Quality Committee Meeting Minutes 5.24.21

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Quality Committee Meeting Notes – Monday, May 24, 2021

Attendees:

Abess, Alex (Dartmouth)

Lacca, Tory (MPOG)

Agerson, Ashley (Spectrum)

LaGorio, John (Mercy Muskegon)

Ahmad, Dennis (Metro Health)

Lewandowski, Kristyn (Beaumont)

Angel, Alan (Bronson Battle Creek)

Liu, Linda (UCSF)

Applefield, Daniel (St. Joseph Oakland)

Lockwood, Holly (Henry Ford Allegiance)

Bailey, Meridith (MPOG)

Loyd, Gary (Henry Ford)

Biggs, Dan (Oklahoma)

Mack, Patricia (Weill Cornell)

Bollini, Mara (Washington University)

Malenfant, Tiffany (Beaumont Trenton/Wayne)

Boutin, Jimmy (Henry Ford)

Mango, Scott (MidMichigan Midland)

Brydges, Garry (MD Anderson)

McKinney, Mary (Beaumont Dearborn / Taylor)

Buehler, Kate (MPOG)

Mentz, Graciela (MPOG)

Charette, Kristin (Dartmouth)

Milliken, Christopher (Sparrow)

Chen, Lee-Lynn (UCSF)

Mockridge, Stacy (Metro)

Clark, David (MPOG)

Mulder, Barb (Borgess)

Cohen, Bryan (Henry Ford Detroit)

Nanamori, Masakatsu (Henry Ford Detroit)

Coleman, Rob (MPOG)

Nurani, Shafeena (Beaumont Troy)

Collins, Kathleen (St. Mary Livonia)

Obembe, Samson (Weill Cornell)

Coons, Denise (Bronson)

Overmyer, Colleen (UChicago)

Cuff, Germaine (NYU Langone)

Owens, Wendy (MidMichigan - Midland)

Cywinski, Jacek (Cleveland Clinic)

Pardo, Nichole (Beaumont)

Davis, Quinten (Mercy Muskegon)

Payne, Gloria (Beaumont Dearborn)

Davies, Eric (HF Allegiance)

Percha, Tina (Beaumont Dearborn)

Dewhirst, Bill (Dartmouth)

Ping Yu, Shao (Weill Cornell)

Domino, Karen (UW)

Poindexter, Amy (Holland)

Doney, Allison (MGH)

Poterek, Carol (Beaumont)

Drennan, Emily (University of Utah)

Pywell, Carol (Beaumont Troy)

Everett, Lucy (MGH)

Qazi, Aisha (Beaumont Troy)

Finch, Kim (Henry Ford Detroit)

Quinn, Cheryl (St. Joseph Oakland)

Gall, Glenn (St. Mary Livonia)

Raty, Sally (MD Anderson)

Goatley, Jackie (Michigan Medicine)

Rubin, Daniel (University of Chicago)

Goorin, Patty (Sparrow)

Ruiz, Joseph (MD Anderson)

Hall, Kathleen (Borgess)

Saffary, Roya (Stanford)

Harwood, Timothy (Wake Forest)

Schonberger, Rob (Yale)

Heiter, Jerri (St. Joseph A2)

Scranton, Kathy (Mercy St. Mary)

Horton, Brandy (A4)

Shah, Nirav (MPOG)

Jeong, Jay (MPOG)

Stewart, Alvin (UAMS)

Johnson, Rebecca (Spectrum & Metro)

Tao, Jing (MSKCC)

Kaper, Jonathan (Beaumont Trenton)

Trummel, John (Dartmouth)

Kenron, Dan (OHSU)

Tyler, Pam (Beaumont Farmington Hills)

Kertai, Miklos (Vanderbilt)

Vachhani, Shital (MD Anderson)

Khan, Meraj (Henry Ford Macomb)

Vaughn, Shelley (MPOG)

Kheterpal, Sachin (MPOG)

Veach, Kristine (St. Joseph)

Koltun, Ksenia (Beaumont Royal Oak)

Vishneski, Susan (Wake Forest)

Wren, Jessica (Henry Ford Wyandotte/Macomb)

Agenda & Notes

1) Roll Call: Will contact QI Champions and ACQRs directly to inquire about participation status if

missing. Other participants can review meeting minutes and contact the Coordinating Center if they

are missing from the attendance record.

