Cardiac Subcommittee Minutes 06.04.21

Cardiac Anesthesia Subcommittee Minutes

June 4, 2021

10:00am – 11:00am EST

Zoom

Abernathy, Jake (Johns Hopkins)

Kertai, Miklos (Vanderbilt)

Andrawes, Michael (MGH)

Kheterpal, Sachin

Billing, Josh (Vanderbilt)

Kileny, Joel (St. Joseph Mercy Ann Arbor)

Bailey, Meridith (MPOG)

Krall, Thomas (TJ) (UCSF)

Bottiger, Bandi (Duke)

Lacca, Tory (MPOG)

Brown, Morgan (Boston Children’s)

Low, Ying (Dartmouth)

Buehler, Kate (MPOG)

Luria, Brent (NYU Langone)

Burrage, Peter (Darmouth)

Mamoun, Negmeldeed (Duke)

Clark, Cantwell (Dartmouth)

Mathis, Mike (MPOG)

Chen, Yunwei (Washington University)

Muehlschlegel, Danny (Brigham and Women’s)

Davies, Eric (Henry Ford Health System)

Neuburger, Peter (NYU Langone)

Douin, Josh (University of Colorado)

Podgoreanu, Mihai (Duke)

Dubovoy, Anna (Michigan Medicine)

Rangrass, Govind (University of Chicago)

Fisher, Clark (Yale)

Reidy, Andrea (Washington University)

Ian Gannon, Michigan Medicine

Rhee, Amanda (Mount Sinai)

Michael Grant, Johns Hopkins

Sera, Valerie (OHSU)

Grewal, Ashanpreet (Ashan) (University of Maryland)

Schonberger, Rob (Yale)

Guruswamy, Jayakar (Jay) (Henry Ford Health System)

Shah, Nirav (MPOG)

Hasmi, Nazish (Duke)

Shook, Doug (Brigham and Women’s)

Janda, Allison (MPOG)

Szymanski, Brooke (MPOG)

Jelacic, Srdjan (University of Washington)

Varelmann, Dirk (Brigham and Women’s)

JohnBull, Eric (Duke)

Vega, Eleanor (Duke)

Katta, Gaurav (Henry Ford Health System)

1. Introductions- MPOG Team

i. Allison Janda, MD – MPOG Cardiac Subcommittee Chair

ii. Nirav Shah, MD – MPOG Director of Quality

iii. Michael Mathis, MD – MPOG Associate Research Director

iv. Kate Buehler, MSN – Clinical Program Manager

2. Cardiac Dashboard on MPOG Reporting Tool

a. Cardiac dashboard is now available for individual providers, site cardiac champions, and

site quality champions to view

b. To access the cardiac dashboard:

i. Default view when logging in from Provider Feedback Emails is your own

performance for site-selected measures

ii. Change ‘Entity’ in upper left corner to your institution rather than your own

name

iii. Choose ‘Dashboards’ then ‘Cardiac’ from the banner along the top

c. Reach out if you have any questions: support@mpog.zendesk.com

3. TRAN 01: % of cases with a blood transfusion that have hemoglobin or hematocrit value

documented prior to transfusion

a. Quality Committee recently voted to exclude all cardiac cases but wanted to pass this

through the Cardiac Subcommittee for consideration

b. Rationale:

i. EBL is not accurately documented for bypass cases

ii. Variable location of documentation for POC labs and blood products by

perfusion team leads to potential inaccuracies

iii. Need for emergent transfusion is more frequent in cardiac cases (i.e. no time to

check hemoglobin or hematocrit)

c. Discussion:

i. Nirav Shah (ASPIRE Director): Quality Committee recommended specifically

excluding cardiac bypass cases vs. all cardiac cases.

ii. Danny Muehlschlegal (BWH): What does the cardiac dashboard actually include

as far as case types? Looks like there are more than just cardiac cases in there

currently.

iii. Allison Janda (MPOG Cardiac Subcommittee Chair) - The current cardiac

phenotype is over inclusive and there are many cases that are actually not

cardiac. Working to use Surgical CPTs, Anesthesia CPTs, whether or not a

clamp/bypass was used etc. It might be best to just exclude bypass cases at this

point.

iv. Kate Buehler (MPOG) - To exclude Bypass cases it might be good to start with

that and then wait until the updated cardiac phenotype is ready.

v. Nirav (ASPIRE Director) - I agree.

vi. Josh Billings (Vanderbilt): Does over-excluding prevent us from getting some

meaningful information from those cases that get flagged? Even if they had

reasonable care during an emergency, for instance, it may still be good to see

those cases.

