ASPIRE Collaborative Meeting
July 16, 2021, 9:00am-12:10pm
I. MPOG Business and Updates
A. CME and meeting notes available on the MPOG website under Events/News
B. ACQR Retreat: September 17, 2021 at DoubleTree in Ann Arbor (Virtual TBD)
C. MPOG Retreat: October 8, 2021 at the Manchester Grand Hyatt, San Diego, CA
D. Healthy Behavior Optimization for Michigan (HBOM)
1. New CQI led by Tammy Chang, MD, MPH, MS with goals to:
a) Improve healthy behaviors in Michigan by ensuring access to effective
and innovative programs that make the healthy choice the easy choice
b) Vision to make healthy behaviors achievable and sustainable for all in
the state of Michigan
c) Plan to intervene during teachable moments in healthcare by partnering
with other CQIs like ASPIRE
d) First goal is to support CQIs to facilitate smoking cessation efforts with
their partnering hospitals and POs
(1) Will identify and disseminate low burden smoking cessation
tools for patients and providers
(2) Will provide guidance on data collection and program
assessment
e) Thoughts from ASPIRE Coordinating Center:
(1) Can work with HBOM to understand how anesthesiologists and
CRNAs can play a role to promote smoking cessation during our
‘teachable moments’ before surgery when patients may be
interested in changing behavior
(2) HBOM can act as partners, reviewing data in the MPOG registry
to understand the opportunities across the state of MI
(3) Based on this knowledge and approval from Michigan ASPIRE
Quality Champions, we can create QI initiatives and tools to help
anesthesia providers incorporate smoking cessation efforts with
their patients
f) Next Steps:
(1) Obtain feedback and approval to move forward with MPOG data
analysis
(2) Create a dataset for HBOM colleagues to access within the
MPOG firewalls
(3) Develop a proposal for ASPIRE MI Quality Champions to respond
to
E. Preoperative Testing Optimization
1. Michigan Value Collaborative (MVC) has identified preop testing as an
opportunity for optimization
2. Contacted ASPIRE Coordinating Center to gauge interest in partnering with them
on a QI initiative to reduce unnecessary testing (see PPT slides for graph
displaying variability across procedures and tests at participating MVC hospitals)
3. Discussion:
a) Is this an area of interest for ASPIRE Quality Champions?
b) What is the role of the anesthesia provider in determining testing at
your facility?
c) What is the best way to work with MVC? Obtain testing metrics and
benchmarking from MVC or generate using MPOG data?
II. Reflections and Lessons Learned on Quality Improvement
A. Henry Ford Allegiance, Holly Lockwood, RN, BSN, MBA
1. TEMP-02 was site selected measures and saw improvement from 88% - 92%
2. Posted TMEP-02 info poster in break room and hallway as a visual reminder to
staff
3. Discussion
a) Nirav - There is an outcome temperature measure TEMP-03, have you
looked at performance for that measure to observe correlation between
TEMP-02 and TEMP-03
b) Holly - Yes, have discussed with PACU nurses and discussed how to
improve documentation. We are also segwaying into SSI rate
improvement so these measures tie in well to that.
B. Henry Ford Macomb, Jimmy Boutin, MD
1. Atmospheric lifetime and global warming potential of anesthetic vapors (see
slides). Strictly using Sevoflurane as Desflurane has been phased out at Henry
Ford Macomb.
2. Current performance for SUS-01 is 60%.
3. Newer absorbents with no KOH and low NaOH do not produce compound A At
Henry Ford Wyandotte the Co2 absorbent has no KOH and less than 4% NaOH
(recommendation from the Anesthesia Patient Safety Foundation Newsletter)
4. Looked at the flow rates for the first 5 minutes (as flows are often higher during
induction) across 10 different cases. It was noted that flow rates after induction
were remaining high after induction while patients were positioned etc.
5. Plan to discuss with staff more efficient ways to get to target concentration of
sevoflurane. Focus on using the default flow rate of 6 at the start of the case so
that maintenance can be achieved at 1L/min
6. Feldman & Hendrickx (2018) analyzed the time to reach a target concentration
(2 MAC = 4%) at variable FGF rates (0.5 L/min, 1 L/min, & 3 L/min) and vaporizer
set at 6%
a) Appears that in 2 mins at a FGF rate of 3 L/min the inspired
concentration is close to reaching the target.
b) A FGF rate of 1 L/min takes approximately 8 mins
7. Tips for improving SUS-01
a) When fresh gas flow exceeds the patient’s requirement, gases and
vapors will enter the scavenging system and into the atmosphere
b) Minimizing the total fresh gas flow limits the environmental impact of
volatile agents
c) Strategies to mange fresh gas flow
d) Turn off the fresh gas flow, not the vaporizer, during intubation
e) Minimize fresh gas flow during maintenance
f) Set the vaporizer to deliver a concentration greater than intended
8. Discussion
a) Thomas Leyden (BCBSM- via chat)- Nirav/Sachin, very interesting and
important work. Curious if this work is primarily being limited to MPOG
participants or is this also being addressed nationally by ASA?
b) Nirav (ASPIRE Director)- There are many at ASA that are interested in
this topic and advocating but am unsure if there are other national
metrics
c) Sachin (MPOG Research Director)- This is a deeply physiologic measure.
Providence health group has done a lot of work on this but is not a part
of the AQI measure list but can definitely reach out.
d) Mike Mathis (MPOG Associate Research Director) - Here is relevant link
to folks at ASA working on this:
https://www.asahq.org/about-asa/governance-and-committees/asa-co
mmittees/committee-on-equipment-and-facilities/environmental-sustai
nability/greening-the-operating-room
e) Sachin (MPOG Research Director) - Are you finding that most of the
failures are in the first 5 minutes then? Is it limited to the beginning of
the case for the most part?
f) Jimmy Boutin (Henry Ford Wyandotte) - When providers have high flow
rates for the first 10 minutes we are finding they can’t make up for that
time throughout the procedure. I plan to focus on discussions of
lowering flow rates during maintenance as well
g) Aisha Qazi (Beaumont Troy- via chat): At our site, one of the main cases
we fail at is bronchoscopies where we use LMAs and requires higher
flows. Could cases where high flows are necessary to obtain adequate
tidal volumes be excluded?
h) Douglas Colquhoun (MPOG/Michigan Medicine) -Would love to chat
about exclusions around airway cases with large leaks
i) Nirav Shah (ASPIRE Director)- there are some challenges teasing out
cases with CPT codes
j) John LaGorio (Mercy Muskegon)- The ASA does have a group that works
on environmental factors in regards to anesthesia care and
equipment/facilities. I would encourage people to go to the ASA website
to get more information on this.
