Obstetric Anesthesia Subcommittee Minutes

February 2, 2022

1:00-2:00 pm EST - Zoom

First Name

Last Name

Institution

Ami

Attali

Henry Ford-Detroit

Dan

Biggs

University of Oklahoma

Laurie

Chalifoux

Spectrum

Kathleen

Collins

St. Mary Mercy Livonia

Carlos

Delgado Upegui

University of Washington

Kim

Finch

Henry Ford

Daniel

Grutter

St. Joseph Mercy Ann Arbor

Ashraf

Habib

Duke

Meridith

Bailey

MPOG QI Coordinator

Kate

Buehler

MPOG Clinical Program Manager

Jerri

Heiter

St. Joseph Ann Arbor, Chelsea, Livingston

Rebecca

Johnson

Anesthesia Practice Consultants

Wandana

Joshi

Dartmouth

Rachel

Kacmar

University of Colorado

Tom

Klumpner

University of Michigan

Victoria

Lacca

MPOG Administrative Manager

Tiffany

Malenfant

MPOG Clinical Informatics Specialist

Angel

Martino-Horrall

Beaumont Health System

Rebecca

Minehart

MGH

Melinda

Mitchell

Henry Ford - Allegiance

Ronnie

Riggar

MPOG Admin Assistant

Denise

Schwerin

Bronson ACQR

Monica

Servin

University of Michigan

Nirav

Shah

MPOG Quality Director

Preet

Singh

Washington University

Jessica

Wren

Henry Ford

Joshua

Younger

Henry Ford-Detroit

Andrew

Zittleman

MPOG Clinical Informatics Specialist

A. Announcements:

a. 2022 OB Subcommittee Meeting Dates

i. August 3, 1pm EST

ii. December 7, 1pm EST

b. MPOG Retreat in New Orleans, LA: October 21, 2022

B. November 2021 Meeting Recap

a. Reviewed unblinded site performance for ‘general anesthesia in cesarean delivery’

measures (GA 01/02)

i. Subcommittee expressed interest in separating elective vs. non-elective

cesarean cases

ii. MPOG can separate ASA ‘E’ cases but not necessarily indicative of elective vs.

non-elective

iii. Many non-elective c-sections do not have an ‘E’ assigned

iv. SOAP Centers of Excellence recommends reviewing cases that converted to

general anesthesia at an institutional level

v. Follow-up question: Would there be interest in developing a list of

considerations for reviewing these cases at your sites?

1. Conclusion:

a. Dr. Habib mentioned that Duke has a standard list of criterion

they use and he would be willing to share with the Coordinating

Center

b. Subcommittee discussed applicability of existing ASPIRE glycemic management

measures for the OB population

i. Subcommittee recommended excluding cesarean deliveries from all glucose

measures (GLU 01-05)

ii. After reviewing cases, Coordinating Center proceeded with excluding cesarean

deliveries from hyperglycemia measures (GLU 01/03/05) as this is typically

managed outside of the OR by obstetrician and nursing

iii. However, we opted to continue to include cesarean deliveries for hypoglycemia

measures (GLU 02/04) at this time due to potential opportunity to improve

health system processes (outside of OB).

iv. Plan to revisit with Quality Committee & see if attribution might be removed for

obstetric anesthesiologists in the future

C. PONV 05: Obstetric Considerations

a. New Proposed Adult Prophylaxis Measure- PONV 05: Percentage of patients, aged 18

years and older undergoing a procedure with appropriate prophylaxis for postoperative

nausea and vomiting, as defined by:

i. At least two prophylactic pharmacologic antiemetic agents of different classes

administered preoperatively or intraoperatively for patients with one or two risk

factors

ii. At least three or more prophylactic pharmacologic antiemetic agents from

different classes preoperatively or intraoperatively for patients with three or

more risk factors

iii. For cesarean delivery cases only: At least two prophylactic pharmacologic

antiemetic agents from different classes preoperatively or intraoperatively.

(per SOAP ERAS 2021 guidelines)

iv. Excludes: Labor epidurals

v. Risk factors not considered for cesarean delivery patients

vi. Measure time period: C-section start time for cesarean conversion cases; preop

start for scheduled c-sections

b. PONV 05 discussion:

i. Antiemetic administration data: most common medication(s) for cesarean

delivery cases in MPOG shared with subcommittee: Ondansetron and

Dexamethasone seem to be most common - see slide 10

ii. Agree on the inclusion criteria for cesarean delivery patients, ignoring risk

factors?

iii. Agree with measure time period for administration: Preop start - PACU Start?

iv. Agree with giving any 2 antiemetics from separate classes? Specify which classes

must be given (or not given)? For example, propofol infusion would be included

as an acceptable antiemetic

v. Exclusions apply?

– ASA 5 or 6

– Patients <18 years old.

– Patients transferred directly to the ICU

vi. Shared blinded performance for PONV 05 for cesarean delivery patients only -

see slide 12

vii. Conclusions:

1. Modify exclusion criteria to include all cesarean delivery patients

regardless of age

2. Modify start time to include 30 minutes before cesarean delivery start

for conversion cases to ensure capture of antiemetics given by nursing

on the unit before OR

3. Antiemetics from 2 different classes is appropriate - no change to

success criteria

D. Unblinded Data Review: PONV 03/03b

a. Unblinded Data Review: Performance for PONV 03/03b 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 site's performance were omitted from the minutes.

b. Current Measure: PONV 03 - Percentage of patients, regardless of age, who undergo a

procedure and have a documented nausea/emesis occurrence OR receive a rescue

antiemetic in the immediate postoperative period

i. Time period: Recovery room in through 6 hours after Anesthesia End

ii. Inclusion: Cesarean Deliveries

iii. Exclusion: Labor Epidurals

iv. Discussion:

1. Ashraf Habib (Duke): Proper timing of dexamethasone is 2 hours before

delivery unless cord blood donor. If cord blood donor- hold and give

after delivery

2. Carlos Delgado (UWashington): U of Washington in Seattle - intraop

admin of antiemetics (ondansetron+dex) is the practice.

