ASPIRE Measures

TEMP 02

June 2021

Holly Lockwood BSN, MBA

Temperature & MPOG SSI Toolkit

• Hypothermia triggers vasoconstriction and subsequent tissue hypoxia which

impairs wound healing.Hypothermia may also impair neutrophil function, reducing

the bodies natural protection against infection

• ASPIRE measures support SSI prevention

• Hypothermia commonly occurs during and after surgery due to impairment of

thermoregulation caused by anesthesia medications and exposure to the cold

environment of the operating room

• Redistribution of body heat from the core to the periphery decreases the core

temperature 1-1.5 degrees Celsius during the first hour of anesthesia.

• After hour one of surgery, core temperature decreases at a slower rate.

• Pre-warming allows the peripheries to warm and decrease the overall impact to

core temperature changes when redistribution occurs.

ASPIRE Measure: TEMP 02

Measure Summary: The percentage of cases where the anesthesia provider documented at least one core

temperature intraoperatively for any patient receiving a general anesthetic.

Core or Near Core Temperature Monitoring Includes:

• Pulmonary Artery Temperature

• Distal Esophageal Temperature

• Nasopharyngeal Temperature

• Tympanic Membrane Temperature

• Bladder Temperature

• Rectal Temperature

• Axillary Temperature (arm must be at patient side)

• Oral Temperature

Inclusions: All surgical patients receiving general anesthesia

Success: Cases with at least one core temperature documented between Anesthesia Start and Patient out of Room.

Responsible Provider: Provider present at induction end

https://mpog.org/files/quality/measures/TEMP-02_spec.pdf

Temp 02 Core Temperature

MPOG Summary of Recommendations: Normothermia

1. Apply active warming to maintain core body

temperature of 36.0 degrees Celsius

2. Surgical patients often experience

hypothermia within the first hour after

induction of general anesthesia due to the

anesthetic induced vasodilation.

3. Maintaining a core temperature below 36

degrees Celsius increases the rate of surgical

site infections

(Allegranzi et al., 2016; Ban et al., 2017; Kurz, 2008; Kurz, Sessler, & Lenhardt, 1996; Sessler, 2016)

Temp 02 Tools

Aim

Initial Values

References

Improving Temperature Monitoring in the OR

A QI Story

Henry Ford Allegiance Health

Holly Lockwood BSN, MBA

Current State

Intervention –Temp 02 Poster & Other Reminders

Strategy to increase awareness by providers

Creation of eye-catching flyer for Temp 02

Posted at key anesthesia locations including

lounges, OR board, inside the OR &

offices/admin areas

Email reminder with flyer attached

Monthly educational emails sent to all anesthesia

providers

Direct observation in OR

Creation of Epic link to ASPIRE dashboard

Next Steps

Abstract

Changes

Barriers

General and neuraxial anesthesia causes vasodilation thus redistributing body heat from the core to

peripheries. This redistribution can cause hypothermia. Core temperatures outside the normal range

pose

significant risks to patients. Pediatric patients are more likely to develop perioperative hypothermia

due to a

high surface area to weight ratio and inability to regulate their own temperature. Published research

has

correlated impaired wound healing, adverse cardiac events, altered drug metabolism, and

coagulopathies

with unplanned perioperative hypothermia. These adverse outcomes resulted in prolonged hospital

stays

and increased healthcare expenditures. The mortality rate is almost 20% higher only monitoring skin

temperature rather than a core temperature for those who experience malignant hyperthermia

during

surgery. Core temperature measurements are less variable than skin temperature measurements and

more accurately represent body temperature..

To understand our current intraoperative anesthetic management of patients for TEMP 02 and

improve core temperature use, ASPIRE (Anesthesiology Performance Improvement and Reporting

Exchange), the quality improvement arm of MPOG (Multicenter Perioperative Outcome Group) has

developed a performance measure called TEMP 02. The measure identifies the percentage of cases

with increased risk of hypothermia that the anesthesia provider documented at least one core

temperature intraoperatively for any patient receiving a general anesthetic. In this report, we found a

prevalence of high risk patients for TEMP monitoring utilizing “skin” temperatures by providers based

on documentation in the chart. Surprisingly, initial utilization/documentation of core temps was

minimal and we encountered initial struggle for improvement. We have shown here that various

strategies to increase provider awareness has made significant progress in implementation of the

guideline.

Temperature 02 Specifications

Success = cases with at least one core temperature documented between Anesthesia Start and Patient out of Room time

or if not available then, Anesthesia End.

Attain a 90% cumulative success rate each calendar year

1. Kim P, Taghon T, Fetzer M, Tobias JD. Perioperative hypothermia in the pediatric population: a

quality improvement project. 2013;28(5):400-406.

