Obstetric Subcommittee Slides 08.4.21

Obstetric Anesthesia Subcommittee Minutes

August 4, 2021

1:00-2:00 pm 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

Jerri

Heiter

St. Joseph Ann Arbor, Chelsea, Livingston

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

Melinda

Mitchell

Henry Ford - Allegiance

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)

Tiffany

Malenfant

MPOG Clinical Informatics Specialist

Andrew

Zittleman

MPOG Clinical Informatics Specialist

Victoria

Lacca

MPOG Administrative Manager

A. Announcements:

a. Two remaining meeting dates

i. November 3rd at 1pm EST

ii. Any interest in an in-person meeting at ASA in October?

1. Poll launched to gauge interest

a. Planning to attend ASA?

i. Yes: 4 (57%)

ii. No: 3 (43%)

b. Interested in an in-person OB meeting?

i. Yes: 5 (71%)

ii. No: 2 (29%)

c. Brooke Szymanski-Bogart

(MPOG OB Program Lead): Will send

details for that event as we get close

d. Wandana Joshi (Dartmouth): Would you do a virtual component

for the meeting at the ASA meeting in October for those of us

who are not attending?

e. Christine Warrick (Utah) - Yes, I would be interested in virtual as

well, given the uncertainty w COVID

f. Nirav Shah (MPOG Quality Director): Something we can

consider as we are doing a hybrid MPOG Retreat. Will follow up

with group after decision is made.

B. May 2021 Meeting Recap

a. Interest in identifying GA 01 cases where neuraxial anesthesia was used before general

anesthesia was used. This has led to the development of a draft measure, GA 02, which

we will discuss during this meeting

b. Interest in being able to filter BP 04 measure results by type of neuraxial used (spinal,

epidural, CSE). We will review the case report tool where this was added

c. Normothermia discussion

i. Committee agreed that the best place to start was with a review of TEMP 03

(hypothermia at the end of the case/PACU). A new measure was developed

based off this feedback (TEMP 05) and will be reviewed

d. Continued discussion regarding standardization of documentation for conversion to

general anesthesia

C. BP 04 - Breakdown by anesthesia type

a. Hypotension (SBP <90) during cesarean delivery between neuraxial start and neonate

delivered

b. Interest at the May meeting to be able to filter cases by anesthesia type

c. This functionality was added to the BP 04 ‘Measure Case Report Tool’

D. Accessing the Measure Case Report Tool

a. Please reach out to support@mpog.zendesk.com

if you do not have access

b. Available on our website under Tools->Quality Case Reports or through the dashboard

i. You will be prompted to log in with your ASPIRE information

ii. Select your institution from the drop down menu (if you have access to

multiple)

iii. Select the date range you are interested in

iv. Select the measures and Pass/Flag/Excluded cases you are interested in

v. Choose ‘Generate Report’ at the bottom of the page

vi. Once report is ready, choose “Download Report”

c. BP 04 Filtering: You will now see a column in the BP 04 Case Report for anesthesia

technique for easy filtering of cases

d. Josh Younger (Henry Ford): The cases in that report are deidentified though right? How

do I look them up in the EHR?

i. Brooke Szymanski-Bogart

(MPOG OB Program Lead): There are a couple of ways

to find the MRN. Can either put each of the MPOG Case ID into the desktop

MPOG Case Viewer (accessible through the MPOG application suite) and can

look up the case that way OR can use the Batch MRN Lookup tool, also

accessible via the MPOG Application suite, which will automatically add a

column for the MRN to the measure case report. Your ACQR can also assist with

this if you don’t have access to the MPOG App Suite. Please contact me with

additional questions.

