Obstetric Subcommittee Minutes 02.3.21

Obstetric Anesthesia Subcommittee Minutes

February 3, 2021

1:00-2:00pm EST - Zoom

First Name

Last Name

Institution

Sharon

Abramovitz

Weill-Cornell

Aymen

Alian

Yale

Ami

Attali

Henry Ford-Detroit

Dan

Biggs

University of Oklahoma

Traci

Coffman

St. Joseph Ann Arbor

Eric

Davies

Henry Ford- Allegiance

Carlos

Delgado Upegui

University of Washington

Ghislaine

Echevarria

NYU

Ronald

George

UCSF

Antonio

Gonzalez-Fiol

Yale

Ashraf

Habib

Duke

Jenifer

Henderson

St. Joseph Oakland

Wandana

Joshi

Dartmouth

Rachel

Kacmar

University of Colorado

Tom

Klumpner

University of Michigan

Joanna

Kountanis

University of Michigan

Stephanie

Lim

UCSF

Angel

Martino-Horrall

Beaumont Health System

Marie-Louise

Meng

Duke

Arvind

Palanisamy

WashU

Carlo

Pancaro

University of Michigan

Monica

Servin

University of Michigan

David

Swastek

St. Joseph Ann Arbor

Mohamed

Tiouririne

UVa

Brandon

Togioka

OHSU

Christine

Warrick

University of Utah

Joshua

Younger

Henry Ford-Detroit

Nirav

Shah

MPOG Quality Director

Kate

Buehler

MPOG Clinical Program Manager

Meridith

Bailey

MPOG QI Coordinator

Brooke

Szymanski-Bogart

MPOG QI Coordinator (OB program lead)

1. Announcements

a. 2021 Meeting Dates

i. May 5,

20201 1-2pm EST

ii. August 4, 2021 1-2pm EST

iii. November 3, 2021 1-2pm EST

b. Obstetric Anesthesia Type phenotype completed!

i. Is able to identify scheduled cesarean delivery cases vs. labor epidural vs.

conversion cases

2. October 2020 Meeting Recap and Follow-up

a. BP 04 Prolonged hypotension measure update and discussion

b. GA 01 General Anesthesia for Cesarean Delivery Measure

i. Unable to capture reason for GA in MPOG Data

ii. Will require review at the local level

iii. Number of cases per month is small for review

c. OB Dashboard released: Please reach out with feedback

i. Steps to access OB Departmental Dashboard

1. Change entity in upper left corner to your own institution

2. Choose ‘Dashboards’ then ‘Obstetric’ from banner along the top

ii. Wandana Joshi (Dartmouth): What OB specific measures are included on the

dashboard currently? Is it just ABX 01 currently or is the blood pressure measure

also available?

1. Brooke Szymanski-Bogart (MPOG): Just ABX 01 currently but BP04

should be available in the next couple of weeks after we finish validating

3. ABX 01 Provider Attribution Discussion

a. ABX 01: Percentage of cesarean deliveries with documentation of antibiotic

administration initiated within one hour before surgical incision

b. Currently does not have provider attribution

c. Which providers should be notified/listed in association with the case (if any)?

i. Angel Martino-Horrall (Beaumont Health System): Think it would be nice to add

provider attribution to this existing measure as long as we can also still see

departmental performance

1. Nirav Shah (MPOG Quality Director): Yes, will still be able to see

departmental performance for this measure on the dashboard in

addition to individual provide performance

ii. Wandana Joshi (Dartmouth): Our institution used to get data by provider for

P4P measures and it reminds providers where they are on the spectrum in

practice/performance. Really only valuable at the provider level.

iii. Aymen Alian (Yale): Should add provider attribution; in our institution, we share

this information with providers to motivate them to improve to be in line with

their peers

iv. Brandon Togioka (OHSU): Agree with adding provider attribution

v. Monica Servin (Michigan Medicine): Does ABX 01 account for emergency cases?

1. Kate Buehler (MPOG): Yes- looks for an antibiotic to be administered

within one hour before incision through anesthesia end for emergency

cases

4. BP 04 Prelim Data Review

a. Final validation in progress

b. Current performance shows little variance in scores with all sites performing between

90-100%.

i. Subcommittee Discussion: Wonder if this is accurate- score seem too high

ii. Brandon Togioka (OHSU): Is this measure looking at 5 minutes of hypotension as

the thresold?

