Cardiac Subcommittee Minutes 09.10.21

Cardiac Anesthesia Subcommittee Minutes

September 10, 2021

11:00am – 12:00pm EST

Zoom

Abernathy, Jake (Johns Hopkins)

Kertai, Miklos (Vanderbilt)

Andrawes, Michael (MGH)

Kheterpal, Sachin (MPOG)

Bardia, Amit (Yale)

Kileny, Joel (St. Joseph Mercy Ann Arbor)

Billings, Josh (Vanderbilt)

Krall, Thomas (TJ) (UCSF)

Bailey, Meridith (MPOG)

Lacca, Tory (MPOG)

Bottiger, Bandi (Duke)

Low, Ying (Dartmouth)

Brown, Morgan (Boston Children’s)

Luria, Brent (NYU Langone)

Buehler, Kate (MPOG)

Mamoun, Negmeldeed (Duke)

Burrage, Peter (Darmouth)

Mathis, Mike (MPOG)

Clark, Cantwell (Dartmouth)

Muehlschlegel, Danny (Brigham and Women’s)

Chen, Yunwei (Washington University)

Neuburger, Peter (NYU Langone)

Davies, Eric (Henry Ford Health System)

Podgoreanu, Mihai (Duke)

Douin, Josh (University of Colorado)

Rangrass, Govind (University of Chicago)

Dubovoy, Anna (Michigan Medicine)

Reidy, Andrea (Washington University)

Freudzon, Leon (Yale)

Rhee, Amanda (Mount Sinai)

Fisher, Clark (Yale)

Sera, Valerie (OHSU)

Ian Gannon, Michigan Medicine

Schonberger, Rob (Yale)

Michael Grant, Johns Hopkins

Shah, Nirav (MPOG)

Grewal, Ashanpreet (Ashan) (University of Maryland)

Shook, Doug (Brigham and Women’s)

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

Szymanski, Brooke (MPOG)

Hasmi, Nazish (Duke)

Szabo, Christopher (Yale)

Janda, Allison (MPOG)

Varelmann, Dirk (Brigham and Women’s)

Jelacic, Srdjan (University of Washington)

Vega, Eleanor (Duke)

JohnBull, Eric (Duke)

Zittleman, Andrew (MPOG)

Katta, Gaurav (Henry Ford Health System)

Meeting Summary

1. Introductions- MPOG Team

a. Allison Janda, MD – MPOG Cardiac Subcommittee Chair

b. Nirav Shah, MD – MPOG Director of Quality

c. Michael Mathis, MD – MPOG Associate Research Director

d. 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. 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: Validation nearly complete - much improved from previous version!

g. Discussed pericardial windows as they are currently binned as either cardiac open or

cardiac other by the phenotype. Consensus among committee members to bin

pericardial windows as ‘Other Cardiac’ to make the Open Cardiac bin as clean as

possible.

4. Post-bypass Hypothermia Avoidance

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

GA/neuraxial, with at least one body temp ≥36℃ (excludes cardiac surgery)

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

8. Update: Measure is coded and is currently undergoing validation by

coordinating center staff (preliminary performance shared)

9. Questions for the group:

a. Do we need to add hierarchy to prioritize core vs near core

temperatures?

i. STS-SCA practice guidelines (2015) referenced: nasal, PA,

bladder all considered as reasonable approximation of

core temp for patients weaned from bypass.

ii. Discussion but no consensus from the group on

prioritizing PA or bladder over nasal route.

Recommendation to review how many cases would be

changed as a result of implementing a hierarchy into

the measure code. If a small number of cases would be

impacted, perhaps leave as is & consider a non-issue.

We will follow up with this issue on Basecamp.

b. Do we need to increase look-back time from the last

temperature to >15 minutes? Consensus from group: No

change needed. 15 minutes is sufficient.

10. Next Steps:

a. Update group with any updates or snags during validation

b. Circulate the revised measure specification for approval

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

Subcommittees

d. Goal to publish by October 8th MPOG Retreat

e. Refining the measure will continue after we launch, please let us

know if you see inappropriately flagged/passed cases on the

dashboard once published.

5. Hyperthermia Avoidance - Literature Review

a. 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

b. Preliminary MPOG data shared (slide 17)

c. Hyperthermia Avoidance (TEMP-07-CARD) Measure Details

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

using cardiopulmonary bypass under general anesthesia of >120 minutes for

whom the temperature did not rise above 37 degrees Celsius while on bypass

for over 10 consecutive minutes

ii. Timing: Cardiopulmonary bypass start until cardiopulmonary bypass end

(phenotype exists but needs improvement)

iii. Artifact algorithm:

1. Less than 32℃ (89.6℉)

2. Greater than 40℃ (104.4℉)

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

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

iv. Attribution: Any provider signed in for ≥40 minutes from bypass start until

bypass end (or the provider signed in for the greatest number of minutes during

this period, if this period is <40 minutes) per staff role

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

surgical procedures using cardiopulmonary bypass (as determined by Procedure

Type: Cardiac Open phenotype and Cardiopulmonary Bypass phenotype) under

GA of ≥120 minutes

vi. Exclusions:

1. ASA 6

2. Organ harvest (CPT: 01990)

3. Non-cardiac cases as defined as those cases not meeting criteria for the

cardiac case type phenotype

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

Transcatheter/Endovascular, EP/Cath groups and Other Cardiac

5. Non-CPB cases

6. Cases with age <18

vii. Consensus amongst the group to prioritize nasal temperatures over core

temperature. Also, the group agrees that anesthesiologists should discuss

these measures with their perfusionist colleagues to gain input and buyin to

address these pertinent issues together. We will be recruiting perfusionists to

have a work group meeting prior to the December meeting. If you have

perfusionists at your institution who would be interested in helping, please

email: ajanda@med.umich.edu (Allison Janda). Also agreed to report

performance scores as an inverse measure (lower is better).

6. Future Measure Planning

a. Top ranked topics:

i. AKI Avoidance

1. 75% ranked in top 3

2. AKI-01 version with just cardiac open cases?

ii. Postop pulmonary complications avoidance

1. 67% ranked in top 3

2. PUL-02 version with just open cardiac cases?

3. Extubation criteria in import manager would require deeper dive as the

data quality may not be appropriate at all participating sites

iii. Glucose management and hypotension avoidance

1. Both with 42%- ranked in top 3

2. High variation with glucose performance

3. May be challenging to establish thresholds and exclusion periods for

hypotension measures

iv. Glucose variation data shared (Slides 22-24)

7. Goals

a. Build 1 cardiac-specific measure in 2021

i. Post-bypass hypothermia avoidance

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

i. On-bypass hyperthermia avoidance

c. Plan next measure in late 2021

i. AKI Avoidance

ii. PPC Avoidance

iii. Glucose Management

iv. Hypotension avoidance

d. Consensus: Start to evaluate extubation within 6 hours of anes end for Import

Manager sites within the MPOG central database.

8. 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. Late 2021 Meeting: December 2021

ii. Winter 2022 Meeting: February 2022

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

9. MPOG Retreat Registration now available

a. In-person and virtual options available

b. Contact Tory Lacca (lacca@med.umich.edu) with registration questions

Meeting adjourned at 1202