Obstetric Subcommittee Minutes 05.5.21

Obstetric Anesthesia Subcommittee Minutes

May 5, 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

Kim

Finch

Henry Ford

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

Jessica

Wren

Henry Ford

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)

Announcements:

A. Two remaining meeting dates

a. August 4th at 1pm EST

b. November 3rd at 1pm EST

B. GA 01 and BP 04 are now available on the QI Reporting Tool OB Dashboard

C. OB Dashboard in New QI Reporting Tool

a. OB Dashboard - Please reach out with any feedback!

b. Steps to access OB Departmental Dashboard

i. Change ‘Entity’ in upper left corner to your institution

1. The default view when logging in from Provider Feedback Emails is your

own performance on your sites’ selected measures

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

D. February 2021 Meeting Recap

a. GA01 that is now available on OB Dashboard

i. Now available on the OB Dashboard

ii. Platelet information added to the Measure Case Report tool to assist in case

review per request from the committee. Helps identify patients in which

neuraxial anesthesia may be contraindicated

iii. Determining the cause for general anesthesia will need to be completed at the

local level through case review due to limitations with EHR documentation

iv. Standardization of this documentation in the EHR is a possible area for

development in order to capture the data within the measure

v. Future interest Normothermia and PONV for cesarean deliveries

E. OB Anesthesia Phenotype

a. Underpinning of how all the OB measures are developed and helps us understand what

type of OB case a given case is (labor epidural vs cesarean delivery vs conversion vs

cesarean hysterectomy)

b. We are continuing to refine the OB Anesthesia Type Phenotype to find and label

“Cesarean Hysterectomies” (current state is only finding a subset of them)

i. If a patient has a cesarean delivery case followed by a separate hysterectomy

case, should the second case still be considered a “cesarean hysterectomy” by

the phenotype?

1. Example: A patient has a case labeled “cesarean delivery” followed by a

second case within 24 hours labeled as “cesarean hysterectomy” and

coded as a cesarean hysterectomy. How do we classify the second case?

2. Angel Martino-Horrall (Beaumont Health System) - For clarification, how

would a separate case that doesn’t have a cesarean section included in

it be considered a cesarean hysterectomy? Is this literally a separate OR

case or a cesarean case that is followed by a planned or unplanned

hysterectomy at the same time?

3. Rachel Kacmar (University of Colorado) - What I could reason out is if

there is a c-section that goes to the PACU, starts bleeding and then has

to return to the OR, so a hysterectomy that shortly follows a c-section

4. Brooke Szymanski-Bogart (MPOG) - This is what I am seeing in the data,

where the cases are back to back. It is not super common, but we are

trying to figure out how to categorize these cases

5. Carlos Delgado (University of Washington)- We use the term

“peripartum hysterectomy” in that case. A c-hyst is a c-hyst where in the

same procedure you do a hysterectomy, but the other scenario where

the patient has a lot of bleeding and goes back, we would call that a

“peripartum hysterectomy” but we wouldn’t call that a c-hyst because

they are not done together

a. Angel Martino-Horrall (Beaumont Health System) - Agree. To me

this would be outside of what we consider for GA 01

6. Brooke Szymanski-Bogart (MPOG)- We are seeing cases where the

second case has a procedure text of “cesarean hysterectomy” or has

billing codes for cesarean hysterectomies. For these cases, we would not

want to label them as cesarean hysterectomies, correct?

a. Angel Martino-Horrall (Beaumont Health System) - I agree. The

data we are trying to capture is that failed epidural converting to

general or the reason why we are doing general for the c-section

portion, but once you get into the bleeding case where the

patient goes to PACU and then comes back, at that point we are

in a different level of thinking for anesthetics

b. Multiple subcommittee members agree

7. Nirav Shah (MPOG)-In any case, both postpartum hysterectomies and a

cesarean hysterectomy would be excluded from GA 01, so from an

exclusion standpoint we are OK, but from a case labeling perspective

there is an issue, likely because these are emergency cases. We may

want to recategorize these cases within OB anesthesia type as

peripartum hysterectomies.

F. BP 04 Measure review

a. BP 04: Hypotension (SBP <90) during cesarean delivery between neuraxial start and

neonate delivered

i. Variation across sites reviewed. Please see slides for the graph.