1. Brooke Szymanski-Bogart (MPOG): That’s correct.

iii. Brandon Togioka (OHSU): What is the average time before neuraxial start?

These scores look too high to me

1. Brooke Szymanski-Bogart (MPOG): I will look into it with my next round

of case review and post to the forum

iv. Wandana Yoshi (Dartmouth): I wonder how many centers are using prophylactic

phenylephrine infusion after the spinal

1. Sharon Abramovitz (Weill-Cornell): All elective cases are hanging

prophylactic phenylephrine infusion at our institution

v. Aymen Alian (Yale): Consider monitoring gaps in blood pressure or duration of

minutes of continuous hypotension. We sometimes just do BP measurements

manually

1. Nirav Shah (MPOG Quality Director): If you do BP manually do you put it

into Epic?

2. Aymen Alian (Yale): Yes, we manually put it into EPIC and note that it is

manual because of ‘shivering issue’

c. BP 04 will be available on departmental level OB Dashboards soon!

5. GA 01 Measure spec discussion

a. Description: Percentage of cesarean delivery cases where general anesthesia was used

b. Measure Time Period: Anesthesia Start to Anesthesia End

c. Inclusions: All cesarean delivery cases (scheduled or conversion)

d. Exclusions:

i. Cesarean hysterectomies – Keep exclusion?

ii. Non-cesarean delivery cases

iii. Add any more exclusions?

iv. Brandon Togioka (OHSU): Any coagulopathy exclusions yet based on platelet

count?

1. Nirav Shah (MPOG Quality Director): Not currently but we could add

this. Could add platelet count to the measure case report details to

allow review

2. Ron George (UCSF): Wouldn’t exclude those patients but would want to

know which patients had coagulopathies: neuraxial anesthesia was

contraindicated and therefore defaulted to general

3. Nirav Shah (MPOG Quality Director): Could standardize approach for

documenting reason for conversion to GA if this group is interested in

drafting those recommendations. Cycle time to get these changes

implemented could take some time but in the end, could help with

allowing MPOG to capture and measure the reason for conversion to GA

a. Ron George (UCSF): Our IT team is working on this now. Could

share with this group when finalized. A lot of it stems from

institutions where you’re using the same LD encounter for

cesarean delivery and that the anesthesia type isn’t clarified.

Putting a stop in the record to ensure you’ve documented the

anesthetic type would help with capturing this data.

b. Angel Martino-Horrall (Beaumont Health System): Agree would

be really interesting because under that you would have to

choose anesthesia types. I’m very interested in that if you could

share data on how you did that with your IT team. Converting to

an epidural to GA due to failed epidural would be helpful. I

thought that was our original goal with this measure?

c. Nirav Shah (MPOG Director): We cannot tease that out from the

MPOG data currently. We can determine if a GA was performed

but figuring out WHY is harder. It’s not documented in a

standardized way currently which is why we can’t create this

measure yet.

4. Wandana Joshi (Dartmouth): Looking at this topic came from my

interest in SOAP centers of OB excellence. They differentiate between

primary cesarean deliveries and those converted to general. What we

should capture is those as a result of failed epidural. What I’m hearing is

that we need to standardize this with Epic or the anesthesia record at

sites to be able to capture this reason.

a. Nirav Shah (MPOG Director): That is correct. Sounds like the

work at UCSF may be able to help us here.

5. Ron George (UCSF): That will be part of the data that we capture. The

reminder that if you do change anesthetic types that will pop up to

identify that. Part of an ongoing process so patients can see 1 hr within

the epidural what the primary reason was for failure and ongoing

assessment tool. Just rolled out this month. Cesarean hysterectomies

would be excluded but what about those that do not get a

hysterectomy? Occasionally we all have imaging that points in the

wrong direction, administer general anesthesia and the placenta ends

up falling out and patient keeps their uterus

a. Nirav Shah (MPOG Quality Director): We may be able to figure

that out with billing codes

6. Kate Buehler (MPOG): This measure will filter down to those that were

converted to a general (scheduled or conversion). Up to sites to do

manual review of those cases and decide what areas to focus on for

improvement. Agree- somewhat of a clunky, manual process right now

because we don’t have standardized documentation across sites but is a

good place to start until we can create a more refined measure in the

future

v. Wandana Yoshi (Dartmouth): How do you tease out if the case was a GA?

vi. Brooke Szymanski-Bogart (MPOG): Identified using our GA phenotype which

specifically looks at airway placement + inhalational gas administered +

paralytics.

e. Success: Cesarean delivery completed without use of general anesthesia

f. Responsible Provider: Which providers should be notified/listed in association with the

case?

g. Threshold: Should a success threshold be added to this measure?

