Quality Committee
Meeting
July 26, 2021
Agenda
Meeting Minutes
May 2021
Roll Call – via Zoom or
contact us
Announcements
New Coordinating Center Staff!
Featured Member July and August 2021
Upcoming Events
Friday, September 17, 2021, ACQR Retreat - in person + virtual
Friday, October 8, 2021, MPOG Retreat - in person + virtual
Monday, September 27, 2021, MPOG QC - virtual
Monday, November 22, 2021, MPOG QC - virtual
July Collaborative Meeting Recap
QI Reporting Tool
Have noticed slowness when navigating
through screens
Still working through issues before
adding opioid equivalency dashboards
Have not been able to officially “retire”
old dashboard
We understand this is causing some
challenges and are trying to resolve as
soon as possible
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• ASA - Brain Health Initiative - Mission: to arm anesthesiologists and other clinicians
involved in perioperative care, as well as hospitals, patients and their families caring for
older surgical patients with the tools and resources necessary to optimize the cognitive
recovery and perioperative experience for adults 65 years and older undergoing surgery.
– https://www.asahq.org/brainhealthinitiative
• IHI – Age Friendly Health Systems Initiative - is an initiative of The John A. Hartford
Foundation and the Institute for Healthcare Improvement in partnership with the
American Hospital Association and the Catholic Health Association of the United States.
• It's a movement helping hospitals, medical practices, retail pharmacy clinics, nursing
homes, home-care providers and others deliver age-friendly care.
– https://www.johnahartford.org/grants-strategy/current-strategies/age-friendly/age-friendly-health-sy
stems-initiative
• ACS – Geriatric Surgery Verification Program - Developing surgical standards (2 of
which are optional) designed to systematically improve surgical care and outcomes for
the aging adult population. The standards provide a framework for hospitals to take an
interdisciplinary approach to continuously optimize surgical care for older adults.
– https://www.facs.org/quality-programs/geriatric-surgery
Geriatric ASPIRE Measures
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Suggested Measures
• Percent of patients age >80 undergoing non-cardiac GA who
received a benzodiazepine from anesthesia start to anesthesia
end.
• Percent of patients age >80 undergoing GA with ETT who
received more that 1.5mg/kg of single propofol dose for
induction.
• Percent of patients age >65 without preoperative hypotension
undergoing GA fro non-cardiac surgery who had episode of
MAP<55mmHg within 15 minutes of induction.
• The use of rescue Sugammadex following full reversal by
neo/glycol.
MPOG
Delirium
Data
Background
● UCSF, Dartmouth-Hitchcock, and other sites have expressed interest in using MPOG data to
evaluate cognitive function and postoperative delirium
● Ad hoc group met to discuss goals of the work and limitations of the data
○ Brooke Szymanski-Bogart (MPOG)
○ Kate Buehler (MPOG)
○ Lee-Lynn Chen (UCSF)
○ Alexander Abess (Dartmouth-Hitchcock)
○ Anne Donovan (UCSF)
○ Stacie Diener (Dartmouth-Hitchcock)
○ Linda Liu (UCSF)
○ Elizabeth Whitlock (UCSF)
○ Phil Vlisides (UM)
○ Nirav Shah (UM/MPOG)
○ Sachin Kheterpal (UM/MPOG)
● MPOG data analyzed through variable mapping spreadsheets and common unmapped
variables across sites summarized
● New MPOG concepts associated with delirium created as needed
New concepts related to Preoperative Screening
● Clock-Drawing Test - Score (3196)
● Clock-Drawing Test - Numbers (3197)
● Clock-Drawing Test - Hands (3201)
● Clock-Drawing Test - Hour Markers (3203)
● Clock-Drawing Test - Face (3204)
● Clock-Drawing Test - Comments (3206)
● Clock-Drawing Test - Time (3207)
● Clock-Drawing Test - Numbers Clockwise (3208)
● Clock-Drawing Test - Indicates Target Time (3209)
● Clock-Drawing Test - Clock Divided by 12 (3211)
● Clock-Drawing Test - Contour (3216)
● Clock-Drawing Test - Details (3217)
Clock Drawing - The patient is asked to draw a clock showing a certain time. Used as a screen for cognitive
impairment and dementia
https://www.verywellhealth.com/the-clock-drawing-test-98619
Preoperative Screening - Mini Mental Status Exam
Cognitive function test measuring
orientation, attention, memory, language,
and visual-spatial skills
● Mini-Mental State Exam Score (3218)
● Mini-Mental State Exam Details (3219)
http://www.fammed.usouthal.edu/Guides&JobAids/Geriatric/MMSE.pdf
Preoperative Screening - Mini-Cog
Used to detect cognitive impairment
and consists of a 3-item recall test
and a clock drawing test
● Mini Cog Assessment
Score (3221)
http://mini-cog.com/wp-content/uploads/2018/03/Standardized-Englis