1. The scale of the y-axis is from 80-100%. The variation is small across

sites.

ii. Generally high performance across MPOG sites

iii. Measure duration (neuraxial start to neonate delivered) on most cases is

between 25 and 46 minutes, with an average of 33 minutes

b. Data review and discussion of data validity

i. Nirav Shah (MPOG)- The duration seems longer than I remember from my OB

training. Some people before said that they were surprised that they did not see

more hypotension

ii. Ron George (UCSF) - This generally shows the nature of practice now, being

vigilant of hypotension has been standard practice now for a number of years,

so I am not surprised by the data. As for the length, things just take longer now,

things have gotten slower

iii. Ashraf Habib (Duke) - Is this measure for only elective cesareans or all

cesareans?

1. Kate Buehler (MPOG) via chat- Only emergency cesareans with dx of

placental abruption or requiring hyster are excluded. Not all emergency

cases. Exclusions listed here: https://spec.mpog.org/Spec/Public/45

iv. Ashraf Habib (Duke) - Are these only under spinal anesthesia or also epidural? So

topping up an epidural is included here too?

1. Nirav Shah (MPOG) - Any neuraxial technique is included

v. Ron George (UCSF) What is your ‘neuraxial start’?

1. Brooke Szymanski-Bogart (MPOG)- Neuraxial start is based on an

algorithm that looks at the earliest medication given or the time of the

placement notes

2. Ashraf Habib (Duke) - This may explain some of the longer times. I am

not surprised by the data, prophy vasopressor infusions have been

standard practice and this looks reasonable

vi. Niravh Shah (MPOG) - There are only two sites below threshold. This may be

something like our hypoglycemia measures where it is a rare event and so sites

use it to investigate every case that has hypoglycemia. Instead of looking at it as

a performance measure, they look at it as a rare or never event. BP 04 may want

to be treated as such where sites looked into flagged cases as individual events

to see if there was a circumstance where it could have been prevented (ie the

vasopressor wasn't available)

vii. Dan Biggs (University of Oklahoma) - If we would have looked at this 10 years

ago, we would not have seen this good of data. Now everyone is starting

phenylephrine prophylactically and we don’t see hypotension the way we used

to.

viii. Niravh Shah (MPOG) - We will continue to follow this. We review each measure

every 3 years to decide if we want to continue as is, modify it, or retire it. If this

problem becomes very rare than we may consider retiring it in three years even

though we just built it.

ix. Joshua Younger (Henry Ford - Detroit) - For the epidurals and loading the

epidurals and monitoring patients afterwards, this may be an opportunity to

capture the hypotension if it isn’t already in here. There is variation in how

people load their epidurals prior to cesarean (where they do it, etc). At Henry

Ford we click a button that says “epidural to procedure” that marks the end of

when it is being used as a labor epidural and the start of it being used for

cesarean.

1. Nirav Shah (MPOG)- The algorithm that we use to determine that it is a

neuraxial does break them down by epidural vs spinal vs CSE, so we may

be able to use that to stratify down these cases and allow the user to

filter by each of these categories

2. Ashraf Habib (Duke) - I do think there may be value in looking at each

type individually (spinal and CSE together and then epidural on its own)

G. GA 01 - General Anesthesia for Cesarean Delivery: Percentage of cesarean delivery cases where

general anesthesia was used

a. Variation across sites reviewed. Please see slides for the graph.

i. Note: The outlier site with >30% is a known data issue being resolved

ii. Variation: Scores range from around 2-12% for rates for GA

iii. These are not risk or case mix adjusted data

iv. Will require review at the local level to find out the cause for GA

v. The number of cases per month per site is small (around 0-10 cases)

b. Discussion:

i. Wandana Joshi (Dartmouth)- I think there is going to be variation depending on

the facility where the data is coming from. I think in a teaching hospital the

epidural success rate may not be as good as in programs where it is mostly

experienced anesthesiologists. The nature of patients may also be a factor.

ii. Nirav Shah (MPOG) - Some sort of adjustment based on those factors may be

interesting. Similar to BP 04, this may be a relatively rare event that might

warrant review of each case to see if there is a pattern.

iii. Ashraf Habib (Duke) - Do we have the ability to differentiate cases that were GA

from the start vs cases that were neuraxial to GA?