E. Unblinding the OB Data

a. MPOG allows participants to view unblinded institutional comparison data on select

measures at collaborative meetings yearly

b. Facilitates further discussion and provides additional context to the comparison scores

on the dashboard

c. Would the OB Subcommittee be interested in an unblinded data review once per year?

i. All participants would be required to sign a confidentiality agreement prior to

the meeting

ii. Only active MPOG sites would be able to participate and view the data

iii. We would encourage low/high performers on the OB measures to speak to the

care they provide and current barriers they face

d. Discussion:

i. Brandon Togioka (OHSU): Good idea. Personal experience with our own

measures- we had the lowest score for the ASPIRE BP measure. I do think there

is opportunity with this unblinded sharing for finding process improvements

that leads to collaboration. Not usually an individual provider issue that causes

low institution performance scores- more process issues. Great opportunity for

learning. We can all be collegial and professional with this.

ii. Josh younger (Henry Ford-Detroit): I agree, this would be beneficial. I was at the

data review session during the ASPIRE meeting in July and think it went well.

iii. Ashrab Habib (Duke) - I agree and would be very interested in this. I think it

would give us an opportunity to share best practices and would be very useful.

iv. Nirav Shah (MPOG Quality Director): Anyone with hesitation? Maybe an

organization that may not be ready to implement this.

v. Ami Attali (Henry Ford Health System): Would be a great idea to share

information across sites for how to best improve given limited resources -

collaboration can help utilize resources in the best way.

vi. Nirav Shah (MPOG Quality Director): We will follow up with communication to

the entire subcommittee for feedback before moving forward

F. General Anesthesia Documentation

a. Standardization of documentation for reason to convert to GA

b. Discussion:

i. Ron George (UCSF): Still putting finishing touches on this within Epic for

anesthesia providers to confirm if general anesthesia was used and why. Will

share any updates at an upcoming meeting

ii. Josh Younger (Henry Ford-Detroit): Are there other EMRs that are incorporated

into MPOG other than Epic?

iii. Nirav Shah (MPOG Quality Director): Yes, the majority of MPOG sites use Epic

however we do have a few others (Cerner, Centricity, Compurecord). We will

always support non-Epic sites but the standardization will continue to align with

Epic. For non-epic sites the content will be in MPOG but will be a lot easier for

those who use Epic.

iv. Josh Younger (Henry Ford- Detroit): I think there is opportunity for us to share

these different Epic infrastructure changes across institutions.

v. Nirav Shah (MPOG Quality Director): Easiest way is for Epic to build it into their

foundation system- all sites will receive that infrastructure or update.

c. GA 01 Provider Attribution

i. Percentage of cesarean delivery cases where general anesthesia was used

ii. Currently, this measure does not include provider attribution, meaning that

individual providers are unable to see their cases for review

iii. Should provider attribution be added?

iv. Who should be the attributable provider?

1. The provider signed in at neuraxial start?

2. The provider signed in when general anesthesia was initiated?

v. Discussion:

1. Ron George (UCSF): I like the idea of attribution. I think it has be done at

the start of the case when GA was initiated

2. Nirav (MPOG Quality DIrector): This does add a little more work for the

site QI champion because providers will reach out with questions why

they had a flagged case in their feedback email. The attribution doesn’t

have to be a single provider - it can be multiple providers.

3. Ashraf Habib (Duke): In regards to records, if they have a labor epidural

that was converted to c-section, then anesthesia start is likely at the

start of the labor epidural and may be a different provider than who is

signed in at the time of the c-section (or when GA is initiated).

4. Josh Younger (Henry Ford-Detroit): would have to agree with that. Our

system is similar to that. Is there value to attribute the obstetrician as

well? In my experience how tolerant they are to wait for the epidural or

spinal to start working may vary.

a. Nirav Shah (MPOG Quality Director): We don’t always have the

surgeon name so would be hard to attribute the obstetrician.

5. Brandon Togioka (OHSU) via chat: I agree. I would attribute to the

provider in the operating room at the time of intubation

6. Ami Attali (Henry Ford) (via chat): Agree , should be at the time of

induction of GETA

7. Wandana Joshi (Dartmouth) : I agree that it should be attributed to the

time of general anesthesia. One of the negative parts of attribution is

that if you have a low rate to begin with, you may be pointing fingers at

people. It may be valuable at sites with a high percentage of general to

see if there is a pattern among those who give GA.

a. Nirav Shah (MPOG Quality Director): There are always systemic

issues involved and so you’re right, you’re never going to get it

down to 0%. We could wait to add this to provider emails to

allow OB leaders and the Quality Champion to explain this to

providers at a departmental level to ensure the culture is there

and ready for this.

