ASPIRE Collaborative Meeting
Afternoon Session
April 23, 2021, 12:15-1:15pm
I. Welcome to New Sites!
A. Spectrum
B. Borgess
C. MidMichigan
D. Metro
II. CME and meeting notes available on the MPOG website under Events/News
III. ASPIRE Virtual Collaborative Meeting: July 16, 2021 9a-noon
IV. Matters Arising/Questions from the Group
V. Performance Review Session
A. Process:
1. Pick measures that have some variability
2. Pick measures of timely interest
3. Describe measure to refresh memory
4. Ask sites to describe their workflow
5. What can the collaborative learn from you?
6. What can you learn from the collaborative?
7. What can we learn from each other?
B. SUS 01- Fresh gas flow < 3 l/min when using inhalational anesthetic agent
1. Description: Percentage of cases with mean fresh gas flow (FGF) ≤
3L/min, during administration of halogenated hydrocarbons and/or nitrous
oxide
2. Inclusion Criteria: Patients administered halogenated hydrocarbons
and/or nitrous oxide, for greater than or equal to 30 minutes from
placement of the airway device to removal of the airway device.
3. Exclusions:
a) Cases in which halogenated hydrocarbons and nitrous oxide are
NOT used
b) Cases with maintenance period < 30 minutes
c) Cases with >20% of Fresh Gas Flow values manually entered
during the case (automated capture of FGF required)
4. Success: Mean FGF ≤ 3L/minute during the maintenance period of
anesthesia, when administering inhalational agents
5. Performance scores shared with group; Feedback:
a) Alex Bouwhuis (Holland): Small hospital with a small group of
providers who have practiced this way for a long time. Could be
that there is also a focus on reducing cost
b) Traci Coffman (St. Joseph Mercy Health System): Culture and
initiative last year was to be ‘greener’ prompted by the ASPIRE
meeting last year. Instituted no use of desflurane and reduced gas
flows.
(1) Nirav Shah (ASPIRE Director): How did you structure this
education?
(2) Traci Coffman (SJMHS): We have an educational lecture
that we distribute to everyone with questions following the
lecture to ensure competence; Removed desflurane from
the ORs. Providers needed to go retrieve it before they
could use it.
(3) Joel Kileny (SJMHS): Use CRNA morning measures to
reinforce this metric on a weekly basis
(4) Nirav Shah (ASPIRE Director): Any pushback?
(a) Joel Kileny (SJMHS): Not really. We live in Ann
Arbor so the culture is pretty environmentally
conscious already.
(5) Ksenia Koltun (Royal Oak): Some confusion at Royal Oak
with implementing this measure. Cases where this is an
issue are those requiring jet-ventilation or the desire is to
perform deep extubation where high flows are turned up.
(6) Bryan Cohen (Henry Ford West Bloomfield): Issue with not
recording the inspired gas at the end of the case, only
pulling over the expired gas.
(a) Nirav Shah: Recommended working with Biomed
teams to pull this data over from ventilator to EHR.
C. BP 03- Low MAP prevention (MAP < 65 for 15 minutes cumulative duration)
1. Inclusions - All adult patients regardless of anesthetic technique
2. Exclusions - Baseline MAP < 65 mmHg, OB , Cardiac, Lung/Liver
Transplant
3. Success: MAP < 65 mmHg that does not exceed cumulative time of 15
minutes
4. Performance scores shared with group; Feedback:
a) Kathleen Collins (St. Mary’s Livonia): Liberal with phenylephrine
and pressors- jump on it quickly and monitor the blood pressure
closely. Just a culture thing but our population tends to be older
but less sick overall. Not doing open hearts or big vascular cases
like some other centers. What we do, we do well but we don’t do
every case type.
b) Aaron Wood (Beaumont FH): Vigilance, education, phenylephrine
administration
c) Joel Kileny (SJ Ann Arbor): Have made this an education focus for
2021 with sending literature updates via email
d) Alex Bouwhuis (Holland): Wonder how many sites really
push/promote clear liquids until 2 hours before surgery. We’re
pretty good about it (often a headache when we want to start a
case early), and perhaps our patient’s are a little less dehydrated
than others.
(1) Kathleen Collins (St. Mary Livonia): Wed do the same
e) Eric Davies (HF Allegiance): Any particular thoughts on the recent
A&A article by Sessler et al on the relationship between providers,
MAP, and outcomes and accompanying editorial?
(1) Nirav Shah (ASPIRE Director): As a single center study
from Cleveland Clinic, it was pretty remarkable how little
variation there was between providers. Still think looking at
hypotension at an institutional level does still make sense
and maybe even at a provider level depending on the
institution
D. TEMP 02- Core temperature monitoring
1. Description: Percentage of cases with risk of hypothermia that the
anesthesia provider measured core (or near core) temperature
intraoperatively
2. Inclusions - All surgical patients receiving general anesthesia
3. Exclusions - ASA 5 and 6 cases, neuraxial or regional technique only,
labor epidural, MRI procedures, cases less than 30 mins
4. Success - Cases with at least one core (ie not skin) temperature
documented between Anesthesia Start and Patient out of Room
5. Performance scores shared with group; Feedback:
a) Masakatsu Nanamori (Henry Ford Detroit): This was a focus area
for our site in past years- have worked on making it easier to
document within Epic; sent monthly education and reminder
emails to assist providers in documenting core routes.