C. Henry Ford Wyandotte, Merajuddin Khan, MD
1. Focus measure for QI: GLU-03
2. Have seen early success in cardiac procedures by controlling glucose.
3. Keeping sugar between 150-200 for all surgical patients do better
postoperatively.
4. Majority of our failures for this measure are inpatients who receive insulin
within a few hours on the floor they want to check it within 90 min and at that
time they are intraop
5. Our site is below the benchmark because providers are not checking glucose
within 90 minutes and not giving insulin to avoid hypoglycemia.
6. What we have done so far:
a) Educated anesthesia providers on glucose measures (June ‘21)
b) Educated Pre and Postop staff on glucose measures (May ‘21)
c) Added time glucose was taken to pre-op handoff sheet
d) Analyzed ASPIRE data and counseled all providers who are not passing
this measure
7. Next Steps
a) Glucose BPA in Epic, Including a reminder to treat or recheck glucose
b) Health system working on revising Tier 1 glucose policy
c) Continue to analyze ASPIRE data and counsel all providers who are not
passing this measure
8. Challenging measure but very important because impacts morbidity and
mortality. The
9. Discussion
a) Nirav (ASPIRE Director) - GLU-03 is an earlier ASPIRE measure. There is
variability among this group in terms of time frame however, the QI
champions made expert consensus on what was a reasonable time
frame which is where the 90 minute threshold originated from
b) Josh Berris (Farmington Hills via chat) - 2 hours please... as I have always
said. 2 hours is what we do here because Humalog is not supposed to be
dosed more frequently than that. It is not conducive to workflow to test
at 2 hours so I can redose, but test also at 90 minutes just to satisfy the
measure.
c) Dan Applefield (St. Joseph- Oakland) - are people failing the measure
because of the time constraint or other reason?
d) Nirav (ASPIRE Director) - We plan to discuss this during the performance
review session (see notes below).
(1) EPIC BPA - we have worked with the Epic team to ensure they
are specific with which BPAs to make available for anyone
participating in MPOG or not.
e) Dennis Ahmad (Metro Health) - We created custom epic intra-op
reminders q2 hrs for glucose checks
f) Jill Mhyre - This is an important equity measure at UAMS. Are other sites
finding differential pass rates based on patient race?
g) Meraj Khan (HFHS Macomb) - Outpatient cases are easier to manage
and see more failures with Inpatients since they have received insulin or
other glucose management on the unit prior to transfer to preop.We
also see failures in the PACU when the Anesthesia provider signs out
before checking glucose before patient goes back to the floor or
discharged home.
h) John Trummel (Dartmouth-Hitchcock) - We have created an EPIC BPA
and I am not sure how much it helps. There may be some BPQA fatigue.
i) Nirav Shah (ASPIRE Director): Thanks for these comments. Looking
forward to more conversation later during the performance review
session. We may need to revisit these glucose measures or at least the
time period of 90 minutes.
III. Postpartum Hemorrhage: Diagnosis, Treatment, and the Michigan Approach- Tom Klumpner, MD
A. Maternal mortality has decreased in the developed world over the last 25 years,
however it has increased in the US over the last few decades
1. This alarming trend has gained national attention. Many news
corporations in the US are investigating this crisis and USA Today asserts
that the United States is now the most dangerous place to give birth in
the developed world.
B. According to the CDC, postpartum hemorrhage is a leading cause of maternal
death. Death from PPH is often preventable
1. Often related to delayed response to clinical warning signs and ineffective care
2. In a review of pregnancy-related deaths (from 2002-2005), the California
Pregnancy-Associated Mortality Review Committee found that 70% of
deaths due to obstetric hemorrhage had a “good-to-strong” chance of
being prevented.
3. We are now at a turning point in maternal care. We must re-evaluate our
approach to common obstetric conditions like postpartum hemorrhage,
where we may be able to have an impact. And, I think this effort starts
with making sure that we have a solid fundamental understanding of the
disease.
C. Incidence
1. According to National Inpatient Sample data from 2012-2013, the
incidence of postpartum hemorrhage in the U.S. is approximately 3%.
2. Worldwide, the incidence is 6-11%
3. The incidence is increasing
a) 26% increase in the US between 1994-2006
b) Severity is also increasing
c) This may be due in part to better reporting, but may also be
related to an increase in comorbidities that increase risk of
hemorrhage, such as obesity and advanced age, in the maternal
population.
D. Risk factors
1. Before pregnancy
a) Maternal Age <19
b) Maternal Age >35
c) Grand Multiparity (>= 5 births)
d) Prior cesarean delivery
2. Antepartum
a) Hypterensive diseases of pregnancy
b) Diabetes
c) Polyhydramnios
d) Infection
e) Placenta previa/abruption
f) Multiple Gestation
g) Macrosomia (>4,000g)
h) Fibroids
3. Intra/Post-Partum
a) Medical Induction of Labor
b) Instrumental Vaginal Delivery
c) Cesarean Delivery
4. Not all risk factors are equal. A retrospective study by Kramer et al (2013)
evaluated 8.5 million deliveries in the National Inpatient Sample to
identify diagnoses (identified by ICD codes) that were associated with
severe postpartum hemorrhage.
a) M.S. Kramer, C. Berg, H. Abenhaim, et al. Incidence, risk factors, and temporal
trends in severe postpartum hemorrhage. Am J Obstet Gynecol, 209 (2013), pp.
449.e1-449.e7
5. Risk factors are not completely predictive
a) 40% of PPH occurs in low risk women
E. Definition
1. Traditionally - 500ml in vaginal delivery, 100ml in cesarean dleivery
2. Now defined as 1000mL blood lost or blood loss accompanied by signs or
symptoms of hypovolemia
3. The goal is to encourage intervention for postpartum hemorrhage if signs
of hypovolemia are present, even in the absence of a set threshold for
estimated blood loss
4. Recent and more robust studies demonstrate a great variability in
measured blood loss that range from <150 mL to almost 700 mL for
uncomplicated vaginal delivery.
5. Moreover, set blood loss thresholds may not adequately represent risk of
poor outcome. Many women will lose >500 mL without any clinical
consequence, and depending on maternal comorbidities some will bleed
less and will still be at risk of adverse outcome.
6. And, the separate thresholds for vaginal delivery and cesarean delivery
are confusing: why would a blood loss of 500 mL represent a risk for
women after vaginal delivery but not for a cesarean delivery?