vii. Allison Janda (MPOG Cardiac Subcommittee Chair): That’s a great point, Josh,

yes, we’re always trying to strike the balance for the quality measures to give

providers pertinent feedback about their cases that may need a review but at

the same time, avoiding over-flagging cases so providers start ignoring the

measure if it inappropriately flags cases frequently.

viii. Josh Billings (Vanderbilt): Will you collect the data and not display it on the

dashboard until the phenotype is complete?

ix. Allison Janda (MPOG Cardiac Subcommittee Chair): This measure will

retrospectively apply and that historical data will still be there for quality

measures or for research purposes.

x. Nirav Shah (ASPIRE Director): We also have the ability to create specific

visualizations in our new QI reporting tool to help provide additional

information for measures.

xi. Mike Mathis (MPOG Assoc. Research Director): Can either take the path of an

informational measure or build a cardiac-specific measure for transfusions in

the future

xii. Vote to exclude cardiac bypass cases in the general TRAN-01 measure:

1. Joel Kileny (SJMAA), Gaurav Katta (Henry Ford) and Danny

Muehlschlegal (BWH)- sounds reasonable.

xiii. Allison Janda (MPOG Cardiac Subcommittee Chair): Decision- Move forward

with excluding cardiac bypass cases first and then move forward with excluding

other cardiac cases if needed using the revised phenotype once available

4. Cardiac Procedure Type Phenotype

a. Coordinating Center is working to develop a new cardiac procedure type phenotype to

better identify types of cardiac procedures

b. This phenotype will be used for quality measures (inclusions/exclusions) & research

projects

c. New categories resulting from this phenotype:

i. Open Cardiac

ii. Transcatheter/Endovascular

iii. EP/Cardiac catheterization

iv. Other cardiac

v. No/Non-cardiac

vi. Missing/unknown/unable to determine

d. Data Elements Utilized:

i. Surgical CPTs (if present)- Not available for all cases

ii. Anesthesia CPTs

iii. Procedural Service IDs

iv. Cardiopulmonary bypass documentation phenotypes and concepts

v. Procedure text phrases

e. Schema: Sequentially bins cases based on utilized fields if present

f. Current Status: Undergoing validation

g. Questions for group:

i. Sternal debridements: Cardiac or non-cardiac

ii. ECMO cases: other cardiac?

h. Discussion:

i. Rob Schonberger (Yale)- Is the procedure type phenotypes for other categories

of procedures a focus for MPOG in addition to cardiac procedures? I have seen

some issues with a recent MPOG research project.

ii. Allison Janda (MPOG Cardiac Subcommittee Chair): We are aware of this but if

you have specific examples of other procedure type phenotypes that aren’t

working as expected, please send them to us. The biggest issue was with the

cardiac procedure type phenotype so we’ve started with tackling this one first.

iii. Danny Muehlschlegel (BWH) What’s the purpose of putting sternal

debridements into separate bins? These are small cases that sometimes have

nothing to do with cardiac. It could be done by the plastics service or others.

Only consistent is that it might be done by a cardiac anesthesiologist. On the

other hand these could be cardiac ‘re-op’ cases

iv. Allison Janda (MPOG Cardiac Subcommittee Chair): We were not considering

this as a bin on its own, we were considering this to be either non-cardiac or

cardiac but wanted to know if we should put this in the other non-cardiac

category. Would you prefer to put it in the non-cardiac bin if you had to pick

one?

v. Danny Muehlschlegel (BWH)- yes, non-cardiac

vi. Josh Billings (Vanderbilt): Exclude sternal washouts/closures from the measure,

but it would be nice to have a toggle. If you’re looking for LOS or other

outcomes I think you would want to distinguish traditional open heart cases. I

wouldn’t call them ‘non-cardiac’ but are just not as ‘major’.

vii. Allison Janda (MPOG Cardiac Subcommittee Chair): There will be gray area in

this other cardiac group. There could be instances where you do want to see

sternal debridement cases but in general, wanted to know from the group, as a

whole, do they fit better in non-cardiac or cardiac. They really are both, but

since they vary in extent (i.e. some may just be a quick debridement above the

sternum whereas others may be a more extensive complete washout for a

bleeding bring-back) without any change in how they are booked or labeled so

we should try to put them in a bin that makes sense, but allows researchers and

the QI measures to either filter them out or in based on the specific question at

that moment.

