Quality Committee Minutes 2.24.20

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Quality Committee Meeting Notes – Monday, February 24, 2020

Abess, Alex (Dartmouth)

Lagasse, Bob (Yale)

Angel, Alan (Bronson Battle Creek)

Leis, Allie (MPOG)

Applefield, Daniel (St. Joseph Oakland)

Lewandowski, Kristyn (Beaumont Royal Oak)

Bailey, Meridith (MPOG)

Loyd, Gary (Henry Ford)

Berndt, Bradford (Bronson)

Lucier, Michelle (Henry Ford)

Biggs, Dan (Oklahoma)

Mack, Patricia (Weill Cornell)

Bledsoe, Amber (Univ of Utah)

Malenfant, Tiffany (Beaumont Trenton/Wayne)

Bodas, Alina (Cleveland Clinic)

Mathis, Mike (MPOG)

Buehler, Katie (MPOG)

McKinney, Mary (Beaumont Dearborn/Taylor)

Chang, Joyce (UCSF)

Mentz, Graciela (MPOG)

Chen, Lee-Lynn (UCSF)

Mulder, Barb (Borgess)

Clark, David (MPOG)

O’Reilly-Shah, Vikas (Washington)

Cloyd, Ben (MPOG)

Qazi, Aisha (Beaumont Troy)

Collins, Kathleen (St. Joseph)

Quinn, Cheryl (St. Joseph Oakland)

Coons, Denise (St. Joseph Oakland)

Pardo, Nichole (Beaumont)

Cuff, Germaine (NYU)

Poindexter, Amy (Holland)

Davis, Quinten (Mercy Muskegon)

Poterek, Carol (Beaumont)

Dewhirst, William (Dartmouth)

Rochlen, Lauryn (Michigan)

Domino, Karen (Washington)

Ruiz, Joseph (MD Anderson CC)

Drolett, Colleen (Henry Ford)

Schmidt, Carol (Beaumont)

Gall, Glenn (St. Mary’s Livonia)

Schonberger, Rob (Yale)

Hall, Kathleen (Borgess)

Shah, Nirav (MPOG)

Harwood, Tim (Wake Forest)

Shannon, Lori (Beaumont)

Heiter, Jerri (St. Joseph A2)

Smith, Susan (Beaumont)

Janda, Allison (MPOG)

Straight, Lindsay (MidMichigan)

Johnson, Ray (Beaumont Wayne)

Szymanski, Brooke (MPOG)

Jiang, Silis (Weill Cornell)

Tyler, Pam (Beaumont Farmington Hills)

Kurz, Andrea (Cleveland Clinic)

Wren, Jessica (Henry Ford Wyandotte/Macomb)

Lacca, Tory (MPOG)

Agenda & Notes

1. Roll Call: Will contact QI Champions and ACQRs directly to inquire about participation status

if missing. Other participants can review meeting minutes and contact Coordinating Center if

missing from attendance record.

2. Minutes from November 25, 2019 meeting approved- posted on the website for review.

Recording available as well.

3. Upcoming Events

a. ASPIRE/MSQC Collaborative Meeting March 27, 2020

i. Registration has been sent out: please register ASAP

ii. ACQR Breakout Session planned during lunch

iii. Speakers/Topics:

1. Dr. Tom Varghese (University of Utah)

2. Dr. Eve Kerr (Michigan Medicine): Appropriateness in Perioperative

Medicine

3. Dr. Daniel Clauw (Michigan Medicine): Cannabinoids and multi-modal

pain management

4. Participant from MIPACT

5. Sustainability in the OR

iv. ASPIRE performance review in the afternoon

b. ASPIRE Summer Meeting: July 17, 2020: Mark your calendars!

4. Announcements

a. Welcome Dartmouth-Hitchcock and MD Anderson as active MPOG sites!

b. Kudos to Kathleen Collins, CRNA and ACQR for St. Mary Mercy Livonia, MI as the MPOG

Featured Member for January/February 2020. Thanks for all your work to implement

ASPIRE QI work at St. Mary’s!

5. Michigan Hospitals – Pay for Performance Program Scorecard

a. 2020 Scorecards are available on the website for review:

b. Performance measures:

a) Cross-cohort measure: PUL 02≥90%

b) All sites to focus on BP 03 with target ≥90%

c) Site directed measure ≥ 90%

6. AKI Toolkit to be released this year- to view other MPOG toolkits, visit website

https://mpog.org/quality/toolkits/

7. Legacy Extract will no longer be supported as of January 2022

a. All sites must convert to Import Manager by 12/31/2021

b. Import Manger is the current method used to move data form the EHR into MPOG

c. Allows Sites to also add data outside of the anesthesia record (Preop/PACU)

d. Conversion takes approximately 6 months to 1 year

e. All sites using ‘legacy’ extract must convert by 12/31/2021

i. As of 1/1/2022, legacy sites will no longer be able to upload data to MPOG

Central until converted

ii. Legacy sites will still be able to access their dashboard, but it will no longer be

updated with new data after 1.1.2022

iii. Legacy site will no longer receive feedback emails as of 1.1.2022 until converted

iv. App Suite upgrade will only be compatible with IM as of 1.1.2022

v. Most sites have already converted to Import Manager or are in the process of

converting. If you’re not sure if your site has converted yet, please contact the

