Quality Committee Minutes 4.27.20

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Quality Committee Meeting Notes – Monday, April 27, 2020

Abess, Alex (Dartmouth)

Lacca, Tory (MPOG)

Applefield, Daniel (St. Joseph Oakland)

Lagasse, Bob (Yale)

Bailey, Meridith (MPOG)

LaGorio, John (Mercy Muskegon)

Berndt, Bradford (Bronson)

Lewandowski, Kristyn (Beaumont Royal Oak)

Berris, Josh (Beaumont)

Lins, Steve (Bronson)

Biggs, Dan (Oklahoma)

Loyd, Gary (Henry Ford)

Bollini, Mara (WUSTL)

Lucier, Michelle (Henry Ford)

Boutin, Jimmy (Henry Ford)

Malenfant, Tiffany (Beaumont Trenton/Wayne)

Bouwhuis, Alex (Holland)

Miliken, Chris (Sparrow)

Buehler, Kate (MPOG)

Obembe, Samson (Weill Cornell)

Chiao, Sunny (UVA)

Onyewuche, Vivian (Henry Ford)

Clark, David (MPOG)

Pardo, Nichole (Beaumont)

Collins, Kathleen (St. Joseph)

Poindexter, Amy (Holland)

Coons, Denise (St. Joseph Oakland)

Poterek, Carol (Beaumont)

Davis, Quinten (Mercy Muskegon)

Rubin, Daniel (Chicago)

Dewhirst, William (Dartmouth)

Ruiz, Joseph (MD Anderson CC)

Domino, Karen (Washington)

Saffary, Roya (Stanford)

Drolett, Colleen (Henry Ford)

Schonberger, Rob (Yale)

Grandinetti, Amanda (ASA)

Shah, Nirav (MPOG)

Gottlieb, Ori (Chicago)

Shebbo, Fadia (American University of Beirut Medical Center)

Hall, Kathleen (Borgess)

Straight, Lindsay (MidMichigan)

Harwood, Tim (Wake Forest)

Szymanski, Brooke (MPOG)

Heiter, Jerri (St. Joseph A2)

Trummel, John (Dartmouth)

Hightower, William (Henry Ford)

Tyler, Pam (Beaumont Farmington Hills)

Horton, Brandy (St. Joes Oakland)

Wren, Jessica (Henry Ford Wyandotte/Macomb)

Jiang, Silis (Weill Cornell)

Yu, Shao Ping (Weill Cornell)

Kurz, Andrea (Cleveland Clinic)

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 February 24, 2020 meeting approved- posted on the website for review.

Recording available as well.

3. COVID-19: Thank you to all sites for the work you have been doing during this time

4. Upcoming Events

a. 2020 Quality Committee Meetings

i. June 22, 2020 @ 10am EST

ii. August 24, 2020 @ 10am EST

iii. October 26, 2020 @ 10am EST

b. ASPIRE/MSQC Meeting March 27, 2020 –

i. Thanks to our invited speakers

1. Dr. Tom Varghese (University of Utah)

2. Dr. Daniel Clauw (Michigan Medicine)

3. Dr. Eve Kerr (Michigan Medicine)

c. ASPIRE Summer Meeting July 17, 2020

i. Mark your calendars and keep your fingers crossed!

ii. Keeping options open for potential virtual meeting

5. Announcements

a. Welcome University of Chicago Medicine as our newest active MPOG site!

b. Dr. Lee Fleisher, Department chair at Penn Medicine is the MPOG Featured Member for

March/April 2020.

c. The MPOG Approach to Research and Quality Improvement featured in Anesthesia &

Analgesia – Congratulations Dr. Douglas Colquhoun et al, from the MPOG coordinating

center!

i. Outlines the work that MPOG does and how it is done. Now available to site in

future publications when using MPOG data for quality and research.

6. April 2020 Upgrade/Application Updates

a. MPOG Database and Application Suite Upgrade now available!

b. Release Notes available on the MPOG website

c. Contact support@mpog.zendesk.com for details or to confirm that your site completed

the upgrade successfully

d. Case Viewer

i. Original Case Viewer officially retired – replaced by new Case Viewer

ii. *NEW* Case Viewer User Guide available on the MPOG website

iii. Copy buttons for MPOG Case ID & MRN reinstated, added patient age filter on

the Case Search page, notes section opens on the right side by default when you

open a case now, date of death displays in banner, if available.

e. Case Validation

i. Sections were reordered by topic to assist case reviewers

ii. Question removed: general anesthesia & preop medication questions

iii. Revised neuraxial/regional question

f. Data Diagnostics

i. Added free text search filter

ii. Updated aesthetic - vertical guide allows for easier data point selection.

iii. “Diagnostic Executed On” now includes time.