1. Nirav Shah (MPOG) - I don’t think that we can do that with this measure.

Would that be of interest?

2. Ashraf Habib (Duke)- I think it would because it would be a measure of

neuraxial converted to GA for a number of reasons, such as the

neuraxial not working well, could be a measure of how well we are

monitoring epidurals during labor and replacing them if they are not

working well.

3. Ron George (UCSF) - Different centers also have different tolerances of

when to convert and when to push the envelope to get the mom

through the delivery. I think this is where we need to start really talking

about how to capture the reason for why they used GA. You will have

cases that converted in the middle and some that converted before

incision all for the same reason.

4. Josh Younger (Henry Ford Detroit)- A similar question would be ‘what is

your epidural replacement rate’? How many people aren’t getting

adequate analgesia

5. Nirav Shah (MPOG)- Most people on this call are on Epid except

University of Michigan and University of Oklahoma. There is an

opportunity here for standardization if one or two sites have

implemented standard documentation for reason for GA then that build

could very easily be shared. Then, sites without Epic could modify that

build into their own anesthesia systems. If there is something to share,

we would be very happy to disseminate.

6. Ron George (UCSF) - We have been trying to incorporate into the

intraoperative record, but I think ultimately (and I think Stanford does

this too) where all the reasons for GA are captured in a postpartum note

iv. Angel Martino-Horrall (Beaumont Health System)- What is the exclusion criteria

for this measure? I would love to know the true failure rate of neuraxial to GA,

but I also would be interested to know other factors like platelet count would be

helpful in determining if the patient was ineligible

v. Kate Buehler (MPOG)- The only exclusions are non-cesarean deliveries and

cesarean hysterectomies. For the conversions, I think we could tease out who

had a neuraxial and who had a GA with the timing of certain data elements.

Should this be a separate measure or part of GA 01?

1. Ron George (UCSF): A separate measure

2. Dan Biggs (University of Oklahoma)-The most common issue I run into

at my institution is that they rush the case back and I don’t have time to

do a neuraxial or top up an epidural

3. Ashraf Habib (Duke) - this is still an important quality metric because it is

related to good communication on your labor floor regarding patients

who might need to go to the OR rather than waiting until the last

second.

4. Kate Buehler (MPOG) - We will do some analysis on our end and present

it at the next meeting to see what that breakdown would look like and

what we can tease out of the data. We probably can’t tell you who had a

failed neuraxial, but we can probably tell you who had a neuraxial and

then received general anesthesia. You would then need to do some

digging to see the reason why.

vi. Brandon Togioka (OHSU) - I am seeing that our rate is lower than expected and

all cases are being excluded

1. Nirav Shah (MPOG) - This is an important review that sites take a look at

their case lists to make sure that cases are being included appropriately.

Please look with a skeptics eye and let us know if you need any help.

vii. Nirav Shah (MPOG) - If your site has done anything to standardize

documentation of reason for GA, please share it with the coordinating center

and we will bring some examples to the next meeting.

viii. Wandana Joshi (Dartmouth) via chat -I feel that this data is important to define

specifically since SOAP has a specific percentage of patients undergoing general

for cesarean delivery for becoming an OB center of excellence.

H. Cesarean Delivery Case volume by MPOG Site - 1 year

a. Graph of case volume reviewed. Please see slides for details.

b. The number of cesarean deliveries done per year by each site his highly variable (from

about 2,000/year to <200/year)

c. There is large variation in the number of labor epidurals that convert to cesarean

deliveries

I. Hypothermia after Cesarean Delivery – Modify TEMP01/TEMP02/TEMP 03 vs new measure

development discussion

a. This is our opportunity to review the current MPOG measures to see if they are relevant

for the OB population, should be modified, or if more relevant OB measures should be

developed

b. Normothermia in Cesarean Deliveries - SOAP ERAC Guidelines for Normothermia (CLASS

I, Level C, Low-Grade Level of Evidence)

i. Benefits: Reduced SSI risk, shorter LOS, improved neonatal umbilical artery pH

and APGAR scores

ii. Active warming = decreased hypothermia and perioperative shivering

iii. Preferred methods of facilitating maternal-neonatal warming in cesarean

delivery

1. Preoperative patient warming

2. Intraoperative fluid warmer

3. Intraoperative forced air warming

4. OR room temp >72 F (23C)

iv. Bollag L, Lim G, Sultan P, Habib AS, Landau R, Zakowski M, Tiouririne M,

Bhambhani S, Carvalho B. Society for Obstetric Anesthesia and Perinatology:

Consensus Statement and Recommendations for Enhanced Recovery After

Cesarean. Anesth Analg. 2021 May 1;132(5):1362-1377. doi:

10.1213/ANE.0000000000005257. PMID: 33177330.

c. TEMP 01: Percentage of cases where active warming was administered by the anesthesia

provider

i. Inclusion: Cesarean deliveries (general or neuraxial anesthesia)

ii. Exclusion: Labor epidurals

iii. Success: Cases with documentation of an active warming device applied OR

cases with at least one temperature greater than or equal to 36.0°C within the

30 minutes before case end.

iv. For cesarean deliveries, fluid warmers are considered an active warming device

v. Reviewed current TEMP 01 scores filtered to Cesarean Delivery Cases. Please see

slides for the graph.

vi. Discussion: Keep measure as is, modify for OB, or exclude OB patients?

1. Joshua Younger (Henry Ford - Detroit) - This is one of the metrics that

really bothers me as much as I am on labor and delivery. The reason is

not that I am not providing quality care for my patients, it’s that I can’t

get a reliable temperature on the patient during this and getting it at 36.

One of the things we are asked is how it is being measured. Skin

temperature is not adequate but if you are trying an axillary

temperature, their arms are out so I am getting temperatures of 32 or

33 which is obviously not accurate. If a patient’s not wanting a bair

hugger because it's too warm for them or you don’t have a fluid warmer

for every single case, it leaves you little wiggle room for hw not to fail

this measure. We have had discussions around foley temperatures, but

those are expensive.

2. Niravh Shah (MPOG)- This measure accounts for some of that in that it

will take temperatures up until the first PACU temperature if I remember

correctly and it will accept temperatures from any route, unlike the core

temperature measure. This is a lot of the discussion we had years ago

when we tried to convince ourselves that this measure was applicable

to the OB population. The feedback we got was that arms are out or, as

Rachel Kacmar mentioned on the chat, there are a number of patients

that don't want a forced air warmer on them while they are holding

their baby which presents a challenge. We want to make sure we are

capturing the things you are doing in the OR, including fluid warmer and

raising the temperature in the room, and things you think would make

sense for us to capture while taking into account this is a unique

population and context.

3. Joshua Younger (Henry Ford - Detroit)- Is there any evidence that there is

improvement in care or temperature of this population? One thing is to

get an accurate temperature, but how much does that really mean? I

feel like I am never getting an accurate temperature. What are we

protecting with this metric?

4. Ron George (UCSF) via chat - We never measure temperature

intraoperatively during c-sections under regional

5. Rachel Kacmar (University of Colorado) via chat- We also never measure

temperature under neuraxial. We also have a significant portion of

patients who don’t even want a blanket on them, let alone a forced air

warmer.

6. Ashraf Habib (Duke) via chat - We used forced air warming, we are

supposed to measure temperature intraop but we are not consistent

7. Nirav Shah (MPOG)- As an overview, TEMP 01 looks at if you are actively

trying to warm the patient during the case. TEMP 02 is a core

temperature measure. TEMP 02 looks at if you are measuring core

temperatures in patients undergoing general anesthesia and again was

developed for the non-cesarean population. TEMP 03 is our

temperature outcome measure that looks at if a patient is hypothermic

at the end of the case or immediately postop. These are the three

measures that comprise our suite of temperature management

measures in ASPIRE right now. What we are trying to figure out is how

relevant these are to the OB population and take into consideration the

SOAP guidelines and relevant evidence. As you can see in the SOAP

guidelines, these are Class I Level C, so not gold standard randomized

controlled trial where normothermia reduces risk of complications

8. Ashraf Habib (Duke) - The issue with normothermia or temperature

outcomes in obstetric patients is that we don’t really have good data

looking into it similar to what we have in the general surgical population.