MPOG support team at support@mpog.zendesk.com

8. BCBS VBR Program Update

a. 2020 BCBS VBR Program

i. Performance period: December 1, 2018- November 30, 2019

ii. To be eligible:

1. Member of a PO for at least 1 year

2. Have at least 2 years of data in ASPIRE

3. Aggregate hospital performance meets target for 2 out of 3 measures:

PUL 02>/= 70%, TEMP 03 >= 90%, TOC >/= 90%

iii. Physicians are assigned to hospital where they have performed the most cases

iv. 3% applied starting March 1, 2020 to anesthesiologist provider payments for all

cases

b. 2021 BCBS VBR Program

i. Performance Period: January 1, 2020-November 30, 2020

ii. To be eligible:

1. Member of a PO for at least 1 year

2. Have at least 2 years of data in ASPIRE

3. Aggregate hospital performance meets target for 2 out of 3 measures:

PUL 02 ≥ 85%, TEMP 03 ≥ 95%, PONV 01 ≥ 85%

iii. Physicians are assigned to hospital where they have performed the most cases

iv. Cumulative average over the time period will be used to determine if threshold

was met

9. MPOG Obstetric Anesthesia Subcommittee

a. Reconvened December 11, 2019

b. 12 obstetric anesthesiologists in attendance (21 members total)

c. Currently, 35 sites submit cesarean delivery data to MPOG

d. Labor epidural conversion to c-section: difficult to identify using CPT codes alone

e. MPOG creating ‘phenotype’ to identify these cases using notes/medications before

building obstetric specific measures

f. Committee selected three OB-specific measures to build for 2020:

i. Antibiotic Timing for Cesarean Deliveries

ii. Antibiotic Selection for Cesarean Deliveries

iii. Prolonged Hypotension for Cesarean Deliveries

g. Next meeting to be scheduled for March 2020: Reviewing OB_ABX 01 Measure

Specification

h. 1

Obstetric Anesthesia Measure: Antibiotic Timing for Cesarean Delivery (OB_ABX 01)

i. Description: Percentage of cesarean deliveries with documentation of antibiotic

administration initiated within one hour before surgical incision

ii. Inclusions:

1. Elective, urgent, or emergent cesarean delivery (CPT: 01961 & 01968)

2. Patients undergoing cesarean section with hysterectomy (CPT: 01969)

3. Labor epidural cases converted to cesarean delivery

iii. Exclusions:

1. Obstetric Non-Operative Procedures – CPT 01958, 01960, 01967 (without

01968)

2. Cesarean delivery with documentation of infection prior to incision and

mapped to one of the following MPOG concepts:

a. 50181 Compliance- Prophylactic Antibiotic Variance Note

b. 50182 Compliance- Prophylactic Antibiotic Variance Note Detail

iv. Responsible Provider: All anesthesia providers signed in at the time of incision. If

uterine incision time is not documented (50357) then providers signed in at the

procedure start time (50006) will be attributed.

10. MPOG Pediatric Anesthesia Subcommittee

a. Peds group reconvened December 2019

i. 23 Pediatric Anesthesiologists were in attendance

ii. Increasing numbers of pediatric cases in the database (1.4m at last count)

iii. Proposed formation of SPA quality metric workgroup to inform the MPOG

Pediatric subcommittee of best practices in pediatric anesthesia.

iv. 2020 plans: build 2-3 pediatric specific measures

1. Temperature management

2. Add tonsillectomy and spine cases to opioid equivalency dashboard

3. Postoperative respiratory complications

4. Intraoperative hypotension (informational measure)

v. If Interested in joining, please contact Meridith Bailey

(Meridith@med.umich.edu)

b. Measure Development: PEDS Temp (Informational measure only)

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

therapeutic procedure whom have a body temperature (core or peripheral) less

than 36 or ≥ 38 degrees Celsius consecutively for ≥ 15 minutes between patient

in room and one hour after Anesthesia End.

ii. Measure Time Period: Patient in OR to 1 hour after Anesthesia End

iii. Exclusions:

1. ASA 5 and 6

2. Anesthesia for diagnostic or therapeutic nerve blocks/injections (CPT:

01991, 01992)

3. Unlisted Anesthesia procedure (CPT: 01999)

4. Organ Harvest (CPT: 01990)

5. Obstetric Non-Operative Procedures (CPT: 01958, 01960, 01967)

6. Cardiac Surgery (CPT: 00561, 00562, 00563, 00566, 00567, 00580)

7. Emergency cases (MPOG concepts: 70142 or 515)

iv. Success: All body temperature measurements (core or peripheral) from Patient

in room to one hour after anesthesia end are between 36 and 37.9 degrees

Celsius.

v. Responsible Provider: Provider present for the longest duration of the case per

staff role.