2) Minutes from April 22, 2021 meeting approved- minutes and recording posted on the website for

review

3) Announcements & Updates

a) Featured Member May and June 2021 – Dr. Gary Loyd

b) New sites:

i) Metro Health Grand Rapids

ii) Froedtert & Medical College of Wisconsin

4) Upcoming Events

a) ASPIRE Virtual Collaborative Meeting: July 16, 2021

b) MPOG Retreat: October 8, 2021

i) Hopefully in-person but plan to have a virtual option as well

c) Quality Committee Meetings via Zoom

i) Monday, July 26, 2021

ii) Monday, September 27, 2021

iii) Monday, November 22, 2021

5) OB Subcommittee Updates

a) May 5, 2021 meeting slides and minutes on website; 15 members in attendance

b) Neuraxial anesthesia type added to the BP 04 OB Case Report Tool as an additional column

i) Request per subcommittee to enable sites to filter out results by neuraxial type

c) Updating GA 01 (General anesthesia used in cesarean delivery) to highlight cases where

neuraxial anesthesia is documented prior to conversion to GA

d) Plan to create new temp outcome measure (TEMP 05 OB) examining hypothermia in PACU for

cesarean delivery patients

e) If your site is doing any work around standardizing documentation of reason for conversion to

GA for cesarean delivery- please contact the Coordinating Center.

f) Please review the OB dashboard for BP 04 and GA 01. Consider if the results accurately reflect

your practice and if the appropriate cases are being excluded

g) Next OB Subcommittee meeting: April 4, 2021 at 1pm Eastern

6) Pediatric Subcommittee Updates

a) May 19, 2021, meeting slides and recording on website; 33 members in attendance

b) Finalized PONV risk factors for patients 3-17y

i) Females (≥ 12y)

ii) Inhaled anesthetic duration ≥ 30 minutes

iii) Hx of PONV (personal or first-degree relative)

iv) At Risk Surgery (Strabismus, adenotonsillectomy, tympanoplasty)

v) Postoperative long-acting opioids (Administered after Induction)

c) Reviewed TRAN-01 and TRAN-02 measure criteria related to patients < 18y

d) TRAN 01/02 Recommendations

i) 1 ‘unit’ transfused definition = 15cc/kg

ii) Massive Transfusion/blood loss: Total transfused volume (or EBL) of 40cc/kg (updated from

30cc/kg)

iii) Include patients ≥ 6mo. (updated from 2 years)

iv) Exclusions

(1) Cardiac bypass cases (and ECMO)

(2) All obstetric procedures

(3) Revisit Burn case exclusion or refine to TBSA.

v) TRAN 02 Success

(1) If No Hb/Ht checked within 18 hours of Anesthesia End, the case should be flagged for

systematic review

vi) Next meeting August 18, 2021

7) PAIN 02 Measure Update

a) Percentage of patients ≥ 18 years old who receive a non-opioid adjunct preoperatively and/or

intraoperatively (at least one non-opioid adjunct - medication, regional block, neuraxial block, or

local injection). Released to dashboard 5/4/2021

i) Study in April Anesthesiology: https://pubmed.ncbi.nlm.nih.gov/33630043/

(1) Modified measure from originally approved specification by removing dexmedetomidine

from list of non-opioid analgesic medications based on POFA study

(2) Discussion:

(a) Karen Domino (University of Washington): There are a lot of other agents used in

this study such as ketamine and lidocaine. What did the other studies with

dexmedetomidine alone show as far as analgesic effectiveness?

