/dL within 48 hours after anesthesia end.
Image Source: Gumbert et al. Anesthesiology. 2020
MPOG Lab Concepts - Microbiology
• New Microbiology Category with prefix ‘Micro’
– Culture type (aerobic, anaerobic, AFB etc.)
– Specimen type (wound, CSF, fluid etc.)
• Immunology – Antibody tests
• COVID-19 Related Concepts available
– Micro – Virology – Coronavirus (SARS-CoV-2)
– Immunology – Antibody – COVID19 - IgG
Measure Performance Review
TEMP-04-Peds
TEMP-04 Considerations
• Nadir temp < 35C removed from success criteria
– Inaccurate temperature monitoring algorithm.
– Plan to refine year and add nadir temp back flag for TEMP-04 at a later date.
• Updated artifact algorithm:
– Exclude all Temperature values that are < 32C and > 40C
– Apply artifact to exclude minute-to-minute values ≥ 0.5 C difference in temperature.
– Exclude first 5 minutes of temperature monitoring to account for probe warming
– Minute-to-minute: exclude first 5 values
– 5 minute intervals: exclude the first value
• Outlier cases: Difficulty capturing general anesthetic patients who are transferred
directly from MRI  OR
– Measure code is inaccurately excluding a few cases
– Working on a solution
Additional information provided in case details
• Nadir temp
• Preop temperature
• Postop temperature
• Lowest temperature
• Total Time @ lowest temperature
• % Time temperature < 36C
• Time from Patient in Room to 1
st
temp value
TEMP-04 Performance comparison across MPOG institutions (Median >36C)
Percentage of patients < 18 years old who undergo a procedure greater than 30 minutes whom
have a median core/near core temperature > 36C (96.8F).
% of pediatric patients with first postop temp < 36C (TEMP-03)
Measure Performance Review
Opioid Equivalency – Pediatric Tonsil/Adenoidectomy
• Opioid Equivalency - Informational Measure
– Opioid equivalents are calculated using conversions given
between anesthesia start and anesthesia end for each
case. This value is normalized to patient weight (kg) and
case length of 1 hour.
– *Does not include Opioids given in PACU
• Case Cohort – Tonsillectomy and Adenoidectomy
– Patients < 18yo
– CPT: 00170, procedure text with ‘tonsil’ and/or ‘adenoid’
• Measure Specification
Average Opioid Administration (mg/kg/hr)
Opioid Route Multiplier
Morphine
1,2
Oral 30.00
Codeine
1,2
Oral 200.00
Hydromorphone (Dilaudid)
1,2
Oral 7.50
Hydrocodone
2
Oral 30.00
Oxycodone
1,2
Oral 20.00
Oxymorphone
1,2
Oral 10.00
Meperidine
1
Oral 300.00
Tramadol
1
Oral 120.00
Methadone
8
Oral 6.00
Fentanyl
2
transdermal 12.50
Buprenorphine (Suboxone)
3
Sublingual 0.40
Morphine
1
IV 10.00
Codeine
1
IV 100.00
Fentanyl
1
IV 0.10
Hydromorphone (Dilaudid)
1
IV 1.50
Oxymorphone
1
IV 1.00
Meperidine
1
IV 100.00
Tramadol
1
IV 100.00
Buprenorphine (Suboxone)
1
IV 0.40
Nalbuphine
1
IV 10.00
Butorphanol
1
IV 2.00
Alfentanil
7
IV 0.50
Sufentanil
5
IV 0.01
Remifentanil IV 0.00
Methadone
3
IV 5.00
Hydromorphone
6
epidural 0.30
Morphine
4
epidural 1.00
Fentanyl
6
epidural 0.03
Fentanyl
6
IT 0.01
Morphine
4
IT 0.10
Hydromorphone
6
IT 0.06
Average Opioid Administration across MPOG institutions
*(mg/kg/hr)
Variation in practice seen
across providers during
tonsillectomy procedures
Variation in opioid administration across age groups
• Infant (0-1y)
• Toddler (1-3y)
• Child (4-7y)
• Adolescent (8-12y)
• Teen (13-17y)
*(mg/kg/hr)
In Progress: Additional Case Details
• Highest Pain Score in PACU (FLACC)
• Opioids given in PACU (yes/no)
• Average opioid equivalency administered in PACU
Opioid Equivalency: Additional Pediatric Case Cohorts
• Up Next: Spine
• Future Considerations
– Cardiac
– Thoracic Surgery
– Urology
– Maxillofacial Surgery
Opioid Free Anesthesia: A QI Project
• Implementation of an opioid-sparing protocol reduced perioperative opioid use by 90% in
pediatric ambulatory surgical patients at Seattle Children’s Hospital
Image Source: Franz et al. Anesthesia & Analgesia. 2020
Outcomes
• Maximum postoperative pain score (FLACC, FACES, or Visual Analog) and Postoperative morphine rescue rate
• Total PACU minutes, Anesthesia Duration and PONV rates remained stable
Image Source: Franz et al. Anesthesia & Analgesia. 2020
Non-Opioid Adjunct Measure
PAIN-01
PAIN-01 Measure Discussion
• Description: Percentage of patients < 18 years old who undergo a surgical or
therapeutic procedure and receive a non-opioid adjunct preoperatively and/or
intraoperatively.
• Success Criteria: At least one non-opioid adjunct medication was administered to
the patient during the preoperative or intraoperative period.
• Measure Time Period: Preop Start → Anesthesia End
• Exclusions
– ASA 5 and 6; Patients transferred directly to ICU
– Organ Harvest (CPT: 01990); Cardiac Surgery (CPT: 00561, 00562, 00563, 00566, 00567, 00580);
Obstetric Non-Operative Procedures (CPT: 01958, 01960, 01967)
– Non-operative procedures; Radiology procedures
• Responsible Provider: Provider at the beginning of the case (prior to incision)
Acetaminophen
Aspirin
Ibuprofen
Naproxen
Celecoxib
Ketorolac
Ketamine
Dexmedetomidine
Dextromethorphan?
Gabapentin
Pregabalin
Clonidine
Magnesium
Lidocaine (Infusion only)
Non-Opioid Adjuncts Included
Image Source: Zhu, Benzon & Anderson.
Pediatric Anesthesiology. 2017
2020 Plans – Next Steps
Measure Build Status
Pediatric Temperature Management (TEMP-04) Complete!
OME Pediatric Cohort #1 - Tonsillectomy/Adenoidectomy Complete!
OME Pediatric Cohort #2 - Spine October
Non-Opioid Adjunct (PAIN-01) October
• Publish additional OME case cohort – Pediatric Spine
• Finalize specification for Non-Opioid Adjunct measure (PAIN-01)
• Send PAIN-01 specification to group and publish measure
Thank you