6. 2021 Planning Survey Results and Next Steps

a. 9 responses – Thank you!

b. Interest from the committee for measures on these topics:

i. PONV in PACU following cesarean delivery (67% very important)

ii. PONV Prevention (antiemetics administered)

iii. First temp in PACU following cesarean delivery (56% very important)

iv. Non-opioid adjunct for cesarean delivery (44% very important; 33% extremely

important)

v. Several write-in measures also added (See slide 12 for topics suggested)

c. Several suggested measure topics align well with SOAP ERAC elements:

i. PONV (Prevention or in PACU)

1. Sharon Abramovitz (Weill-Cornell): We have an ERAC protocol but I

don’t think it mentions in there when to give an antiemetic in relation to

when the baby is born. Do most sites wait until delivery to administer

ondansetron or given at the beginning of the surgery? When do other

centers administer ondansetron and dexamethasone?

a. Wandana Yoshi (Dartmouth): We give at the beginning of

surgery

b. Monica Servin (Michigan Medicine): We give both ondansetron

and dexamethasone at the beginning of the case at Michigan

Medicine

c. Brandon Togioka (OHSU): Not standardized- do give two agents

but just depends on when provider decides to administer

d. Dan Biggs (University of Oklahoma): Give ondansetron in preop

with azithromycin

e. Ron George (UCSF): Give metoclopramide preop and

ondansetron after the case

ii. First temp in PACU following cesarean delivery: Could be modification of TEMP

03 (Existing adult MPOG measure) or could create a new TEMP 05 (OB) measure

that includes cesarean delivery; current measure excludes cases less than 60

minutes in length

iii. Non-opioid adjunct for cesarean delivery

d. Existing related MPOG measures include:

i. TEMP 01: Percentage of cases that active warming was administered by the

anesthesia provider

1. Cesarean deliveries are included

2. Labor epidurals are excluded

3. Success: documentation of an active warming device (including fluid

warmer for CD) OR temp ≥ 36.0 within 30 minutes before case end

ii. TEMP 02: Percentage of cases with at least one core temp documented

intraoperatively for any patient receiving a general anesthetic

1. Cesarean deliveries included, but this measure is limited to only those

that received general anesthesia

2. Cases <= 30 minutes are excluded

3. Ayman Alian (Yale): What kind of temp probe are you using: bladder,

cutaneous, axillary, in epidural/spinal CD cases?

a. Brandon Togioka (OHSU): All labor epidurals and cesarean

deliveries are going to start using foley catheter probes moving

forward – should improve our temp outcomes

b. Angel Martino-Horrall (Beaumont Health System): Are skin

temps excluded or do they fail for TEMP 03?

c. Nirav Shah (MPOG Quality Director): Will need to check

measure spec again but I don’t believe skin temps are included

for the current temperature outcome measure

d. Correction: Skin temps are reviewed for TEMP 03 and if the

temperature is >36.0 degrees Celsius during the measure time

period, the case will pass. Spec is available here.

iii. TEMP 03: The percentage of cases with hypothermia (< 36) within 30 minutes

before or 15 minutes after anesthesia end

1. Limited to cases >60 minutes in duration

2. Excludes labor epidurals and labor epidurals converted to cesarean

deliveries

iv. PONV 01- The percentage of cases with appropriate antiemetic administration

for postoperative nausea and vomiting prophylaxis

1. Inclusions: patients receiving inhalational general anesthesia with three

or more risk factors for PONV

2. Include cesarean deliveries, but is limited to only those that received

inhalational general anesthesia

v. PONV 03- Percentage of patients who undergo a procedure and have a

documented nausea/emesis occurrence OR receive a rescue antiemetic in the

immediate postoperative period.

1. Includes cesarean deliveries

2. Excludes labor epidurals

3. Modifications for OB?

vi. Which measure is the top priority for development in 2021?

1. “PONV 04- OB” PONV in PACU

a. Include antiemetic administration as criteria for flag?

b. Merge into PONV 03?

vii. “PAIN 02 – OB” Multimodal analgesia for cesarean deliveries

Meeting adjourned at 1406