8. Dan Biggs (U. Oklahoma) via chat: It should be the person signed in at

induction

9. Dan Biggs (U. Oklahoma): It also depends on what kind of practice you

are in. I am in a high risk unit now and may do three GA in a day, but in

private practice almost never. What we are looking for is the percentage

of failed regionals, which will be hard to get until we can extract that.

10. Christine Warrick (University of Utah): I do worry about focusing on the

number for GA rates so much because the other side of avoiding GA is

getting a lot of sedative meds for a poorly neuraxial block which I think

would be interesting to look at as well.

11. Wandana Joshi (Dartmouth): SOAP has a lot of information out there

under their centers for excellence. In general whether you’re at a high

risk academic center, their guideline is that the rate of GA should be <

5%. There is also a lot of literature out there on how to prevent

epidurals from failing.

12. Ron George (UCSF): In the UK great documents on rates of GA whether

they are under emergent or normal conditions.

13. Christine Warrick (Dartmouth): they use less epidurals in the UK as well

and more spinals

14. Ron George (UCSF): That’s another area we can learn from as well!

15. Nirav Shah (MPOG Quality Director): Not sure if there is consensus

around adding provider attribution to this measure yet. If we do decide

to add attribution, the group seems to agree that it should be the

provider signed in at induction or time of conversion to GA but we

won’t move forward with that change yet. We’ll bring this up at a future

meeting to gain consensus around when/if attribution should be added

to GA 01.

d. GA 02: New Measure

i. Description: Percentage of cesarean delivery cases where general anesthesia

was administered after neuraxial anesthesia

ii. Measure Time Period: Anesthesia Start to Anesthesia End

iii. Inclusions:

1. Cesarean Delivery cases where neuraxial anesthesia was used

a. Cesarean delivery cases as determined by the ‘Obstetric

Anesthesia Type’ Phenotype. Phenotype results included:

i. Cesarean Delivery

ii. Conversion (Cesarean Delivery Portion)

iii. Conversion (Labor epidural and cesarean delivery

combined)

b. Neuraxial anesthesia use is determined by the ‘Anesthesia

Technique Neuraxial’ phenotype. Results included:

i. Combined Spinal Epidural (CSE)

ii. Epidural

iii. Spinal

iv. Caudal

v. Neuraxial - unknown type

vi. Neuraxial - multiple types listed

iv. Exclusions:

1. Cesarean hysterectomies as determined by the ‘Obstetric Anesthesia

Type’ phenotype

2. Cesarean delivery cases that only use general anesthesia without

neuraxial anesthesia

3. Non-cesarean delivery cases

v. Success: Cesarean delivery with neuraxial anesthesia completed without use of

general anesthesia

vi. Other Measure Build Details:

1. Use of general anesthesia is determined by the ‘Anesthesia Technique:

General’ phenotype

2. Time of general anesthesia administration is defined as the time of the

earliest flag considered by the ‘Anesthesia Technique: General’

phenotype

3. Use of neuraxial anesthesia is determined by the ‘Anesthesia Technique:

Neuraxial’ phenotype

4. The start time of neuraxial anesthesia is determined by the ‘Obstetric

Neuraxial Anesthesia Start Time’ phenotype.

5. Time of general anesthesia administration is defined as the time of the

earliest flag considered by the ‘Anesthesia Technique: General’

phenotype

6. Cases where ‘measure end’ precedes ‘measure start’ will be excluded

from the measure

vii. Responsible Provider: n/a, departmental only measure

viii. Threshold: n/a information only

ix. Measure performance by site (blinded) was shared with the committee- see

slides 15-17 in the recording or PPT slides

x. Discussion:

1. Ami Attali (Henry Ford Health System): There are a number of factors

that can contribute to conversion from neuraxial to general technique.

One of those reasons may be that the surgeon is not willing to wait for

the labor epidural to be converted to spinal. Would be ideal to capture

these reasons?