7. Visual estimation of blood loss
a) Most frequently practiced
b) Most people receive no formal training in estimating EBL
c) Training might not improve estimation
d) Often underestimates blood loss
e) Underestimation increases as blood loss increases
8. Quantitative methods now supported by PPH bundles:
a) More sensitive
b) Not always rapidly available
F. Diagnosis
1. Signs of symptoms of hypovolemia with blood loss
a) Increased blood volume in pregnancy limits sensitivity -The
physiological increase in circulating blood volume during
pregnancy means that the signs of hypovolemic shock become
less sensitive in pregnancy, and often, signs of hypovolemic shock
are a late finding in severe obstetric hemorrhage.
b) Clinical signs of >1000-1500cc loss (from the Royal College of
Obstetricians and Gynecologists):
(1) Tachycardia
(2) Tachypnea
(3) Slight decrease in SBP
c) Clinical signs of >1500cc loss:
(1) Increased tachycardia
(2) Increased tachypnea
(3) SBP <80
(4) Altered mental status
2. Early recognition is key
a) A healthy pregnant person must lose a significant amount of blood
before clinical signs of hypovolemia are recognized
3. The Maternal Early Warning Criteria
a) Understanding the importance of early recognition of vital sign
abnormalities in the identification and management of
postpartum hemorrhage and other maternal morbidity, the
National Partnership for Maternal Safety has encouraged
institutions to adopt early warning systems
b) These maternal early warning systems include vital sign
thresholds, such as a heart rate greater than 120, or a systolic
blood pressure less than 90 mmHg that should prompt a physician
evaluation.
c) Criteria
(1) Systolic BP <90 or >160
(2) Diastolic BP >100
(3) Heart rate <50 or >120
(4) Respiratory Rate <10 or >30
(5) Oxygen saturation on room air, at sea level <95%
(6) Oliguria <35mL/hr for >= 2 hours
(7) Maternal agitation, confusion, unresponsiveness; PAtient
with preeclampsia reporting a non-remitting headache or
shortness of breath
G. Pathogenesis - the 4 Ts: Tone, Trauma, Tissue, Thrombin
1. Tone - Uterine atony: overdistension, muscle fatigue, GA, chorioamnionitis
a) While a broad differential is important, uterine atony is most often the
cause of postpartum hemorrhage (80%)
2. Trauma - Genital tract laceration, uterine inversion, surgical misadventure
3. Tissue - retained placenta, invasive placenta, placental abruption
4. Thrombin - placental abruption, pre-elcampsia, coagulopathy
H. Treatment
1. EBL >1000mL, brisk bleeding or signs of hypovolemia -> resuscitate and
determine cause and treat
2. Resuscitation
a) Call for help
b) Establish (multiple) large-bore IV access
c) Obtain baseline laboratory studies: CBC, INR, fibrinogen,
viscoelastometric testing (if available)
d) Type and Screen/Type and Cross - contact the blood bank early on
e) Correct hypovolemia - IV fluids opened to gravity
f) Escalate monitoring
g) Monitor urine output
h) Move to the OR quickly
i) Maintain normothermia, electrolyte management, etc
3. Determine cause and treat - while resuscitation occurs, consideration must be
given to the cause of the hemorrhage and appropriate steps must be taken to
control the bleeding
a) Cause: Tone
(1) Remember that uterine atony is the cause of 80% of
postpartum hemorrhage.
(2) Uterotonics are routinely administered. Choice of
uterotonic agent is based on clinical preference and
contraindication.
(a) Evidence supporting the use of a specific uterotonic
agent to supplement oxytocin is lacking.
(b) Oxytocin is our first line uterotonic. Our OBs are
usually quick to move to secondary uterotonics as
needed. Methylergonovine should be used
judiciously in patients with hypertension and
remember that carboprost can cause
bronchospasm, so reactive airway disease is a
relative contraindication.
(3) Uterine massage
(4) Intrauterine balloon tamponade
(5) Uterine compression sutures - at MM uterine compression
sutures are uncommonly performed during a cesarean
delivery to control post-delivery bleeding due to uterine
atony
b) Cause: trauma/tissue
(1) Evaluation by obstetric team
(2) Laceration repair
(3) Uterine exploration
(4) Manual removal of placenta
(5) Curettage
c) Cause: Thombin
(1) Evaluation of clotting
(2) Replace clotting factors, platelet
(3) Hematology consult for congenital clotting disorders to target
treatment - ideally done prior to admission to labor and delivery
(4) We typically send coagulation studies, including POC
viscoelastic testing and CBC
(5) Coagulopathy may be an early finding in postpartum
hemorrhage and certainly as the severity of hemorrhage
increases, close attention must be paid to the coagulation
system
I. Transfusion management
1. The ideal transfusion strategy during obstetric hemorrhage is unknown. pRBC:
FFP - fixed ratio? 1:1?
2. In line with the 2017 ACOG Practice Bulletin on Postpartum hemorrhage,
a recent survey study published in 2017, found that more than 80% of
institutions responding using a fixed RBC:FFP ratio of 1:1 in their massive
transfusion protocol. Emerging evidence demonstrates that a different
approach may reduce unnecessary transfusions.
3. Hypofibrinogenemia is associated with postpartum hemmorrhage.
a) Hypofibrinogenemia is often the first coagulation defect seen in
obstetric hemorrhage.
b) Hypofibrinogenemia is also an independent predictor of
progression of the hemorrhage
c) Early hypofibrinogenemia is associated with final blood loss in
excess of 2.5L, an increased risk of fall in hemoglobin >4g/L or
administration >= 4 units of pRBCs. Early hypofibrinogenemia is
also associated with need for an invasive procedures, such as
selective arterial embolization or hysterectomy, to control
bleeding.
d) This has led many to believe that fibrinogen is an important
therapeutic target in PPH.
e) The severity of hypofibrinogenemia is also dependent on the
etiology of the hemorrhage.
f) For example, placental abruption and amniotic fluid embolism are
associated with early profound hypofibrinogenemia. Whereas
hemorrhage due to uterine atony does not cause near as
profound a decrease in fibrinogen (at least early in the
hemorrhage).
g) While hypofibrinogenemia characterizes severe obstetric
hemorrhage, early empiric administration of FFP as part of a 1:1
transfusion strategy may actually dilute plasma fibrinogen.
h) A normal fibrinogen level in the third trimester of pregnancy is
373-619 mg/dL.
i) FFP contains about 200-250mg/dL fibrinogen.
j) While empiric FFP may increase fibrinogen levels in the setting of
profound hypofibrinogenemia caused by placental abruption.
k) Because fibrinogen is normally high at term, empiric
administration of FFP in other common causes of PPH may
actually decrease plasma fibrinogen level
l) So, empiric administration of FFP as part of a 1:1 transfusion
strategy make actually decrease a patient’s fibrinogen level in the
majority of postpartum hemorrhages.
m) As a consequence, some centers have moved toward
viscoelatometric testing to guide transfusion therapy.