2. American journal of medical quality : the official journal of the American College of Medical

Quality. Larach MG, Brandom BW, Allen GC, Gronert GA, Lehman EB. Malignant hyperthermia

deaths related to inadequate temperature monitoring, 2007-2012: a report from the North

American malignant hyperthermia registry of the malignant hyperthermia association of the

United States. Anesthesis and analgesia 2014;119(6):1359-1366.

3. Sun Z, Honar H, Sessler DI, et al. Intraoperative core temperature patterns, transfusion

requirement, and hospital duration in patients warmed with forced air. 2015;122(2):276-285.

Anesthesiology.

4. Insler SR, Sessler DI. Perioperative thermoregulation and temperature monitoring.

Anesthesiology clinics. 2006;24(4):823-837.

5. Sessler DI. Temperature monitoring and perioperative thermoregulation. Anesthesiology.

2008; 109(2): 3-18-338.

Description: Percentage of cases with increased risk of hypothermia that the anesthesia provider

documented at least one core temperature intraoperatively for any patient receiving a general

anesthetic.

Measure Type: Process

Inclusions: All surgical patients receiving general anesthesia

Exclusions:

ASA 5 & 6 cases

Cases with neuraxial anesthesia as the primary technique

Cases with regional anesthesia as the primary technique

Obstetric Non-Operative Procedures & those with procedure text: “Labor Epidural”

Diagnostic Procedures (CPT: 01922)

MRI Rooms, MRI with procedure text: MRI, MR Head, MR Brain, etc.

MPOG/ASPIRE

MPOG (Multicenter Perioperative Outcome Group)

Organizations that are developed and administered

by providers and hospital partners from over 50

institutions from 18 states and 2 countries

Funded in part by BCBS of Michigan

Focus on reduction of errors, prevention of

complications, and improvement of patient

outcomes

ASPIRE (Anesthesia Performance Improvement and Reporting Exchange)

Anesthesiology quality improvement group which was built on infrastructure of MPOG

Governed by the ASPIRE Quality Committee which consists of members of each institution.

Support continuous quality improvement and the development of best practices

Tracks performance and provide incentives

Generation of monthly anonymous

individualized Temp 02 Score Cards for each

provider groups (Senior Staff, CRNAs and

Residents) which includes:

Employee ID numbers

Failed case %

Failed case numbers

Total case numbers

Poster in several locations (Resident, CRNA

break room, etc.) that anesthesia providers

can view and compare their scores among

peers

Email distribution of score cards to each

provider groups

Exploring further interventions with Epic

Despite comprehensive guidelines for temperature monitoring, TEMP 02 remains a frequent problem

in the operative period. Prior to implementation of ASPIRE measures, we were unaware of the

prevalence of effective documentation in our general anesthesia cases.

Our aim was to achieve above 90% cumulative success rate for TEMP 02 patients with general

anesthesia cases as per ASPIRE guidelines. (5/5/21met with March 2021 data= 91% & continues to

increase)

Our aim is to expose current usage of temperature monitoring techniques and use only the core

temperature monitoring Pulmonary Artery, Distal Esophageal, Nasopharyngeal, Tympanic

Membrane, Bladder, Rectal, Axillary (arm must be at patient side), and Oral Temperature.

(5/5/21met with March 2021 data= 91%)

TEMP 02 values for last 12 months (% of success)

Despite our understanding of temperature monitoring in

surgical patients and the existence of established best

practice in our institutions, we made improvement in

2021.

In late 2020 the score was 86%. Great efforts to promote

awareness using educational departmental meetings,

small group sessions (residents, CRNA etc.), &

educational email, we achieved 90% threshold in March

21 and as of June 2021 it is 93% (6/11/21 with May

data). ASPIRE was new 2020 & below threshold.

Outcomes

Need to educate staff regarding the measure & only core temps are acceptable.

Overnight urgent/emergent cases

Documentation issue: simple to note “skin” but often they are using nasopharyngeal probes.

Initial record of TEMP 02 in need

of improvement April 2020

ASPIRE

Introduced

August 2020

Cumulative numbers

for 2020 were 86% &

increased to 90% by

end of the year

June 2021 = 93%

Provider ID Numbers

Provided direct provider emails

with their own scoring and data.

Also shared monthly results of

data after uploads and

cumulative score.

Education provided in meetings and

via boards of change, direct

intervention and meeting with

key stakeholders to improve

methods of monitoring.

Education shared after all

MPOG/ASPIRE large general

meetings.

The temperature monitoring was

implemented in March to view

OR cases and discuss the

approach for monitoring.

Material, posters, flow charts of

data improvement shared to

illustrate changes & positive

improvement.

Education was provided via the

physician QI Champion and

ACQR/Quality RN.

Intraoperative use of temperature

monitoring

Possible removal of the option to chart

“skin” temperature monitoring via IT

Anesthesia.