2. Nirav (MPOG Quality Director): MPOG doesn’t always have access to

that information - either it isn’t included in the anesthesia

documentation in a standardized form. Often times, this data is stored

as free text on a note. We don’t have a good way of gathering that data

and using it for measure build. UCSF and others are working on

standardizing this documentation and in the future MPOG could use this

data for measures.

3. Ami Attali (Henry Ford Health System): If we talk to Epic about adding a

reason for conversion so we can pull that data and subsequently pull to

review?

4. Nirav (MPOG Quality Director) - Yes. I think Dr. Ron George at UCSF and

others have already started working with their IT teams to build this in.

We can take that information and then share with non-epic sites to help

them gather this data as well.

e. TEMP 05 - OB

i. Description: Percentage of patients who undergo cesarean deliveries under

general or neuraxial anesthesia for whom no body temperature was greater

than or equal to 36 degrees Celsius (or 96.8 F) recorded within the 30 minutes

immediately before or the 15 minutes immediately after the case

ii. Measure Time Period: 30 minutes before ‘anesthesia end’ to 15 minutes after

iii. Inclusions:

1. Cesarean Delivery cases as determined by the ‘Obstetric Anesthesia

Type’ phenotype. Phenotype results included:

a. Cesarean Delivery

b. Conversion (Cesarean Delivery Portion)

c. Conversion (Labor epidural and cesarean delivery combined)

d. Cesarean Hysterectomy

e. Conversion (Cesarean Hysterectomy Portion)

iv. Exclusions:

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

2. Cases with no temperatures during the measure period

v. Success: At least one body temperature measurement equal to or greater than

36 degrees Celsius (or 96.8 degrees Fahrenheit) achieved within the 30 minutes

immediately before or the 15 minutes immediately after anesthesia end time.

vi. Other Measure Build Details:

1. Cases with no temperature measurements within the measurement

period will be marked as flagged - Does this criteria make sense for OB?

a. Brandon Togioka (UCSF) - We have ways of getting this

temperature (foley, etc) in the OR, despite this it isn’t getting

done. Our monitors don’t tend to work well for patients who

are on the cold side. For us, this means that they tried to get a

core temp and it wouldn’t work, meaning that the patient was

too cold. From a QI and patient focus standpoint, we should

continue to flag it and use those cases to try and improve on the

labor floor.

b. Ashraf Habib (Duke) - Is it possible to let people know this is the

reason why it was flagged?

c. Nirav Shah (MPOG) - Yes, we can add that information to the

measure results so that providers know that the temperature

was missing vs hypothermic

d. Ashraf Habib (Duke): I think this would be important- workflow

may vary from institution to institution. Providing information

on not recorded vs. not warm

e. Melinda Mitchell (Henry Ford Allegiance)- We don’t use temp

sensing foleys and have frustrations with axillary temps not

being accurate. It may look bad on the record if the patient has

a low temperature and it isn’t reflective of the core

temperature.

f. Nirav Shah (MPOG Quality Director)- This is why the measure

extends to the PACU so that we can take the oral temperature

taken in PACU into account, as we know it may be difficult in

the OR when the arms are out, etc.

g. Ami Attali (Henry Ford)- Can you share the workflow around the

temperature sending foley?

i. Brandon Togioka (UCSF): Great question- I think it’s

about $10-15 more for foley catheter placement. My

approach was to ask the OB dept to pay for this so it

didn’t come out of the anesthesia budget. These foleys

are placed after labor epidural is placed and you should

know the temp at that point. These patients are high-

risk because they are so exposed. Because this is

important outside of the OR for laboring patients too,

that’s how the OB dept decided to cover this cost.

2. Temperature documented within the postoperative vital sign note in

the anesthetic record or temperatures documented and mapped to the

temperature physiologic concepts are acceptable sources for this

measure.

3. Conversion from F to C: F=32 +9/5 (°C)

a. Artifact algorithm:

i. Less than 32.0°C (89.6F)

ii. Greater than 40.0°C (104.0F)

iii. Any minute-to-minute jumps >0.5°C equivalent.

Example: 0.125°C /15s, 0.25°C / 30s, 1°C / 2mins

Meeting concluded at: 1405 EST