J. Using Viscoelastometric Testing to Guide Transfusion Therapy
1. Viscoelastometric tests, such as the ROTEM or TEG systems, provide a
point-of-care qualitative assessment of clotting function. In many cases,
an assessment of clotting function can be obtained in 5-10 minutes.
2. The ROTEM system (rotational thromboelastometry) uses a cylindrical pin
immersed in a cuvette of patient blood that is then oscilated to the left
and right. The pin encounters resistance as a clot begins to form.
Eventually lysis of the clot causes resistance on the pin to decrease.
3. A graph of this resistance produces characteristic plots that are useful for
determining clotting function.
4. Various reagents can be added to the cuvettes of patient blood to isolate
the contributory effects of various aspects of the clotting cascade.
5. Of particular use in obstetric hemorrhage are the tests that evaluate the
intrinsic and extrinsic systems as well as the contribution of fibrinogen to
clotting firmness
6. For example, the Rotational Thromboelastometry (or ROTEM) machine
provides an INTEM, EXTEM and FIBTEM result that provide an assessment
of the intrinsic system, extrinsic system and evaluation of fibrinogen
contribution to clot firmness.
7. While ROTEM is used at the University of Michigan, this is not an
endorsement of any one particular viscoelastic testing method.
8. Viscoelastic point of care assessments of the fibrinogen contribution to
clot firmness, such as the FIBTEM A5 test correlate with severity of PPH,
and correlate with fibrinogen concentration.
9. (As Collins demonstrates, as the severity of postpartum hemorrhage
increases, hypofibrinogenemia worsens. The FIBTEM A5 result also
decreases as the severity of hemorrhage increases.)
10. Based on the fact that hypofibrinogenemia and FIBTEM value are
associated with severity of postpartum hemorrhage, I think an important
question is whether restoring fibrinogen level to pre-hemorrhage levels
based on point of care testing results will decrease blood transfusion.
11. In the OBS2 study, 55 women with hemorrhage of 1000-1500cc, ongoing
bleeding and a FIBTEM level < 16mm (which correlates to a fibrinogen
level of about 300mg/dL) were randomized to receive a dose of
fibrinogen adjusted based on patient weight and FIBTEM A5 value at time
of randomization. The goal was to raise a patient’s fibrinogen level to the
level closer to term.
12. There was no difference in the number of units of blood products
transfused in those who received fibrinogen concentrate or placebo.
13. In subgroup analysis, the authors also found no difference in outcomes in
those women who had been randomized to placebo or treatment with a
FIBTEM A5 between 12 and 16 mm. A FIBTEM A5 of 12mm correlates to a
fibrinogen level of about 200mg/dL. … leading the authors to conclude
that perhaps there is little benefit to treating a fibrinogen level in excess
of 200mg/dL.
14. Therefore, it appears as if the raised fibrinogen at term is a physiologic
buffer rather than something required for hemostasis.
15. What if a lower fibrinogen threshold of 200mg/dL or FIBTEM A5 of < 12
mm is used to trigger administration of fibrinogen concentrate?
16. This was a prospective observational study at a single hospital in the UK
evaluating the effect of an updated maternal massive hemorrhage
protocol
17. Patients were included if they had massive hemorrhage defined by EBL >
1500cc with evidence of coagulopathy, as determined by ROTEM findings
(FIBTEM A5 < 12mm, indicative of a plasma fibrinogen level of 2 g.l
−1
)
18. Patients receiving anticoagulant therapy were excluded.
19. The initial “shock pack” PPH protocol emphasized early treatment with
transfusion for PPH while formal laboratory studies and point of care
studies (including ROTEM) were pending.
20. The revised, “fibrinogen” PPH protocol instead emphasized
ROTEM-guided transfusions with use of fibrinogen concentrate in place of
cryoprecipitate.
21. The ROTEM-guided PPH protocol resulted in fewer administrations of
blood products.
22. Not surprisingly, there were fewer administrations of cryoprecipitate, but
there were also fewer administrations of FFP and platelets.
23. And, while the study was underpowered to detect major differences in
complications, there were fewer cases of transfusion-associated
circulatory overload with the ROTEM-guided transfusion protocol
24. Interestingly, there were fewer hysterectomies in the ROTEM-guided
transfusion group, however this may have been due to chance.
25. What about using ROTEM to evaluate other aspects of clotting function?
26. In this retrospective cohort study at Yale-New Haven Hospital, these
investigators evaluated the effect of introducing ROTEM-guided
assessments of clotting function in their massive hemorrhage protocol
between 2011 and 2015.
27. The ROTEM point of care testing protocol was introduced in 2014. The
new testing protocol included a structured didactic course, a
hands-on-session, skills testing and certification.
28. (The protocol was used for severe hemorrhage, which was defined as
1500cc.)
29. These investigators included set thresholds on the ROTEM to guide
administration of cryoprecipitate (using the FIBTEM value), FFP (using the
clotting time) and platelets (using the maximum clotting firmness)
30. After introduction of the ROTEM-guided massive transfusion protocol, the
authors found a significant reduction in the number of pRBC, FFP and
platelet transfusions. The authors also found a decrease in the length of
stay, the number of ICU admissions and the number of hysterectomies.
31. All of this translated to a total reduction in hospitalization costs.
K. Tranexamic Acid
1. Early activation of fibrinolytic pathways appears to be a characteristic of
traumatic hemorrhage.
2. The WOMAN trial, was a randomized controlled trial between 2010 and
2016
3. It included 193 hospitals in 21 countries and a little over 20,000 women
were randomized to either 1g of tranexamic acid vs. placebo at the first
clinical diagnosis of hemorrhage
4. In women given tranexamic acid within three hours of delivery, a
reduction in death due to bleeding was seen without an increase in
thrombotic or other adverse events
5. However, mortality rates in both treatment groups were very high, which
makes it difficult to generalize this study to developed countries.
6. As a comparison, the mortality rate in the US from postpartum
hemorrhage is 1.7 per 100,000. This is a 1,000 fold difference in mortality.
7. Nonetheless, tranexamic acid is being included on many PPH protocols,
including the protocol in use at the University of Michigan.
L. The Michigan Medicine PPH Transfusion Protocol
1. I think the evidence now definitively demonstrates that using some point
of care testing method to guide transfusion during postpartum
hemorrhage will decrease the total number of blood products transfused.
Using POC testing may also decrease length of hospital stay, ICU
admissions, number of hysterectomies and total hospitalization costs.