viii. Mike Mathis (MPOG Assoc. Research Director)- If we plan to study sternal

debridements in the future, then it does make sense to separate. If the goal is to

remove the dilution of other cardiac, maybe we call them non-cardiac, but they

do have more similarities with cardiac cases than a general case.

ix. Josh Billings (Vanderbilt) - Could label the bucket above as ‘Major Open Cardiac’

procedures and these sternal debridements as ‘other cardiac’ since these cases

are still in our service line and shouldn’t be dumped into non-cardiac. I like the

idea of putting them in the ‘other-cardiac’ bucket.

x. Allison Janda (MPOG Cardiac Subcommittee Chair) - Either way we are making

an improvement to the current state but it is still a grey zone which is why we

are bringing it to this group. For now, are we okay to separate the smaller cases

into the ‘other-cardiac’ bucket

xi. Rob Schonberger (Yale) / Mike Mathis (MPOG Assoc. Research Director) - Agree

xii. Decision: Categorize sternal debridements & ECMO cases as ‘Cardiac: Other.’

5. Post-bypass Hypothermia Avoidance

a. Current TEMP 03 Measure: % of patients, with procedures >60 minutes under

GA/neuraxial, with at least one body temp ≥3 6 ℃ (e x c lu d e s c a r d ia c s u r g e r y )

b. New TEMP-06-CARD measure

i. % of patients, ≥18 years age, who undergo open cardiac surgical procedures

under GA of >120 minutes for whom last non-artifact body temperature prior to

anesthesia end was ≥35.5℃

ii. Timing:

1. Last non-artifact temperature documented, if more than one,

preferentially use core temperature

2. Look back period of 15 minutes

a. Use core temperature if present in the anesthesia record within

15 minutes of the last documented non-artifact body

temperature

3. Core or Near Core Temperature Monitoring Includes:

a. Pulmonary Artery Temperature

b. Distal Esophageal Temperature

c. Nasopharyngeal Temperature

d. Tympanic Membrane Temperature

e. Bladder Temperature

f. Rectal Temperature

g. Axillary Temperature (arm must be at patient side)

h. Oral Temperature

i. Zero-Flux Thermometer Temperature

4. Artifact Algorithm:

a. Less than 32℃ (89.6℉)

b. Greater than 40℃ (104.4℉)

c. Any minute-to-minute jumps >0.5℃ equivalent

d. Example: 0.125℃/15s/0.25℃/30s, 1℃/2mins)

5. Attribution:

a. Any provider signed in for ≥40 minutes from bypass end until

anesthesia end (or the provider signed in for the greatest

number of minutes during this period, if this period is <40

minutes) per staff role.

b. If bypass was not used, the window would be expanded to any

provider signed in for ≥40 minutes for the entire case

6. Inclusions: All patients, 18 years of age or older, who undergo open

cardiac surgical procedures (as determined by Procedure Type: Cardiac

phenotype) under GA of greater than or equal to 120 minutes

7. Exclusions:

a. Organ harvest (CPT: 01990)

b. Non-cardiac cases as defined as those cases not meeting criteria

for the cardiac case type phenotype

c. Within the general cardiac case type phenotype, exclude:

Transcatheter/Endovascular and EP/Cath groups

d. Invalid cases where Measure End results prior to Measure Start

e. Cases with age <18

f. Potential exclusions to add:

i. Cases with an intraoperative note mapped to

intentional hypothermia (MPOG concept: 50037)

ii. Circulatory arrest cases

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

iv. “Other Cardiac” bin

v. “Transcatheter/Endovascular” bin

g. Discussion regarding exclusions:

i. Allison Janda (MPOG Cardiac Subcommittee Chair):

Does anyone object to including circulatory arrest

cases?

1. Rob Schonberger (Yale): Makes sense

ii. Allison Janda (MPOG Cardiac Subcommittee Chair):

Other cardiac cases: include or exclude?

1. Mike Mathis (MPOG Assoc. Research Director):

If we are placing value on assessing if we

improve, we want to be able to identify

performance changes vs. the changing nature of

cardiac surgery in case volume/type. Want to

be able to understand changes over time and

be over exclusionary to really be able to detect

true changes in open cardiac cases.