It does make sense and we suspect that it does make a difference similar

to what we see in the general surgical population but we don’t have

data for it. There are meta analyses that show active warming does

improve temperature and might improve outcomes. There is sparse data

in the obstetric patient population. I see on the chat that there is

variability in what folks do in terms of active warming or not active

arming and the practicalities of that. So maybe an important metric to

look at would be the temperature in PACU measure. This would be an

important place to see if we have a problem or not. In our practice, we

do use active warming and we thought that we weren’t doing a good

job, and then we looked at our data and were pleasantly surprised with

our PACU data

9. Brandon Togioka (OHSU) - Each of the three temperature measures have

different exclusion in terms of the length of the case

10. Nirav Shah (MPOG) - Measures were built at different times and while

TEMP 03 is an outcome measure, TEMP 01 and TEMP 02 are process of

care measures. For a core temperature perspective, the discussion was

around how short a case would need to be to not require placement of a

temperature probe. The thought was that for any case with GA, you

should place a temperature probe to reduce the risk of surgical site

infections and other potential known issues. This leads us to our

discussion regarding TEMP 03, where many cesarean deliveries are

being excluded from this measure due to the exclusion of cases <60

minutes

d. TEMP 03: Percentage of patients, regardless of age, who undergo surgical or therapeutic

procedures under general or neuraxial anesthesia of 60 minutes duration or longer for

whom at least one body temperature was less than or equal to 36 degrees Celsius (or

96.8 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15

minutes immediately after anesthesia end time

i. Included: Cesarean Deliveries >60 minutes

ii. Excluded: Labor epidurals, cesarean deliveries marked as emergent, cases less

than 60 minutes

iii. Reviewed current TEMP 03 scores filtered to Cesarean Delivery Cases. Please see

slides for the graph. There is wide variation in performance across sites,

although we have not done a further analysis.

iv. Case counts show that many cesarean deliveries across sites that are excluded

currently, likely due to the case being <60 minutes. To make this more relevant,

we may want to include all these cesarean delivery that were done in <60

minutes to provide a more complete picture of what the temperature outcomes

are for this patient population.

v. Discussion

1. Niravh Shah (MPOG) - Does anyone feel otherwise that we should not

change the length of case exclusion? Agreement or disagreement that

we should focus on the outcome (TEMP 03)?

2. Ron George (UCSF)- This is where we should focus and if we see that is is

an outcome problem then we can start to target the need for better

measurement intraoperatively and other warming techniques

3. Niravh Shah (MPOG)- TEMP 02 (core monitoring) is probably the least

relevant for the OB population because there are so few cases where

you have the option to have a core or near core temperature probe on.

There are sites in MPOG that are monitoring their active warming, so we

will continue to have TEMP 01 on their OB dashboard so that those sites

can continue to have that data. Our ask is to view this through your

dashboard and, like we did for BP 04 and GA 01, let us know if this

accurately reflects your practice or if we are potentially over or under

excluding cases

4. Ron George (UCSF)- TEMP 01 may become more useful as we collect

more TEMP 03

5. Brandon Togioka (OHSU) - For TEMP 01, how long do you need to have

active warming in place to get an effect? I wouldn’t want to encourage

people to put one on just to meet the quality metric. Forced air warmers

are also more expensive than foley temperatures. I wonder if there is

any data around that.

6. Ashraf Habib (Duke) - There is no data. The studies that were conducted

say to just use active warming in the OR and during the cesarean

delivery, or preoperative warming, but there is no data as to the

practice.

7. Nirav Shah (MPOG)- TEMP 01 is a yes/no measure that looks to see if

any active warming was used.

8. Brooke Szymanski-Bogart (MPOG)- Sounds like the plan moving forward

is to look at TEMP 03, what kinds of modifications

(inclusions/exclusions) we can make to the measure to make it more

relevant to TEMP 03. This will likely be broken out into its own separate

OB temperature outcome measure. We will work on getting a spec for

this measure and we appreciate subcommittee feedback along the way

e. (Not explicitly discussed during the meeting) TEMP 02: 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.

i. Inclusion: Cesarean deliveries with general anesthesia only

ii. Exclusion: Labor epidurals

iii. Success: Cases with at least one core or near core temperature documented

between Anesthesia Start and Patient out of Room. If not available then,

Anesthesia End.

1. Pulmonary Artery Temperature

2. Zero-Flux Thermometer Temperature

3. Distal Esophageal Temperature

4. Oral Temperature

5. Nasopharyngeal Temperature

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

7. Tympanic Membrane Temperature

8. Rectal Temperature

9. Bladder Temperature