Finally, tranexamic acid may prevent death from PPH, but the NNT in
developed countries is likely high
2. These studies therefore form the basis of the postpartum hemorrhage
transfusion protocol we use at the University of Michigan.
3. When a hemorrhage is diagnosed or suspected, several labs are sent
automatically, including a ROTEM
4. We make an initial assessment of the patient’s fibrinogen level and
administer fibrinogen concentrate based on viscoelastometric testing.
5. Tranexamic acid is given early in the hemorrhage.
6. Administration of FFP and platelets are also guided by viscoelastic testing
results. These thresholds for EXTEM A10 and EXTEM CT are similar to
those at other institutions where ROTEM guided transfusion therapy is
used for PPH. (Yale New Haven Hospital)
a) (A retrospective before and after study at this hospital found that
using similar thresholds in a ROTEM guided PPH transfusion
strategy resulted in fewer blood product transfusions, lower
estimated blood loss, lower rate of hysterectomy, ICU stay and
total hospital costs)
b) Snegovskikh, D. et. al. Point-of-care viscoelastic testing improves
the outcome of pregnancies complicated by severe postpartum
hemorrhage. Journal of Clinical Anesthesia 44 (2018) 50–56.
M. Preparation and Response
1. Maternal Early Warning System: National Partnership for Maternal Safety has
encouraged hospitals to adopt Maternal Early Warning Systems to improve
response and treatment of PPH
2. Maternal Early Warning Criteria:
a) Systolic BP <90 or >160
b) Diastolic BP >100
c) Heart Rate < 50 or >120bpm
d) Resp Rate <10 or >30
e) O2 Sat on RA: <95%
f) Oliguria ml/hr for >/=2 hours <35
g) Maternal agitation, confusion, or unresponsiveness; patient with
preeclampsia reporting a non-remitting headache or SOB
3. Maternal Early Warning System Cycle:
a) Monitor
b) Identify Trigger
c) Alert
d) Evaluate
e) Diagnose
f) Respond and repeat
4. University of Michigan has implemented AlertWatch (computer software tool) to
assist with recognizing physiologic deterioration in L&D
5. Simulation and drills practicing detection and response of PPH is needed to
improve maternal outcomes (see slides for studies to support simulation and
impact on outcomes)
6. Resources for PPH management:
a) Use of a postpartum hemorrhage management protocol is
recommended by ACOG
(1) UM PPH protocol shared- see PPT slides
(2) Council of Patient Safety in Women’s Health Care
(3) Society for Obstetric Anesthesia and Perinatology (SOAP)
(4) American College of Obstetricians and Gynecologists (ACOG)
N. Quality Measures:
1. Few quality measures for anesthesiologists in this space
a) Some aspects of PPH can be difficult to concretely measure
b) Some aspects of PPH care are outside the domain of anesthesiology
2. However, anesthesia team involvement in multidisciplinary QI projects is
important
3. Consider measuring maintenance of normothermia or tx of electrolyte
derangements
4. Look forward to hearing more about this from the MPOG OB Subcommittee
O. Conclusion:
1. Maternal mortality in the US is rising, while it is decreasing in other developed
countries.
2. Improving our response to PPH may reverse this trend.
3. Early identification of PPH is important.
4. Get involved early.
5. Quickly escalate care.
6. Consider viscoelastic testing/send labs early.
7. PPH protocols improve outcomes.
IV. Obstetrics Panel
A. OB Panel moderated by Nirav Shah, MD (ASPIRE Director)
B. Members of panel:
1. Angel Martino-Horrall, MD (OB Regional Medical Director, Beaumont Health
System, Northstar Anesthesia)
2. Josh Younger, MD (Henry Ford-Detroit)
3. Tom Klumpner, MD (Michigan Medicine)
C. Nirav Shah (ASPIRE Director): The coordination of many resources that require fast
mobilization presents challenges at large hospitals and small hospitals, Angel, since
you’ve been at both, what differences or barriers did you encounter in setting up these
resources that require 24-7 coverage with hospitals of different sizes and
infrastructures?
1. Angel Martino-Horrall (Northstar/Beaumont Health System): I think that one of
the biggest things is the smallest thing: provider communication., Doesn’t
matter the size- know the members of your team and how to get in contact with
them regardless of time of day and setting up consistency is important. Trying to
remove the barriers of ‘we’ve always done it this way’ is the hardest thing to do
and exist at a small or large institution. At a smaller institution, it is sometimes
easier to get in contact with people and a little bit easier to make changes as
there are fewer staff to communicate with. Will take much longer to disseminate
the information at a larger institution but then the impact is much larger as well.
2. Josh Younger (HFHS): That hits the nail on the head! Cultural change on labor
and delivery units can be hard as it’s a melting pot of people with different
backgrounds and experiences and it’s important to create a positive culture to
be able to effectively communicate. In crisis, it’s necessary to have already built
the collaboration beforehand so it all comes together when it’s most needed.
3. John Lagorio (Mercy Muskegon)- do you feel higher maternal mortality in the US
compared to the world may be demographic related as opposed to care related?
If so, how may we help recognize and address that?
a) Tom: That’s a loaded question. 49 states have seen an increase in
maternal mortality in the last 30-40 years, but California has actually
seen a decrease. Many systemic issues in the way we provide care in the
US. Access to care can be an issue in the US and around the world but
this is definitely a complex problem with several factors contributing.
4. Jill Mhyre (UAMS) - We just opened a shared workroom with the obstetricians.
Definitely a culture shock for some members of the team, but excited to break
down barriers to communication. This was a 5 year effort which included the
addition of a 3rd OR so we saw a big need for increased patient safety. It’s a
relatively big room with 10 computers with a large table in the center for
medical students, residents etc. We have suffered communication gaps but I feel
this is coming to an end now - when obstetricians are reviewing/discussing strips
etc we are now all a part of that conversation. I don’t have stories to share yet
but I think it will definitely improve care and how decisions are made.
a) Angel Martino-Horrall (Northstar/Beaumont Health System): Do you use
this as a debrief space as well? It’s hard to get the team back together
after the procedure
b) Jill Myhre (UAMS)- Yes I think that’s a good idea and is on our agenda.
It’s tricky to get anesthesia and surgical attendings present to mandate a
debrief after incision closure. We do call nurses to the room when we
are debriefing after a major event.
D. Nirav Shah: How do you measure improvement around PPH? Are there metrics in this
space? Or is this early stages and we’re still trying to figure out what the appropriate
process and outcome measures are?