(b) Nirav Shah (ASPIRE Director): Previous studies have shown that dex can function as

an analgesic and many use it as non-opioid adjunct

(i) Karen Domino (University of Washington): Would leave it in until there is more

literature to prove otherwise

(ii) John LaGorio (Mercy Muskegon): Support no change to Dex

(iii) Alex Abess (Dartmouth): recommend continuing to have dexmedetomidine as

an adjunct (don't change the measure based on this study)

(iv) Shafeena Nurani (Beaumont Health System): I agree, it should count as an

analgesic

(v) Conclusion provided by Nirav Shah (ASPIRE Director): Lots of support to continue

dexmedetomidine as analgesic despite this study. Will add back into PAIN 02

measure. Will post to forum when updated on dashboards

8) Measure Review and Vote (Drs. Linda Liu /UCSF; Dr. John Trummel / Dartmouth; Dr. Masakatsu

Nanamori / Henry Ford Health System)

a) TRAN 01 – Click here for Measure Review

i) Literature review: Unable to find a particular hgb/hct value for which transfusion would be

indicated but literature states restrictive transfusion strategies are the gold standard but

there is no literature about how much.

ii) Linda Liu (UCSF): 350 cc/unit definition is not consistent across centers, our cases have failed

at transfusion #4 (MPOG thinks it’s 3.4 units) because we use 300 cc/unit

iii) Masakatsu Nanamori (Henry Ford Detroit): Is it possible to develop exclusion criteria of red

blood transfusion associated with profound or prolonged intraoperative hypotension

requiring a vasopressor use or sign of the end organ damage?

iv) Linda Liu (UCSF): There are considerations made for hemodynamics for C/S patients

(HR>110, SBP<85, DBP<45, or O2Sat <95%) Should there also be considerations for other

surgical patients who are hemodynamically unstable? (ie: where the successive unit is given

without stopping for a hct check)? Or else if 2 units are given within 15-30 minutes, they are

considered as passed based on 1 prior hct/hgb check?

v) Masakatsu Nanamori (Henry Ford Detroit): Consideration for separation of cardiac and

non-cardiac cases?

vi) Discussion:

(1) Eric Davies (Henry Ford Allegiance): Look at the TRAN 02 measure, most sites performing

better than expected so it may indicate that the benchmark is clearly showing it’s not set

correctly and should be set lower.

(2) Linda Liu (UCSF): Workflow is likely different across institutions but at both UCSF and

Henry Ford Detroit, EBL is not charted for cardiac bypass cases so the exclusion of 2L

cannot be applied. These cases are typically included & flagged as anesthesiologists will

document units given but perfusionists document hgb/hct values. Perfusion module is

being added to Epic at some point but not currently available.

(3) Definition of a unit and originally we had all sites submit what they consider a unit and

when we were building the transfusion toolkit, there was a standard of 300ccs per unit.

We may need to revisit how we classify a unit.

(4) Jing Tao (Memorial Sloan Kettering): I think using hemodynamics is a great idea. There

are plenty of cases where blood loss is quick and patients are clearly symptomatically

anemic. These times, abg either takes too long or the clinical picture does not

necessitate abg before transfusion

(5) If there are specific parameters we can use would be helpful but that becomes difficult

across all sites and setting it at 90% may be inappropriate.

TRAN 01 Measure Vote:

Continue as is: (12) 35%

Modify: (20) 59%

Retire: (2) 6%

b) TRAN 02 – Click here to review measure

i) John Trummel (Dartmouth) conducted review of current measure and provided Quality

Committee with a summary of his findings.

(1) Last reviewed June 2018

(2) Literature review: Reviewed prior studies & any new studies published since measure

was first released. Bottom line is that there was not any new literature to suggest that a

liberal policy would be better. Still supports restrictive transfusion strategy.