g. Import Manager Assistant

i. Additional filters to sort by AIMS source system and module columns

ii. Months with partial data are now indicated with a half green/half gray box

h. Dashboard 2.0 - Release by end of May

i. Can use alongside the existing dashboard

ii. New dashboard is more data driven

iii. Individual sites will be able to have multiple dashboards and can organize by

what measures are of current focus, peds subgroup, OB subgroup specific etc.

iv. Measure Detail screens will provide same trend and benchmarking information

1. Will include more visual representation breakdown of measure

performance

2. Improvements to the filter section

v. Plan to retire old dashboard by MPOG retreat in October by ASA

7. MPOG Pediatric Anesthesia Subcommittee

a. Peds group met on April 21, 2020

b. 30 Pediatric Anesthesiologists were in attendance

c. Partnering with SPA Q&S Workgroup, established to inform the MPOG pediatric

subcommittee of best practices in pediatric anesthesia. First meeting October 2020 at

ASA-Washington, D.C.

i. Liaisons: Brad Taicher (Duke) and Vikas O’Reilly-Shah (Seattle Children’s)

d. UM Peds Quality Champion – Bishr Haydar and Lisa Vitale

e. Temperature Management Measure Criteria Confirmed (TEMP-04-Peds)

i. Description: Percentage of patients < 18 years old who undergo any procedure

greater than 30 minutes whom have a median core temperature < 36

C (96.8

or nadir temp < 35

C (95

F) intraoperatively.

ii. Measure Time Period: Patient in Room  Patient out of Room

iii. Exclusions

1. Cases < 30 minutes duration

2. MAC/Sedation Cases

3. Cases without documentation of a core or near core temperature route

4. ASA 5 and 6

5. Cardiac Surgery

f. Peds Opioid Equivalency Specification

i. Adding Tonsillectomy and/or Adenoidectomy for pediatric patients < 18yo

ii. Cases included: CPT code 00170 and with procedure text ‘tonsil’ and/or ‘adenoid’

8. MPOG Obstetric Anesthesia Subcommittee

a. Last meeting was on March 17, 2020

i. Decision to proceed with ABX 01 (OB): Antibiotic Timing for Cesarean Deliveries

1. Anticipated release: May 2020

ii. Discussion on BP 04 (OB): Prolonged Hypotension for Cesarean Deliveries

1. Committee able to reach consensus on initial measure build

2. Measure specification in progress

b. BP-04-OB: Hypotension during Cesarean Deliveries

i. Description:

1. Total cumulative minutes of hypotension after spinal placement

2. Total cumulative minutes of hypotension will be resulted for two time

periods: spinal placement to delivery and delivery through anesthesia

end

3. For patients with pre-eclampsia, hypotension is defined as >20% decline

from baseline systolic blood pressure

4. For patients without pre-eclampsia, hypotension is defined as

SBP<90mmHg

ii. Inclusions:

1. All cesarean deliveries (Determined using the MPOG Obstetric

Anesthesia Type phenotype) with neuraxial anesthesia only

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

iii. Exclusions:

1. Cesarean delivery with general anesthesia only (without neuraxial

anesthesia)- determined using Anesthesia Technique-Neuraxial MPOG

phenotype

2. Emergency cesarean delivery with diagnosis of placental abruption (ICD-

10: O45*)

3. Rupture of uterus (spontaneous) before onset of labor (ICD-10: O71.0)

4. Newborn affected by intrauterine blood loss from ruptured cord (ICD-10:

P50.1)

5. Abnormal uterine or vaginal bleeding, unspecified (ICD-10: N93.9)

6. Placenta previa with hemorrhage, third trimester (ICD-10: O44.13)

7. Hemorrhage from placenta previa, antepartum condition or complication

(ICD-10: 641.13)

8. Hemorrhage from placenta previa, delivered, with or without mention of

antepartum condition (ICD-10: 641.11)

9. Cardiac Subcommittee Proposal

a. Many current ASPIRE measures either exclude cardiac cases or do not incorporate

cardiac-specific factors

b. We have brainstormed about potential cardiac ASPIRE measures but want more input

from the group

c. Please join the Cardiac Subcommittee! Contact Allison Janda (ajanda@med.umich.edu)

or Nirav (nirshah@med.umich.edu) if you wish to participate

10. Measure Updates

a. Surgical Site Infection Measure (SSI 01)

i. Includes only cases that were present in both the MSQC and ASPIRE registries

(denominator)

ii. Displays surgical site infection data (superficial, deep, organ space, and ALL)

iii. Using MSQC sample of cases

iv. SSI data abstracted by nurse abstractors in each participating site

v. Will display the previous 12-month trend over time including risk-adjusted and

non risk-adjusted rates

vi. Refreshed quarterly (based on data integration schedule with MSQC)

vii. Ability to filter by surgical procedure (MSQC covers general surgery, vascular

surgery, and hysterectomy)

1. Limited to cases that are sampled only for the above listed surgical

services.

viii. Available at institution level only initially (not on provider emails)

ix. Good Opportunity for Quality Champions to review with ASPIRE process

measures affecting surgical site infections

x. Can enable for sites submitting NSQIP data at quarterly intervals.