11. Measure Updates

a. Updated Glycemic Management Measures

i. GLU 01 (high glucose treated or remeasured) and GLU 02 (low glucose treated or

remeasured) evaluate intraoperative management only

ii. MPOG now receives preoperative and PACU medication and fluid data for several

Import Manager sites

iii. GLU 03 – High glucose rechecked or treated during the perioperative period

(preop through PACU)

iv. GLU 04 - Low glucose rechecked or treated during perioperative period (preop

through PACU)

v. Sites can add GLU 03 and GLU 04 based on when preop and PACU medication

data was submitted to MPOG (>50% of cases have preop/PACU meds)

vi. Will continue to see historical data for GLU 01 and GLU 02 in dashboard

b. PONV 03 Outcome Measure

i. Dexamethasone and Methylprednisolone have also been removed from the list

of rescue anti-emetics considered

ii. Cases ‘flagged’ if

1. Rescue anti-emetic administered

2. Patient reported nausea

3. Patient has documented episode of emesis

c. PONV 03B- Subset of PONV 03 Measure

i. Removes rescue anti-emetic administration from ‘flagged’ criteria

ii. Cases ‘flagged’ for PONV03b if

1. Patient reported nausea

2. Patient has documented episode of emesis

d. PONV 01/02 Changes

i. PONV 01/02 now exclude patients who are transferred directly to ICU to exclude

patients who remain intubated postoperatively

ii. Add Meclizine for prophylaxis?

1. Meclizine is not currently considered as an anti-emetic in our measures

2. Society for Ambulatory Anesthesiology Consensus Guidelines for the

Management of Postoperative Nausea and Vomiting 2014

3. “Meclizine has a longer duration of PONV effect than ondansetron.

Meclizine 50mg per os plus ondansetron 4mg IV is more effective than

either ondansetron or meclizine alone”

4. Limited evidence

5. PO Meclizine given the night before surgery and/or in preop along with

intraoperative ondansetron reduces nausea following discharge

6. Bopp et al (2010). Biphasic dosing regimen of meclizine for prevention of

postoperative nausea and vomiting in a high-risk population. AANA

Journal, 78(1), 55–62.

7. Forrester et al (2007). Meclizine in Combination with Ondansetron for

Prevention of Postoperative Nausea and Vomiting in a High-Risk

Population. AANA Journal, 75(1), 27–33.

8. Karen Domino (University of Washington): In support of adding

meclizine. Administered as PONV prophylaxis at University of

Washington and seems to work well when patient has contraindication

for scopalomine patch. Though there seems to be limited published

evidence in this area- it does seem to work well for patients.

9. Tim Harwood (Wake Forest): In support of adding meclizine as well,

seems to work well when used with ondansetron.

10. Michelle Lucier (ACQR) Henry Ford: In support of adding meclizine- used

as prophylaxis at Henry Ford West Bloomfield.

12. Application updates

a. DataDirect 2.0

i. New version rolled out in January 2020

ii. Able to add measure performance as an output variable for your own institution

iii. Next steps: Revise the filter section: June 2020

b. Dashboard 2.0

i. Goals

1. Flexible

a. Ability to view measures in different ways

b. Accommodate site participation differences

2. Visually Interesting

a. Changes to how we can manipulate and view the data

3. Links to other MPOG apps easily

a. Ie phenotype browser and data direct

ii. Shared a mock-up of the new dashboard with the Committee (see PPT slides)

iii. Informational measures, inverse measures, outcome and process measures need

to be able to be displayed in a way that can easily be interpreted by the user

iv. Want to add the ability to build multiple dashboards per site (peds, OB, cardiac,

main)

v. Sites will be able to choose a select set of measures to display for their institution

(rather than all displaying all 30 measures as is the default currently)

vi. Also will be able to filter much easier

vii. Plan to release in late April, early May- development is already underway!

13. ABA-MOCA Project Introduction: Benjamin Cloyd, MD, MIPH (University of Michigan)

a. Dr. Benjamin Cloyd was the 2019-2021 FAER-ABA Research in Education Grant Awardee

b. Introduced project aimed at studying variation of measure performance across Michigan

ASPIRE sites

c. Goal: Evaluate the value of primary certification and the MOCA program to clinicians and

the public, including assessment of how certification is related to clinical performance

and novel means to analyze and utilize data

d. Why study this?

i. Aim to continue to evaluate and improve our ASPIRE metrics

ii. This will develop a different pathway to research and spread ASPIRE findings and

best practices

iii. Can utilize the performance distribution data to evaluate which ASPIRE metrics

may be useful for research projects and further analysis

e. Next Steps: Developing PCRC proposal to present to MPOG researchers for approval but

wanted the site quality teams to be aware of this project as well

Meeting concluded at 10:57am