Obstetric Subcommittee Minutes 11.3.21

Obstetric Anesthesia Subcommittee Minutes

November 3, 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

Brendan

Carvalho

Stanford

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

Jackie

Goatley

University of Michigan ACQR

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

Philip

McClarty

Metro Health

Marie-Louise

Meng

Duke

Rebecca

Minehart

MGH

Melinda

Mitchell

Henry Ford - Allegiance

Arvind

Palanisamy

WashU

Denise

Schwerin

Bronson ACQR

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

James

Xie

Stanford

Joshua

Younger

Henry Ford-Detroit

Nirav

Shah

MPOG Quality Director

Kate

Buehler

MPOG Clinical Program Manager

Meridith

Bailey

MPOG QI Coordinator

Tiffany

Malenfant

MPOG Clinical Informatics Specialist

Andrew

Zittleman

MPOG Clinical Informatics Specialist

Victoria

Lacca

MPOG Administrative Manager

A. Announcements:

a. 2022 Meeting Dates

i. February 2, 1pm EST

ii. August 3, 1pm EST

iii. December 7, 1pm EST

b. GA 02-OB and TEMP 05-OB are now released to your OB dashboards

B. August 2021 Meeting Recap

a. BP 04 filtering by neuraxial anesthesia type is available through the “Measure Case

Report Tool”. Please reach out to the coordinating center if you do not have access to

this tool and would like access or if you have any questions about how to download the

reports

b. Subcommittee confirmed interest in a review of unblinded institutional data at a future

meeting

c. Please continue to share your practices around standardization of documentation for

reason to convert to general anesthesia for cesarean delivery cases

d. Provider attribution for GA 01 was discussed- consensus to continue without attribution

e. For TEMP 05 (hypothermia at the end of the case or in PACU), cases will be flagged if

there are not temperatures taken during that time frame per the recommendation of

the subcommittee

C. Glucose Monitoring Measures

a. Background: Sites document labor epidural cases that are converted to cesarean

deliveries two ways:

i. The labor epidural and cesarean delivery are documented as one case. MPOG

labels these as “Conversion (Combined)” Cases

ii. The labor epidural and cesarean delivery are documented as separate cases.

MPOG labels these as “Conversion (Labor epidural portion)” Cases and

“Conversion (Cesarean Delivery portion)” Cases

b. Perioperative glucose measure (GLU 03/04/05) start time for conversion cases

discussion

i. Ron George (UCSF) via chat - continue to exclude labor epidural cases from GLU

measures

ii. Josh Younger (Henry Ford, Detroit)- workflow in LD is scheduled and conversions

to cesarean. Patients who are severely premature on betamethasone will be out

of glucose control. Do we differentiate between these different cohorts?

iii. Sharon Abramovitz/Ashraf Habib/Carlos delgado/Mohamed Tiourirhine/Antonio

Gonzalez/Dan Biggs - agree. Exclude OB patients from GLU measures

iv. For those measures only measuring intraop glucose (GLU 01 and 02). Do we

exclude cesarean deliveries for those cases as well?

1. Josh Younger (Henry Ford, Detroit) - average C-section is 2 hours….so

your surgery is over before you have time to treat or recheck.

2. Wandana Joshi (Dartmouth) - I agree as well. We have limited time

with the patients for the cesarean delivery. The nurses are more

involved with the glucose management than we are involved.

3. Josh Younger (Henry Ford, Detroit) - should also consider the baby

outcomes as well, not just the mom.

4. Ron George (UCSF) - If we open this door in the future it will need to be

very specific to the OB population as a separate series of measures.

c. Conclusion: Consensus from the group to exclude cesarean delivery patients from all

glucose measures (GLU 01-05); can revisit glucose management in the future and will

create OB-specific glycemic management measures if needed

D. Unblinded Data Review: Performance for GA 01 and 02 was shared with the subcommittee- this

was a confidential session; unblinded data was removed from the presentation before posting.

General discussion topics are noted below- any comments specific to a sites performance were

omitted from the minutes.

a. GA 01/GA 02 Review

i. Ron George (UCSF) - Are we able to separate scheduled vs. non-scheduled C-

sections?

ii. Kate Buehler (MPOG) - GA02 gives a glimpse of that but we can look into this

iii. Wandana Joshi (Dartmouth) - SOAPs Center of Excellence recommends an

overall GA rate of 5% or less for cesarean deliveries, whether they are scheduled

or not.

iv. Ron George (UCSF) - The UK world college uses 5% for scheduled and 10% for

non-scheduled/emergent c-sections

v. Mohamed Tiouririne (U.Virginia) via chat - I believe the standard is between 5-

11% all comers (scheduled and urgent/emergent)

vi. General Discussion Topics:

1. Evening/weekend coverage being staffed by the general pool- not OB

anesthesiologists. Could this contribute to higher GA rates? One site

reports this was not the case, instead, about half were cases that fit into

high acuity/fetal tracing.

2. Surgeons not wanting to wait for epidural to take effect. This could lead

to higher GA rates

3. Brandon Togioka (OHSU): There have been some patient reports of

dissatisfaction if GA was not used: could be some liability with patient

satisfaction; with the use of glidescopes and C-MAC now, it may be safer

and okay to use GA in these circumstances

4. All GA cases should be reviewed at an institution level each month by a

committee to determine appropriateness of GA

a. Is there a standard review criterion from SOAP for which

providers can base their review of the GA cases to determine if

they were 'appropriate?' Just wondering if the review is similar

at every site...

5. UCSF is now reviewing all GA 02 cases to determine if failed spinals

were the reason for conversion. This review is identifying opportunities

to improve epidurals/spinal placement and dosing to avoid the need to

convert to GA

6. Cornell is working on standardizing re-dose management of epidurals

and replacing catheters that don’t seem to be working

7. Josh Younger (HF) – Interesting to see if a dedicated OB Anesthesiologist

team makes a difference with GA Rates. (Ron George – 50% call by non-

core OB anesthesiologists at UCSF)

Meeting concluded at 2:01pm