3. Wandana Joshi (Dartmouth): We don't send all our CD patients to PACU.

Most patients will recover in their labor room. Will this affect data

collection?

4. Rebecca Minehart (MGH): Is anyone using pain dosing for

dexamethasone (>0.1mg/kg)? I have been toying with this idea,

especially since the higher PDPH risk reported with dex hasn't borne out

in subsequent studies. Also, We've been reprimanded for raising blood

glucoses in DM with dex

5. Angel Martino-Horrall (Beaumont Health System): Wonder how much

PONV can be attributed to azithromycin administration. Can this be

examined?

a. Nirav Shah (MPOG): Yes

6. Ashraf Habib (Duke): Many other factors impact antiemetic selection.

We are at the top of ‘discrepancy’. Many of the patients who experience

PONV is out of our control.

7. Preet Singh (WashU): two time frames that are consistent 1)BP is low

and 2) when baby is delivered?

8. Monica Servin (Michigan Medicine): PONV03 looks through PACU;

Measure looks 6 hours after Anesthesia End. However, some sites are

only contributing data through PACU end only.

9. Ashraf Habib (Duke): Sites could have more PONV rates if they are

sending data post-PACU. Can we look at measure performance for 2

hours after anesthesia end vs. 6 hours?

a. Kate Buehler: How should we define PACU end?

b. Ashraf Habib (Duke): Most patients go to PACU but there are

some that recover in their rooms. If we are able to use 2 hours

as a cutoff it will standardize a timeframe we are looking at

across all sites

c. Monica Servin (Michigan Medicine): I agree. Nurses at our

institution consider 2 hours that ‘PACU’ window.

d. Angel Martino-Horrall (Beaumont Health System): Is there a way

to see which sites have scored well for PONV03 and what

antiemetics they have used? I’m wondering if there is something

specific to the PACU timeframe if there is a specific ‘cocktail’

sites are finding effective.

i. Nirav Shah (MPOG): Yes. We do this collaboration within

the state of Michigan with unblinded data reviews once

a year as well.

c. PONV 03b: Percentage of patients, regardless of age who undergo a procedure and have

a documented nausea/emesis occurrence with or without receiving an antiemetic in the

immediate postoperative period.

i. Time period: Recovery room in through 6 hours after Anesthesia End

ii. Inclusion: Cesarean Deliveries

iii. Exclusion: Labor Epidurals

d. PONV 03/03b Discussion: Both are already available on the OB Dashboard

e. Recommended modifications to PONV 03/03b for the OB population?

i. Modify measure for OB to include patient out of room to 2 hours after surgery

rather than 6 hours postop in order to standardize data capture across sites

ii. Assess whether data from OB units is coming into MPOG before and after

cesarean delivery cases - if so, what is the time window on either side of the

case that MOST sites are able to contribute? - MPOG Coordinating Center to

investigate

E. 2022 Planning

a. Progress in 2021

i. Created new postop temperature measure for cesarean deliveries: TEMP-05-OB

ii. Created measures focused on general anesthesia rates for cesarean deliveries

1. GA 01: Percentage of cesarean delivery cases where general anesthesia

was used

2. GA 02: Percentage of cesarean delivery cases where general anesthesia

was administered after neuraxial anesthesia

iii. Added consideration for cesarean deliveries in new PONV prophylaxis measure:

PONV 05

b. Recap of 2021 Plans

i. Sent out survey in late 2020: 9 responses

1. PONV in PACU following cesarean delivery: Complete!

2. First temperature in PACU following cesarean delivery: Complete!

3. Non-opioid adjunct used for post cesarean delivery pain: Still priority?

ii. Reviewed survey ‘write-in’ topics that were rated as ‘Extremely Important’ or

‘Very Important’

iii. Discussion:

1. Sharon Abramovitz (Cornell) - Should also consider looking at patients

with spinals on phenylephrine infusions.

iv. Next Steps:

1. Modifications to PONV process measure (PONV 05) for the obstetric

population:

a. Modify exclusion criteria to include all cesarean delivery

patients regardless of age

b. Modify start time to include 30 minutes before cesarean

delivery start for conversion cases to ensure capture of

antiemetics given by nursing on the unit before OR

c. Antiemetics from 2 different classes is appropriate - no change

to success criteria

2. Modifications to PONV outcome measure for obstetric population:

a. Modify measure for OB to include patient out of room to 2

hours after surgery rather than 6 hours postop in order to

standardize data capture across sites

b. Assess whether data from OB units is coming into MPOG before

and after cesarean delivery cases - if so, what is the time

window on either side of the case that MOST sites are able to

contribute? - MPOG Coordinating Center to investigate

3. Will send out survey to OB Subcommittee members to assess potential

topic areas for new measures: please complete survey and committee

will reconvene in August to determine future measure build priorities

4. Potential focus areas based on 2020 survey results:

a. Multimodal analgesia for cesarean deliveries

b. Azithromycin use

c. Phenylephrine infusion use

d. ERAS area of focus

Meeting concluded at: 1402