2. Danny Muehlschlegel (BWH): Makes sense to

separate or exclude transcatheter cases as they

are so different from open cardiac cases but

should include circulatory arrest cases as they

should be warm by the end of the case unless

we’re intentionally cooling someone after

circulatory arrest

iii. Allison Janda (MPOG Cardiac Subcommittee Chair):

Addressing question in the chat from Morgan Brown

(Boston Childrens)- Transcatheter cases such as a PFO

repair would fall into the transcatheter/endovascular

bin. Cardiac cath cases where they are doing a right

heart catheterization for instance, would fall under

cardiac cath; ablations would fall under the EP category;

If just getting echo or cardioversion, those would be

under EP; cardiac MRI would be in MRI phenotype but

would be considered non-cardiac for the cardiac

phenotype.

iv. Mike Mathis (MPOG Assoc. Research Director) via chat:

One comment re: using last non-artifact, non-core

temperature... if we have 2 core temperatures

document (e.g. nasopharyngeal + bladder), which were

disconnected at a relatively similar time (e.g. within 15

minutes of each other), I would favor the *higher* of

the two temperatures... getting at the issue of oliguric

patients potentially having a low bladder temp. Maybe

an issue to discuss via basecamp, given we have 5

minutes here... would be interested to hear what the

group thinks.

8. Next Steps for TEMP-06-CARD

a. Incorporate your feedback in V2 of the measure specification

b. Incorporate suggestions into the Cardiac Procedure Type

Phenotype

c. Apply the measure specification to past cases and test

functionality

d. Update group with any updates or snags during validation

e. Circulate the revised measure specification for approval

f. Synergize efforts with SCA Quality & Safety Committee / CPI

Subcommittees

6. Goals:

a. Build 1 cardiac-specific measure in 2021 (Post-bypass normothermia avoidance)

b. Build 1 additional cardiac-specific measure in late 2021

i. On-bypass hyperthermia avoidance?

1. Allison Janda (MPOG Cardiac Subcommittee Chair): Is this the next

measure we should be tackling?

2. Mike Mathis (MPOG Assoc. Research Director): I think it’s a good

measure but wonder what the group thinks about the agency

anesthesia has in controlling this though?

3. Josh Billings (Vanderbilt): We do have responsibility for this- I don’t

think perfusionists are advocating for hyperthermia. I’m shocked at the

performance you’ve just shown on the bar graph. Worth measuring.

4. Rob Schonberger (Yale) via chat: Agency is an issue - though it may give

us ammunition when we show a comparison with other institutions

5. Ashanpreet Grewal (University of Maryland) via chat: It’s not directly

under our control but we can and should influence it

6. Rob Schonberger (Yale): Want to make sure we aren’t harming patients

with our QI so agree with having hyperthermia as the counter measure

is a great idea.

ii. Josh Billings (Vanderbilt): What is the best way to communicate with the group?

Basecamp?

iii. Michael Mathis (MPOG Assoc. Research Director): Basecamp is best.

iv. Allison Janda (MPOG Cardiac Subcommittee Chair): I think we will send out

another survey to determine what third measure we should build after the hypo

and hyperthermia measures.

c. Opportunities for STS-merged outcome reports->requires institutions to integrate with

STS

7. Hyperthermia Avoidance (>38℃)

a. Preliminary MPOG data shared: % of cases with any recorded temp above 38℃ by

institution (see slides for bar graph)

b. Literature Review (see slides for full references)

i. 2020 Updates from the Adult Cardiac Anesthesiology Section of STS (Del Rio et

al., 2020)

1. Avoidance of temp >37 while on bypass

ii. Guidelines for perioperative care in cardiac surgery: enhanced recovery after

surgery recommendations (Engelman et al., 2019)

1. Avoid >37C for arterial outlet blood temperature while on bypass

iii. STS Practice Guidelines for temperature management while on bypass

(Engelman et al., 2015)

1. Avoid >37C for arterial outlet blood temperature while on bypass

iv. ERAS cardiac recommendations (Gregory et al., 2020)

1. Avoid >37.9C while on bypass

v. Current cardiac hyperthermia avoidance Anesthesia Quality Institute measure

1. AQI65, for cerebral hyperthermia avoidance defines hyperthermia as

≥37C while on bypass

8. Interested in STS-MPOG Integrations?

a. Consult the Surgical Registry page and the FAQ

i. Surgical Registry Page

ii. Surgical Registry FAQ

9. Cardiac Anesthesia Subcommittee Membership

a. Open to all anesthesiologists or those interested in improving cardiothoracic measures

i. Do not have to practice an active MPOG institution to participate

b. Proposed 2021-2022 meeting schedule

i. Summer 2021 Meeting: August 2021

ii. Fall 2021 Meeting: October/November 2021

iii. Winter 2022 Meeting: January/February 2022

c. Thank you for continued use of the Basecamp forum for discussion between meetings!

Meeting adjourned at 1101