1. NSQIP data dictionary is very similar to MSQC data dictionary and so the

ability to match cases from NSQIP is there.

2. If interested, we recommend reaching out to your surgical champion

locally to discuss submitting registry data to MPOG.

b. In Hospital Mortality (MORT 01)

i. Have used in hospital mortality data in research previously and may be relevant

from a QI perspective as well.

ii. Finalizing the specification currently and will post for feedback prior to

publishing.

iii. Description:

1. Percentage of patients where inpatient death was reported within 30

days after anesthesia

2. Post Anesthesia Mortality Rate:

# of cases where pt died within 30 days (exclude subsequent cases, only count one case per pt)

total # of cases performed

iv. Inclusions:

1. All patients undergoing anesthesia

v. Exclusions:

1. ASA 6

2. Anesthesia for access to central venous circulation (00536)

3. Diagnostic imaging

vi. Responsible Provider: No provider attribution

11. Measure Discussion

a. Glucose Management

i. Glucose 03 (perioperative hyperglycemia treated or rechecked) and Glucose 04

(perioperative hypoglycemia treated or rechecked) were introduced at the last

Quality Committee meeting and rolled out to institution level dashboards only

ii. Originally built with no provider attribution. After single center review, the

necessity for alerting providers on flagged GLU 03/04 cases was clear.

iii. Proposed provider notification strategy

1. For cases that were flagged for GLU 03/04, notification would go to the

provider signed in at the start of the case

2. For cases that were flagged intraoperatively, attribution would follow

GLU 01/02 model

3. For cases that were flagged postoperatively, notification would go to the

provider signed in at the end of the case

iv. Lucy Everett (Massachusetts General Hospital) – makes sense to attribute

provider intraop and postop but not preop. May see push back from providers on

preop attribution. Hypoglycemia is rare enough that review would occur at the

departmental level.

v. Nirav Shah (University of Michigan) – provider attribution for the GLU 01 and

GLU 02 is the provider signed in at the time the glucose lab re-check or treatment

should have taken place.

1. Josh Berris (Beaumont Farmington Hills) – Would preop attribution be

the first person starting the case? What about the provider who signed

the PACU discharge?

a. Nirav Shah (University of Michigan) Yes, preop attribution would

go to providers signed in at the start of the case. For cases

flagged in the PACU, the attribution would go to provider signed

in at the end of the case. Interesting thought on using the PACU

discharge note which we can look at. Working to balance on

whether we should leave at the institutional level or add

provider notification.

b. Proposed Glycemic management measure (GLU-05)

i. Description: Percentage of cases with intraoperative glucose > 180 mg/dL with

administration of insulin within 60 minutes of original glucose measurement

ii. Inclusions:

1. All patients with glucose level greater than 180 mg/dL between

Anesthesia Start and Anesthesia End

iii. Exclusions:

1. ASA 5 and 6 cases

2. Patients < 12 years of age.

3. Glucose measurements > 180 mg/dL within 60 minutes before

Anesthesia End

4. Outpatient cases with Anesthesia Start to Anesthesia end time less than

4 hours long

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

6. Obstetric Non-Operative Procedures with procedure text: “Labor

Epidural”

iv. Responsible Provider: The provider signed in at the first administration of

insulin. If no insulin administration occurred, then the responsible provider is the

one signed in 60 minutes after the high glucose measurement.

c. Feedback Requested

i. Does it make sense to separate glucose checking from hyperglycemia treatment

measures?

1. Ori Gottlieb (UChicago Medicine) – Is there a measure to see if another

glucose is checked elsewhere.

a. Nirav Shah (University of Michigan) In previous glucose measures

we have defined success as if the provider had administered

insulin OR re-checked the blood sugar. If its trending downward,

maybe that is what we should look at rather than checking.

Current glucose measures refer to treatment or lab re-checks.

There is an opportunity to shift the focus of these measures to

targeting the appropriate blood glucose level and inform on best

practice of glucose management.

2. William Hightower (Henry Ford Health System – West Bloomfield) GLU

01/02 performance at our institution is influenced by surgical patients

with really well managed diabetes OR if providers are not checking a

glucose intraoperatively. It would be interesting to see how many

diabetics in general had their glucose checked intraop and if checks were

being done in PACU.

a. Nirav Shah (University of Michigan) Interesting point! This leads

to another measure that may be more applicable and could focus

on if we are checking glucose in preop and PACU on the right

cohort of patients (diabetes, high risk surgery etc). Agree - GLU

01/02 denominators are really low and we may not be checking

enough in preop.

Meeting concluded at 11:02am