Provide the appropriate skin probes for the

anesthesia carts.

Support to staff and work with the crew

obtaining supplies.

Group presentation of data & PI project

5/6/21 & presentation of QI project at

ASPIRE collaborative meeting 7/16/21.

Brainstorming solutions/barriers as a team

Thank You!

GLU 03

Measure Description:

• Percentage of cases with perioperative glucose > 200 mg/dL with administration of insulin or

glucose recheck within 90 minutes of original glucose measurement

Measure Time Period:

• Preop through PACU

GLU 03

Inclusions:

• All patients with glucose level greater than 200 mg/dL

• Patients with and without diagnosis of diabetes

Exclusions:

• ASA 5 and 6 cases

• Patients < 12 years of age.

• Glucose measurements > 200 mg/dL within 90 minutes before measure end

• Outpatient cases with Anesthesia Start to Anesthesia end time less than 4 hours long

• Obstetric Non-Operative Procedures

• Labor Epidurals

GLU 03

Success:

• Administration of insulin within 90 minutes

• Recheck of glucose level within 90 minutes

GLU 03- Current Scores

GLU 03- Breakdown of Scores

GLU 03- Actions

• Educated anesthesia providers

on glucose measures (June 21)

• Educated Pre and Postop staff

on glucose measures (May 21)

• Added time glucose was taken

to pre-op handoff sheet

• Analyzed ASPIRE data and

counseled all providers who are

not passing this measure

• Glucose BPA in Epic

o Including a reminder to

treat or recheck glucose

• Health system working on

revising Tier 1 glucose policy

• Continue to analyze ASPIRE data

and counsel all providers who

are not passing this measure

Thank you!

SUS- 01: Low

Fresh Gas Flow

Dr. Jimmy Boutin

Henry Ford Wyandotte

Measure Description:

• Percentage of cases with mean fresh gas flow (FGF) equal to, or less than 3L/min, during

administration of halogenated hydrocarbons and/or nitrous oxide

▪ Indirect measure of gas waste

▪ Measure includes the time between placement of endotracheal tube or supraglottic airway

and removal of the device

▪ Excludes pre-oxygenation and emergence (inspired gas equal to zero)

SUS 01

Rational:

• Halogenated agents and nitrous oxide leaking or vented into the atmosphere are environmental

pollutants. Reducing fresh gas flows can reduce cost of anesthesia without compromising

patient care

Inclusions:

• Administration of anesthetic gases for greater than or equal to 30 minutes

Exclusions:

• Cases in which halogenated hydrocarbons and nitrous oxide are NOT used

• Cases in which maintenance period ˂ 30 minutes

• Cases with ˃ 20% of FGF values manually entered during the case

• Cases in which nitric oxide is administered

Success:

• Mean FGF equal to, or less than 3L/minute when inspired halogenated hydrocarbons is >0.2%, or

nitrous oxide FGF >0.2L/min, during the maintenance period of anesthesia

SUS 01

SUS 01-Current Data

*Data subject to change once inspired agents recorded in Epic

SUS 01- Prior Recommendations

• Recommendations for FGF rates using sevoflurane from the FDA and sevoflurane manufacturers were

made prior to safer CO2 absorbents

• This recommendation was exposure should not exceed 2 MAC – hours at flows 1-2 L/min

• FGF rates less than one not recommended

• CO2 absorbents with strong bases are worse

• 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

SUS 01- Observational Data

Providers were observed for 5 minutes after induction and FGF rates were noted.

SUS 01-Pharmacokinetics of Propofol

• The peak concentration for a bolus dose of propofol is approximately 2 minutes

• At 5 minutes there is approximately slightly less than half the peak concentration

SUS 01- Sevoflurane

• Due to sevoflurane’s low blood-gas coefficient there is a quick onset

• The rate of induction is related to the gas coefficient, pulmonary blood flow, and

minute ventilation

• A study 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%

▪ Appears that in 2 mins at a FGF rate of 3 L/min the inspired concentration is

close to reaching the target.

▪ A FGF rate of 1 L/min takes approximately 8 mins

SUS 01- Sevoflurane

SUS 01- Tips/Actions

• Review this presentation with

all providers –

anesthesiologists and CRNA’s

• Analyze ASPIRE data and

counsel all providers who are

not passing this measure

• When fresh gas flow exceeds the patient’s requirement,

gases and vapors will enter the scavenging system and

into the atmosphere

• Minimizing the total fresh gas flow limits the

environmental impact of volatile agents

• Strategies to mange fresh gas flow

• Turn off the fresh gas flow, not the vaporizer, during

intubation

• Minimize fresh gas flow during maintenance

• Set the vaporizer to deliver a concentration greater

than intended

Tips Actions

Thank you!