1. Tom Klumpner (Michigan Medicine) - My impression is that this is a space that’s
evolving but that doesn’t mean we shouldn’t start measuring things. We should
look at the data and discuss it as a collaborativelooking at practice patterns. At
Michigan, we are looking at transfusion amounts per case and starting to
examine practice patterns. Some obstetricians will say ‘Oh, she’s bleeding -give 2
units.’ That seems like the first place to start as an opportunity to reduce
unnecessary transfusions.
a) Jill Mhyre (UAMS) - How do you operationalize that measure? Is it total
of units of blood product?
(1) Tom Klumpner (Michigan Medicine): Total units of red cells for
any delivery. Also looking at a maternal hemorrhage cart.
Another low-hanging fruit area. Are you doing an obstetric
hemorrhage risk assessment? Do you have blood available?
(2) Angel Martino-Horrall (Northstar/Beaumont Health System)- We
have used our OB data analyst to get some of this information.
I’ve also gotten a lot of information from our blood bank since
they track what the lab values were and if those products were
given: did we give them wisely? What was wasted? These were
all learning points for us as OB anesthesiologists and then had a
broader discussion with the obstetricians. Our blood bank would
shut down blood transfers to other units once we called a PPH
which gave us some necessary awareness.
(3) Josh Younger (HFHS) - We see similar things at HFHS. We have
analysts that actually pull out data and come through to refine it
but we were able to look at this together and discuss how to
make meaningful changes. There is room for people to redefine
certain metrics and how we can best use EMRs to our benefit.
(4) Nirav Shah (ASPIRE Director): Can work with Epic and other
EMRs over time to see that the documentation and data is
available to build these metrics
(5) Josh Younger (HFHS): Could also look at AKI metrics and even
examine those patients who maybe needed blood and didn’t get
it to prevent certain outcomes. Did we apply the appropriate
interventions in trying to prevent AKI.
E. Nirav Shah (ASPIRE Director): The lessons learned from PPH management and
coordination are certainly applicable to other emergency situations, have any of you
taken your systems applied to PPH management and adapted them for other
emergency response or clinical situations?
1. Angel Martino-Horrall (Northstar/Beaumont Health System): During my time at
Sparrow, after we implemented the PPH protocol, we developed an OB
emergency team that would be mobilized across the hospital for a variety of OB
emergencies, not just PPH. But PPH led us to this decision. We also noticed that
a lot of people showed up at a code and everyone didn’t exactly have a role or
know their role so we made lanyards to identify each person’s role in the code
which is what we did at other hospital codes and just applied to OB team
emergency response team as a solution.
2. Josh Younger (HFHS) - What I’ve seen is where we use protocols it seems to
bleed into other areas. The other thing is stakeholders. It’s about
communication and culture but also about relationships across the health
system.
3. Sydney Brown (Michigan Medicine via chat): Has anyone used a checklist for
hemorrhage? Both to be used prior to the OR, and in the OR? For instance, to
be posted on a monitor for everyone in the room to reference
a) Angel Martino-Horrall (Northstar/Beaumont Health System via chat): Yes
Sydney- we use it at Beaumont. Ours is not posted on the wall. it’s a
clipboard. but I recently screen shot that exact idea of a board from Dr
Nixon’s soap presentation in the spring! she is in Chicago I think?! it
looked like a great tool ….if we can find a space to hang it that is
functional for viewing & writing on it at the same time?!
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. GLU 03- Treatment or recheck of hyperglycemia (BG>200): Preop-PACU
1. Inclusion- All patients with glucose level greater than 200 mg/dL
2. Exclusion -
a) ASA 5 and 6 cases
b) Patients < 12 years of age.
c) Glucose measurements > 200 mg/dL within 90 minutes before measure
end (see ‘Other Measure Build Details’ for more information)
d) Outpatient cases with Anesthesia Start to Anesthesia end time less than
4 hours long
e) Obstetric Non-Operative Procedures (CPT: 01958)
f) Labor Epidurals (as determined by the MPOG 'Obstetric Anesthesia
Type' Phenotype results 'Labor Epidural' and 'Conversion (Labor Epidural
Portion)')
g) Cases where the ‘Measure End Time’ precedes ‘Measure Start Time’ will
be excluded and marked 'invalid'
3. Success - Administration of insulin within 90 minutes (either IV or sub Q routes)
or recheck of glucose level within 90 minutes
4. Performance shared with the group. There is a wide variation in performance for
this measure. Some sites have very high performance, and we know those sites
spend a lot of time working on glucose management. There is also high
variability on the low end as well. For many sites, the glucose measures have a
low denominator which will affect performance. The actual difference between
sites may not be as high when taking that into consideration as well.
5. Discussion:
a) Do you have a perioperative hyperglycemia management protocol at
your institution?
b) If yes, what are lessons learned from implementing this protocol?
c) If no, why no protocol? What are the barriers?
6. Feedback:
a) Josh Berris (Beaumont Farmington) - At Farmington Hills we have a
protocol we developed years ago and we order it for every DM patient.
It is distinct from anything the rest of the hospital does.
b) Alex Bowhouis (Holland) - I think it is a low denominator and a lot of
times the glucose will come back in the low 200s and we will choose to
ignore it, or we figure that it is a short case and we will have the postop
nurse re-check it, and the follow up communication isn’t done so it
doesn’t get rechecked in postop. It has to be a very high glucose for
someone to want to check and treat given that many of our cases are
very short. We also don’t have glucometers in every room, so we have to
call for a glucometer if we want to check intraop.
c) Nirav Shah (Michigan Medicine/MPOG)- Dr. Khan’s thought about having
it as part of a handoff and time of last checked may be important. Is
there a standard periop/institutional protocol that you use?
d) Alex Bowhouis (Holland) - the reason why we have a protocol is because
of ASPIRE, from about 2017. It is in line very close with ASPIRE and is for
glucose >200. I often forget to tell the postop nurse that we gave the
patient insulin and to ask that they recheck the sugar
e) Josh Berris (Beaumont Farmington) - Our PreOp nurses are also really
good at handing off to CRNAs when the recheck is due.
f) Kathleen Collins (St. Mary’s Livonia): Posted St. Mary’s Livonia’s
perioperative glycemic protocol in the chat. Laminated copies posted in
POHA, OR on machines, and PACU. Just as a reminder. (ASPIRE has this
protocol saved if you’d like to view it, please contact the coordinating
center: support@mpog.zendesk.com)
g) Daniel Applefiled (St. Joseph Oakland) - We are also not hitting the bar.
We have not focused on this measure as we are focusing more on P4P.