(1) Nirav Shah (ASPIRE Director): DId you remove skin temp
probes?
(a) No, we didn’t need to remove the skin probes from
the ORs. Just needed to correct documentation
b) Kathleen Collins (St. Mary’s Livonia): No way to document with
Epic transition; has since been added to Epic documentation but
that’s why we dipped in performance for a period of time. When
we are sharing the airway we use the skin temp probe and place it
in the nasopharynx until we get a core temp. Are other sites doing
this as well?
(1) Eric Davies (HF Allegiance): Yes we use nasopharyngeal
probes
(2) Bradford Berndt (Bronson): We are using skin probes in a
similar matter for many types of cases at Bronson
Methodist
(3) Sachin Kheterpal (Michigan Medicine): That's what we
used to do at UM, but had some safety events with the
"sharp" part of the probe. removed for those reasons, side
benefit was getting rid of the skin temp ability
(4) Aaron Wood (Beaumont FH): There is a nasopharyngeal
probe made
6. PONV 03- PACU nausea/vomiting rates
a) PONV 03 Description: Percentage of patients, regardless of age,
who undergo a procedure and have a documented nausea/emesis
occurrence OR receive a rescue antiemetic in the immediate
postoperative period.
b) PONV 03b Description: Percentage of patients, regardless of age
who undergo a procedure and have a documented nausea/emesis
occurrence
c) PONV 03b doesn’t take into account if patient received antiemetic
in the immediate postoperative period
d) Exclusions - Patients transferred directly to the ICU, liver
transplant, labor epidural
e) Success: Patient does not report nausea, have an emesis event or
receive an antiemetic during the immediate postoperative period.
f) Performance Scores shared with group; Feedback:
(1) A lot of variation across sites with PONV 03 scores.
(2) Brad Berndt (Bronson Kalamazoo): We have been working
on PONV 01/02 over the past year and encouraging
providers to administer 2 antiemetics consistently for
high-risk patients and are encouraged to see this PONV 03
score.
(3) Nirav Shah (ASPIRE Director): New PONV Guidelines
released in 2020 that we plan to incorporate into PONV 01
as there is come concern at the coordinating center that
improvement on PONV 01 does not necessarily correlate
with improved PONV 03 scores. Interested to hear from
sites if they are finding this to be true in their own practice.
(a) Amy Poindexter (Holland): Found that there were
very few people that failed the process measure
and also failed the outcome measure.
(4) Eric Davies (Henry Ford Allegiance): Is there still a concern
over this data not accurately reflecting PACU nurse
practices based on documentation concerns?
(a) Kate Buehler (ASPIRE Coordinating Center): Over
the past year, sites have been working on
improving this data capture so we believe this is
more accurate now. PONV 03 could be higher than
PONV 03b if nurses routinely administer
antiemetics immediately upon PACU admission vs.
actual documentation of nausea or vomiting in
PACU (PONV 03b).
E. MORT 01- 30 day in hospital mortality
1. Description: Percentage of patients with in hospital death reported within
30 days after procedure.
2. Measure Time Period - Anesthesia Start to 30 days after Anesthesia End
3. Inclusions - All patients undergoing anesthesia
4. Exclusions - ASA 6
5. Performance Scores shared with group; Feedback:
a) Nirav Shah (ASPIRE Director): Is this useful? Have you started
looking into flagged cases? How are sites using this or not using
this measure?
b) Eric Davies (Henry Ford Allegiance): We aren’t the only site that
hasn’t looked at this measure, mortality after surgery is a pretty
complex thing. Still trying to drill down on simpler process
measures like temperature and sustainability. I want to applaud
ASPIRE for getting this data and creating this measure - its a
major achievement! We all need this data as a long term goal to
drill down on this data to help….opposed to reporting individual
provider performance. Focus should be more on systematic
performance.
c) John Lagorio (Mercy Muskegon): Mortality is something the
hospital tracks and something that is reported to CMS, part of
VBP. Most hospitals are looking at this. Working with hospital
administrators and letting them know we are looking at this metric
and trying to improve in this area is very helpful.
d) Davies (Henry Ford Allegiance): How valid is this data? Have sites
compared this data with their actual hospital mortality data
e) Lagorio (Mercy Muskegon): As an anesthesia provider, no we are
not reviewing this data but as a medical director we are reviewing
the hospital mortality data. We have not compared ASPIRE
mortality data vs. our own hospital mortality data.
f) Nirav Shah (ASPIRE Director): This data does come from
administrative data from your hospitals EHR