(3) In summary, do not recommend any changes to this measurement at present. However,

some may view the body of knowledge on perioperative transfusion and conclude there

may be some subgroups of patients (possibly patients with severe cardiac disease

undergoing cardiac procedures and elderly orthopedic patients) for which the benefits of

a liberal transfusion policy outweigh the risks. At this point, there is not evidence to

definitively support this viewpoint and nothing in the literature since June 2018 would

suggest that these patients or any other group of operative patients would benefit from

liberalized transfusion as compared to a restrictive approach.

ii) Based on recommendations from Pediatrics Subcommittee: If No Hb/Ht checked within 18

hours of Anesthesia End, the case should be flagged for systematic review

(1) John Trummel (Dartmouth): would be reasonable to flag these cases

(2) Rob Schonberger (Yale): In the instance that there is hct value of 30 after the last

transfusion and then the next hct value is lower, indicating the patient did continue to

bleed, which value does TRAN 02 use?

(a) Nirav Shah (ASPIRE Director): We take the lowest hemoglobin value

(b) Kate Buehler (MPOG Coordinating Center) via chat: All hemoglobin/hematocrit lab

values drawn after the last transfusion and within 18 hours after anesthesia end will

be evaluated. If the lowest of these values is ≤10g/dL or ≤30%, the case will pass.

(3) Eric Davies (Henry Ford Allegiance): I think failure to check H&H following transfusion

would make a great informational measure.

(a) Germaine Cuff (NYU): Agree with this approach.

(4) Lucy Everett (MGH): Can you clarify - is a separate measure “continue as is” or “modify”?

Separate measure would be to modify

(a) I support the separate informational measure and just wanted to know which way to

vote to accomplish that.

TRAN 02 Measure Vote:

Continue as is: (17) 50%

Modify: (15) 44%

Retire: (2) 6%

c) PONV

i) New guidelines released (Fourth Consensus Guidelines for the Management of

Postoperative Nausea and Vomiting) August 2020- suggesting some significant changes to

existing ASPIRE measure.

ii) New guidelines provide updates to both risk factors and prophylaxis recommendations for

adults and pediatrics

iii) MPOG Pediatric Subcommittee creating new measure for pediatrics PONV prophylaxis

iv) Need feedback from Quality Committee for new adult prophylaxis measure

v) Consider new measure rather than revision to old measure to enable comparison between

two processes and impact on outcome (PONV 03)

vi) Michigan data presented in aggregate form to Quality Committee: PONV 01 improved

between 2018-2020 and yet PONV 03 and PONV 03b scores suggest increased incidence of

PONV in PACU. There are discrepancies between the process and outcome measure as far as

exclusion criteria but still suggests that a potential change to the prophylaxis measure is

needed.

vii) Need feedback regarding:

(1) Risk factors

(2) Inclusions/Exclusions

(3) Success Criteria

(4) Prophylaxis

viii) Proposed Risk factors:

(1) Female sex

(2) Non-smoker

(3) Age < 50 years

(4) At Risk Surgery

(5) Cholecystectomy

(6) Laparoscopic

(7) Gynecological

(8) Hx of PONV or motion sickness

(9) Use of volatile anesthetics and/or nitrous oxide (> 1 hour?)

(10)Use of opioid analgesia - medium and long acting

ix) Next Steps

(1) Create measure specifications

(2) Circulate among Quality Committee for feedback

(3) Review at next Quality Committee meeting (July)

(4) Vote to approve

d) Discussion:

i) Kate Buehler (MPOG Coordinating Center): We need feedback on risk factors, inclusion

criteria, and definition of success

ii) Steve Lins (Bronson Battle Creek): I think PONV was underreported until import manager

was available

iii) Lucy Everett (MGH): Acupuncture or acupressure or both?

(1) Kate Buehler (MPOG Coordinating Center): Both

iv) Germaine Cuff (NYU): If we are discussing acupuncture/pressure, our Peri-op nurses are

using aromatherapy in the holding room through PACU for PONV.

v) Karen Domino (University of Washington): Is dexamethasone and ephedrine on the list?

Please also keep haloperidol.

vi) Amy Poindexter (Holland Hospital): I really like the apples to apples comparison option.

Meeting concluded at 11:02 am