We have a protocol in place for a number of years. The success we are
showing is attributed to the preop nurses. They are very good about
calling if the glucose is >180. They will contact us and ask if we are
treating it and for an order. We have POC machines in our rooms. It is
easy and we implement it into the handoff in PACU. It is part of the
culture here, but we do have room for improvement. We also face
challenges with having residents and teaching them about ASPIRE (the
dashboard, establishing buy-in, teaching them about the measures).It is
often hard to keep up with all the new measures so we try to focus in on
the ones that we think we can improve and will have an impact in care.
It really all comes down to preop nursing. Dr. Davies when he was here
worked hard to get POC machines in all the rooms and in preop.
h) Pam Tyler (Beaumont Farmington/Troy)- The nurses in preop have it in
their handoff to see if the sugar check is due within 90 minutes and if it
can be checked again before going into the OR.
i) Brad Berndt (Bronson Kalamazoo) - As part of our ERAS protocols for
specifically ortho, spine and OB, part of the protocol is that these
patients are supposed to have a carbohydrate drink 3 hours before
surgery. These patients are presenting to preop with elevated glucoses
(ie 210 -220) even if they aren’t diabetic. We have a protocol to recheck
it if >200, but we have a lot of questions from providers on how to
manage this.
j) Pam Tyler (Beaumont Farmington/Troy) - at some places for ERAS they
will sub for G2 gatorade if diabetic instead of the carbohydrate drink.
k) Kim Finch (HF Detroit/WB) - What benefit does the G2 drink have if it
isn’t carb loading?
(1) Pam Tyler (Beaumont Farmington Hills) - It is for providing them
hydration without putting them into overload.
(2) Kim Finch (Henry Ford Detroit and West Bloomfield) - The
research says the carb loading drink is good for diabetics and
non diabetics. We are moving towards testing all of our patients
(regardless of diabetes status) in preop. We are finding some
without diabetes that have elevated glucose.
(3) Mike Mathis (Michigan Medicine/MPOG)- The definition of
diabetes involves a glucose tolerance test. I am not sure how
much the glucose load compares, but this may be a way to find
out that these patients have pre-diabetes.
(4) Allison Janda (Michigan Medicine/MPOG)- is anyone organizing
follow-up for these patients for the ones that may have
diabetes?
(5) John LaGorio (Mercy Muskegon) - I will often let the patients
know that they should follow up with PCP and let the surgeon
know
(6) Douglas Colquhoun (Michigan Medicine/MPOG)- This may
actually change their postop management if we can get them
set up prior to discharge
l) Sydney Brown (Michigan Medicine via chat): Are there instructions
provided to patients about following up with their PMD about elevated
glucoses in this setting?
C. GLU 05 - Treatment of hyperglycemia (BG>200) within 90 minutes
1. Similar to GLU 03 but only looks at treatment (not recheck)
2. Percentage of cases with a blood glucose >200 mg/dL with documentation of
insulin treatment
3. Exclusions:
a) ASA 5 and 6 cases
b) Patients < 12 years of age
c) Glucose measurements > 200 mg/dL within 90 minutes before measure
end
d) Outpatient cases with Anesthesia Start to Anesthesia end time less than
4 hours long
e) Labor Epidurals
4. Please note: documented blood glucose <200 within 90 minutes of a blood
glucose >200 mg/dL prevents a flag
5. See bar graph comparing participating site performance in PPT slide. See similar
variation across sites as compared to GLU 03- sites that perform well on GLU 03
also perform well on GLU 05. A lot of variability in performance for sites inside
and outside the state of Michigan
6. Feedback:
a) See notes from GLU 03 discussion.
D. GLU 04 - Treatment or recheck of hypoglycemia (BG<60): Preop-PACU
1. Performance shared with the group. Generally high performance across our
institutions. Counter measure to aggressive hyperglycemia treatment.
2. Discussion - What is the process for reviewing and following up on these cases?
Should this be a never event? Or are there cases where it is appropriate to have
a GLU <60 without treatment or rechecking?
a) Tim Dubovoy (Michigan Medicine) - We’ve had some adverse events
that have had poor patient outcomes due to hypoglycemia. We don’t
have Centricity fully integrated with Epic which is what is used in
preop/pacu which makes it difficult. At our institution, we decided this
requires active intervention - if a patient has a BG< 60 the anesthesia
provider will receive a notification page. It's difficult for providers to
ignore an abnormal lab page sent directly to them. We also review all
hypoglycemia on a monthly basis and make a determination if it should
be categorized as a QA event. If the provider misses the time window
but did the appropriate thing, we usually consider it a pass. If we don't
see a response from the provider then we will 1) see if the alert was
generated and 2) if appropriate treatment was given. We then have a
conversation with the provider, not in a punitive way. This is something
we constantly need to monitor and provide feedback to avoid
unexpected events.
b)
E. 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 the group. Overall the performance across the
collaborative is very good. There is some variation both within Michigan and
across the country. This is also a P4P measure for this year. Do you have
consensus within your practice on the management of hypotension? What is the
vasopressor of choice in your institution? How do you manage hypotension in
free flap cases?
5. Feedback:
a) Aisha Qazi (Beaumont Troy) - The way that we try to avoid hypotension
is through education with CRNAs and staff in terms of the guidelines and
when we should consider treating. Once you have treated, to recheck
the blood pressure so that the cumulative time of hypotension is not as
long. We mainly use phenylephrine and ephedrine depending on the
heart rate.
b) Brad Berndt (Bronson Kalamazoo) - It is all dependent on heart rate, our
first step is phenylephrine or ephedrine. We have easy access to
phenylephrine infusions and try to encourage quicker utilization of
infusions as opposed to boluses if it is a longer duration case. In OP for
patients under regional anesthesia with little surgical stimulation, trying
to get our providers to determine if we should keep the MAP elevated
even if it may not be required. I get pushback from the CRNAs regarding
younger patients who may not need a MAP of >65
c) Dennis Ahmad (Metro Health) - We are experiencing cultural issues
around managing BP in younger and healthier patients. Having readily
available phenylephrine and ephedrine in intraop is important. The
availability and access is there and is what we need from a process
improvement perspective in order to treat the MAPs <65 a little more
aggressively
d) Mike Mathis (Michigan Medicine/MPOG via chat) - Re: vasopressor issue
during free flaps -- this is an interesting one -- there was recent expert
consensus (including oto surgeons) publication on this, favoring
vasopressors for hypotension once correcting other contributing causes:
https://journals.lww.com/johnajournal/Fulltext/2021/05010/Expert_co
nsensus_statement_on_the_perioperative.8.aspx?WT.mc_id=HPxADx20
100319xMP
e) Josh Berris (Beaumont Farmington via chat) - While we are still doing
well on this measure. Having ephedrine as a controlled med has made
things more difficult because people don't want to make it up "just in
case" because of all the documentation.