h-Mini-Cog-1-19-16-EN_v1-low-1.pdf
Preoperative Screening - Montreal Cognitive Assessment
MoCA - 30 item, 10 minute assessment of 8 cognitive domains
● Montreal Cognitive Assessment (MoCA) - Details (3222)
● Montreal Cognitive Assessment (MoCA) - Score (out of 30) (3223)
● Cognitive Screening: MoCA Total Score (3224)
● MoCA:Delayed Recall (how many words did patient recall) (3226)
● MoCA: Read the list of 5 words for the patient to remember (3227)
● MoCA: Oriented to Year? (3228)
● MoCA: Oriented to Place? (3229)
● MoCA: Oriented to Month? (3231)
● MoCA: Oriented to Day? (3232)
● MoCA: Oriented to Date? (3237)
● MoCA: Oriented to City? (3241)
● MoCA: Fluency: Name as many words that start with the letter "F" that you
can (1 min) (3242)
https://www.sciencedirect.com/topics/nursing-and-health-professions/montreal-cognitive-assessment
● Confusion Assessment Method (CAM) Altered LOC (3243)
● Confusion Assessment Method (CAM) Disorganized Thinking (3244)
● Confusion Assessment Method (CAM) Inattention (3246)
● Confusion Assessment Method (CAM) Acute Mental Change and Fluctuating Course (3247)
● Confusion Assessment Method (CAM) Overall CAM-ICU Score (3248)
● Confusion Assessment Method (CAM) Overall CAM-ICU/Short CAM Score (3249)
● Confusion Assessment Method (CAM) Overall CAM-ICU Modified Score (3251)
Delirium screening tool that assesses for acute onset mental
change/fluctuating course, altered LOC, disorganized
thinking, and inattention
Postoperative Assessments - CAM
https://www.researchgate.net/figure/Diagnosis-of-delirium-by-CAM-ICU-
CAM-ICU-confusion-assessment-method-for-the-intensive_fig2_2763386
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Postoperative Assessments - Cornell Assessment Pediatric Delirium
● CAPD - Cornell Assessment of Pediatric Delirium Result (3252)
● CAPD - Does the child make eye contact with the caregiver? (3253)
● CAPD - Are the child's actions purposeful? (3254)
● CAPD - Is the child aware of his/her surroundings? (3256)
● CAPD - Does the child communicate needs and wants? (3257)
● CAPD - Is the child restless? (3258)
● CAPD - Is the child inconsolable? (3259)
● CAPD - Is the child underactive-very little movement while awake? (3261)
● CAPD - Does it take the child a long time to respond to interactions? (3262)
Pediatric Delirium
Other Suggested Assessments
● Unable to find variables for these in available data
● MPOG data is limited to 4 hours before anesthesia start to 6 hours after
anesthesia end
● If you would like concepts to be created for the screening tool at your site,
please contact the coordinating center for discussion
AWOL-S, AD8, 4AT
Mapping to the Delirium Concepts
1. Run ‘Content Synchronization’ on your app suite if not up to date
2. Use ‘Variable Mapper’ and map to these concepts under the ‘Observation
Type’ or ‘Observation Detail Type’ categories
3. Once mapped, these concepts will appear in the physiologic section of Case
Viewer
Next Steps
Consider incorporating these
assessments into practice (Sites)
Analyze concept fill rates
(Coordinating Center)
Informational Measures (MPOG QC)
Research Projects including surveys,
observational analyses, etc (PCRC)
Quality Improvement Initiatives
% of patients are being
screened preoperatively for
cog impairment or frailty”
% of patients are being
screened postoperatively
for delirium
Standardized
Data File
Mike Mathis
MPOG research process challenges and progress
• Adjusting research passion to data available in
MPOG
• Postoperative outcome data limited to mortality,
ICD10 discharge diagnoses, lab results
• Understanding what is and is not possible with
MPOG data
• Iterative, detailed data query specification and
query process
• Time between ideation to data ready for analysis
can be many months to years
• DATADirect Self-serve access for local data and
multicenter cohort ID maturing
• Most centers use data for quality improvement, so
data validation robust and continual
• Hundreds of patient, process, and outcome
phenotypes available
• Deep understanding of data quality for existing
phenotypes
• Research facilitation process
2017 Strategy: We’re building 200+ Legos
• Data common to many different
research and QI projects
• Data specific to a project, but helpful
in the future
• Making “technics” not “duplos”
• Organizing them is real work
2021 Strategy: Time to make the Lego Millennium Falcon
• Combine the building blocks into a
usable product
• Standardized data file composed of
mature phenotypes
• Released every 6 or 12 months
• Available on MPOG stats server
immediately upon PCRC proposal
approval
• No data query specification or iterative
query process
• What kind of Falcon we talking about?