f) Nirav Shah (Michigan Medicine/MPOG) - We have been moving to dilute
norepinephrine in free flap cases in order to help flap perfusion
g) Joseph Ruiz (via chat) We looked at our free flap experience, Fang, Lin
MD, PhD∗; Liu, Jun PhD∗; Yu, Cuicui MD†; Hanasono, Matthew M. MD∗;
Zheng, Gang MD†; Yu, Peirong MD∗ Intraoperative Use of Vasopressors
Does Not Increase the Risk of Free Flap Compromise and Failure in
Cancer Patients, Annals of Surgery: August 2018 - Volume 268 - Issue 2 -
p 379-384 doi: 10.1097/SLA.000000000000229)
(1) Nearly 6000 cases, no negative effects at any dose and at any
time
h) Allison Janda (Michigan Medicine) - dilute norepinephrine does not
come standard from the manufacturer. At other sites, are you having to
compound it yourself or is pharmacy compounding it?
(1) Angel Martino-Horrall (Northstar/Beaumont) - We have to
compound it ourselves, which is a limiting factor to utilization
(2) Brad Berndt (Bronson Kalamazoo) - Do you have pre-made
syringes of norepinephrine at University of Michigan?
(a) Nirav Shah (Michigan Medicine/MPOG) - we do, which
has been very helpful. In both large and small syringe
sizes, which has tilted me towards using more of it and
less phenylephrine in general.
(b) Allison Janda (Michigan Medicine via chat): Yes, we have
pre-made syringes compounded by our pharmacy
(4mcg/mL). We have two sizes of syringes because you
can go through the smaller syringes very quickly if using
as an infusion. Same concentration (4mcg/mL) for the
20mL bolus syringes and the larger, 60mL infusion
syringes to use on the Alaris syringe pumps.
(c) Christopher Miliken (Sparrow)- (via chat) Sparrow has
pre-filled 10 ml phenylephrine syringes we use for Braun
pumps. Infusion setup easy.
(3) Mike Mathis (Michigan Medicine/MPOG) - Pharmacy
compounding has a big influence on whether or not you are
going to use it.
i) Ksenia Koltun (Beaumont Royal Oak)- Are people starting phenylephrine
infusions on the young and healthy patients just to meet the measure
letting the lower MAP go because they are young and healthy?
(1) Josh Berris - Have always done this, not just for the measure
j) John LaGorio - Patients are coming in on more medications. I met with
the quality director to go over that and see how we might have to adjust
recommendations for holding preop medications (traditionally only ACEs
and ARBS). May need to hold them further or liberalize NPO guidelines
for those with afternoon surgeries to stay hydrated in the morning.
k) Kristine Veach (via chat) I have found that our Philips monitors report
lower MAPs than if you were to calculate it with the equation. So if it is
reporting 63-64 if is actually 65-66. Not sure if our staff is letting these
"close enough" MAPs slide in young/healthy patients.
l) Josh Berris (via chat) What concentration of NE syringes are people
using?
(1) Nirav - dilute epi is 4mcg/mL
m) Joseph Ruiz - (MD Anderson - via chat) If you decide to do a case where
a patient has taken an ACE or ARB, what is the vasopressor of choice?
Vasopressin or Norepi?
n) Joel Kileny (St. Joseph Ann Arbor - via chat) Is there a correlation
between BP-03 performance and the end organ measures (AKI/Card 02
and 03)?
o) Josh Berris (Beaumont Farmington - via chat) Since osc. BP measure
mean directly and calculates SBP and DBP, I don't see how that is
possible on any OR monitor
p) John LaGorio (Mercy Musckegon - via chat) we often use vasopressin to
address hypotension associated with ACEI/ARB
q) Kathleen Colins (St. Mary Livonia) -(via chat) We have phenylephrine,
ephedrine and vasopressin in each OR. Rarely use NE. Interesting
discussion
r) Mike Mathis (Michigan Medicine/MPOG) - (via chat) @Joel -- don't
know answer to exactly that question, but we do have MPOG study
looking at hypotension & AKI -- conclusion is that association does exist
for moderate or high risk patients (strongest for high risk)… whereas no
association for very low risk patients.
https://pubs.asahq.org/anesthesiology/article/132/3/461/108876/Preo
perative-Risk-and-the-Association-between
s) Joseph Ruiz (MD Anderson - via chat) - Thanks John, case I usually face is
in Interventional Radiology for an ablation a 2-3 hr. I was using Norepi, a
colleague vasopressin which I will try in future. But I have delayed more
and more
F. 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; Very interesting comparison between
sites inside and outside the state of Michigan
a) Feedback: We are currently working with a few sites who are diligently
working with on site technical team to capture this data.
6. This is ASPIRE’s first population health measure. Should ASPIRE focus on
population health issues like SUS 01? Or stay focused on measures related to
patient outcomes? Is there risk with this measure (ie what is the downside)?
7. Peter Panagopolous (Beaumont Dearborn) - We saw our scores jump after a
really good re-education effort getting providers in the same room a few months
in a row and then ‘bread and butter’ vigilance. I think this has made a really
good impact on us.
8. Nirav Shah (ASPIRE Director) - are these areas for ASPIRE to focus on?
a) Peter - When you talk about smoking I think it definitely takes a village
and key is definitely repetition. Once providers hear it more than once
thats when it starts to sink in. Starting from PAS all the way through
postop visits. These things are very impactful and really don’t cost us
much with the impact we are looking to make.
b) Ksenia Kolton (Beaumont Royal Oak) - We have been working hard on
this measure and have had a department wide lecture mainly focusing
on this measure because we were doing poorly. In the month of May we
have improved to 86% after that department meeting. Very happy to
report we are heading in the right direction. Communication and getting
everyone on the same page is key. We plan to do the same after this
meeting to remind everyone we are still focusing on this.
c) Nirav Shah (ASPIRE Director) - have you had any pushback from your
providers on a measure like SUS01
d) Ksenia Koltun (Beaumont Royal Oak) Not so much push back as much as
providers are hesitatne to making change as theyve been providing
anesthesia for 20+ years and are ‘set in their ways’. Its still a touch and
go, ie a little difficult, to get the fresh gas flows down immediately after
induction and then to turn them back up for emergence. I think its a
slow and steady change of culture/practice and i think providers
understand the benefit.
e) Ashley Screws (St. Marys GR) - This is new for us I think its just built into
our practice. We are still working on educating providers about this
measure.
Meeting concluded at: 1210