Standardized Data File Spec
• Some “flat and wide” data
– Deidentified center and provider IDs
– Patient and case characteristics
– Patient demographics & anthropometrics Patient comorbidities (Elixhauser)
– Surgery info Anesthesia technique & base CPT
– Case timed events (anes start, surgery start) Preop labs
– Clinical summary (fluids, hypotension, ventilator parameters, vasopressor totals)
– “Clean” outcomes (AKI, mortality, MI)
– ASPIRE quality metrics: to be discussed with Quality Committee
• A few tall skinny tables
– ICD10 diagnoses, CPT
– Medication totals?
• Specification for your commentary via google docs
Appropriate expectations
CAN do with a standardized file
• Focus on mature, common clinical
exposures (hypotension, common
medications, anesthesia technique,
processes of care)
• Explore variation in processes of care,
prediction indices
• Use any of the several hundred existing
phenotypes
• Build ad-hoc queries with a more
robust, automated foundation
CAN’T do with a standardized file
• Use the most recent data from just a
few months ago
• Explore novel exposures not currently
codified or validated in MPOG
phenotypes
• Use raw underlying data to define new
outcomes or exposures
• Integrate across emerging MPOG
sources (NSQIP, STS, CMS, etc)
Assumptions
• Standardized file only available to contributing MPOG centers (just like NSQIP PUF)
• 2021 File is based upon currently (ie, 2021) available phenotypes or those easily created
• File is placed on MPOG stats server and made available to PCRC approved research team
• Descriptive statistics & documentation available from day 0
• PCRC review process still applies but may be expedited / streamlined
– Electronic review / voting only since data quality discussions at PCRC unnecessary
– PI may request a full presentation at PCRC for scientific contribution
– Some projects may be “standardized data file”+ a few custom elements; full PCRC presentation required
Measure
Updates
& Feedback
PAIN 01 and 02 Provider Attribution Proposal
PAIN 01 - Administration of non-opioid adjuncts in pediatric population
PAIN 02 - Administration of non-opioid adjuncts in adult population
Responsible Provider:
Option 1: Providers signed into case at induction
Option 2: Providers signed into case for longest duration
Option 3: Providers signed into case at emergence
Option 4: All of the above
Option 5: Continue with no provider attribution
Will decide with ranked choice voting - sent out after meeting
GLU 03/04/05: Provider Attribution Added
GLU 03 - Hyperglycemia managed by Insulin or recheck of glucose
GLU 04 - Hypoglycemia managed by dextrose or recheck of glucose
GLU 05 - Management of Hyperglycemia with Insulin
Responsible Provider
● Preop Time Period (preop start through anesthesia start): first providers
signed into the case
● Intraop Time Period: The provider signed in at the first glucose recheck or
first administration of insulin/dextrose. If neither occurred, then the
responsible provider is the one signed in 90 minutes after the high glucose
measurement.
● Postop Time Period (anesthesia end through PACU End): The last providers
signed into the case
GLU 03/04 Bug
● Error uncovered that was causing the measures to exclude high/low glucose
values at the beginning (preop) and end (PACU) of the measurement period.
● Resolving this error has resulted in the change in score performance for some
sites
● Scores updated on dashboard
● Sites with largest changes contacted in advance
TEMP 03 - Temperature Outcome Measures (≤ 36.0 C at
end of case)
TEMP 03 was an MPOG QCDR measure and it assigns an 'Incomplete' when there is
no temperature recorded, per alignment with the MIPS measure
TEMP 03 is the only measure that has the 'Incomplete' result and it is not compatible
with our measure framework
Since we do not participate as a QCDR anymore, we changed Incomplete to Flagged
No material change in performance across sites
Thank You!
