Obstetric Anesthesia Subcommittee Minutes

July 20, 2022

1:00-2:00 pm EST - Zoom

First Name

Last Name

Institution

Ami

Attali

Henry Ford-Detroit

Dan

Biggs

University of Oklahoma

Christine

Warrick

University of Utah

Kathleen

Smith

University of North Carolina

Laurie

Chalifoux

Spectrum

Sharon

Abramovitz

Weill Cornell

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

First Name

Last Name

Institution

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. Upcoming Events

■ OB Subcommittee Meeting: December 7, 1pm EST

■ MPOG Retreat in New Orleans, LA: October 21, 2022

b. PONV Toolkit Released

■ OB considerations minimally addressed

■ Anyone can access (does not need to be an MPOG active site to download from

the MPOG website)

■ Current version of the PONV toolkit focuses on the general adult surgical

population, does not focus specifically on obstetric patients and the unique

challenges presented with managing PONV for laboring women. If a PONV

Prevention/Treatment Toolkit for Cesarean Delivery is of interest to the group,

MPOG would partner with the OB Subcommittee team to assemble and publish.

Contact kjbucrek@med.umich.edu with any questions/interest.

B. February 2022 Meeting Recap

a. Reviewed unblinded site performance for PONV measures

■ Subcommittee recommended changes to PONV 05 (prophylaxis measure)

b. Subcommittee seeking further clarification on the timeframe for MPOG data before and

after cesarean delivery cases

c. Survey distributed after the meeting to all subcommittee members to assess measure

focus areas for 2022

C. PONV 05 Updates since February

a. Percentage of patients, aged 18 years and older undergoing a procedure requiring

anesthesia and administered appropriate prophylaxis for postoperative nausea and

vomiting, as defined by:

b. For cesarean delivery cases only (any age): At least two prophylactic pharmacologic

antiemetic agents from different classes preoperatively or intraoperatively. (per SOAP

ERAS 2021 guidelines)

c. Excludes: Labor epidurals

d. Risk factors not considered for cesarean delivery patients

e. Measure time period update:

■ Was: Cesarean delivery start time for conversion cases & preop start for

scheduled c-sections

■ Now: 2 hours before cesarean delivery for conversions & preop start for

scheduled c-sections

D. MPOG Obstetric Data Capture Before Surgery

a. Average across all MPOG sites

Medication Documentation populated in the MPOG database (data capture rate)

% of cases with medication __hrs before

c-section start

0-1 hrs

1-2 hrs

2-3 hrs

3-4 hrs

Conversions

44%

42%

39%

Cesarean Delivery

70%

20%

14%

12%

Discussion:

● Kate Buehler (OB Subcommittee Lead): By opening up to 2 hours prior to cesarean section start,

it did not make a significant difference in PONV 05 scores.

● Christine Warrick (University of Utah): I’m curious to know what the most commonly used agents

are for PONV ppx

○ Kate Buehler (OB Subcommittee Lead): This was displayed during a previous meeting-

we’ll add to this slide deck as well before posting on the website: Ondansetron and

Dexamethasone

● Angel Martino-Horrall (Beaumont): Conversion data…is this data from the intraop record or is

this the patient received any medication ie oxytocin

○ Kate Buehler (OB Subcommittee Lead) : Any medication. Some sites have more cases

with medications coming over outside of the intraop period for cesarean deliveries,

some sites have less but the average across MPOG was 44% for cesarean conversion

cases. We were attempting to get an overall sense of the data coming over as part of the

standard MPOG extract from Epic for cesarean delivery cases that start as labor

epidurals.

● Ami Attali (HFHS-Detroit): What is the general purpose for only capturing 44% of all medications.

○ Kate Buehler (OB Subcommittee Lead): The MPOG extract is new in terms of capturing

data outside of anesthesia start to anesthesia end. We’ve only recently started to open

that window from preop through PACU. These time periods are nebulous for C-section

cases. This data pull was to see how the Epic extract captures data for c-sections. We

confirmed the standard MPOG extract does pull in medications within 1-2 hours prior to

Anesthesia Start. Therefore, we can open up the window for certain measures.

○ Ami Attali (HFHS-Detroit): Opening this window can help capture surgical site infection

rates. Our site is asking when and how our antibiotics are coming through and it’s

difficult for us to pull. It’s exciting to see MPOG opening the extract.

○ Kate Buehler (OB Subcommittee Lead): We are working with Epic currently specifically on

the OB data extract to improve this data capture. We should be able to use the nursing

record for c-section start and other start/end times if it is not available in the anesthesia

record. This way any site that joins MPOG with an Epic EHR may have a more ‘turn key’

solution to adding data outside of the intraop window.

E. 2022-2023 Planning

a. Survey Results - 10 Total Respondents

■ Questions: Submit your level of interest for each proposed measure topics:

■ % of patients with pain ≥3 during labor with epidural (within 60 minutes

of initiation)

● Low interest: 2 respondents

● Moderate interest: 6 respondents

● High interest: 2 respondents

■ % of patients with intraoperative blood product administration

● Low interest: 0

● Moderate interest: 7

● High interest: 3

■ Failed extension of epidural for cesarean delivery

● Low interest: 0 respondents

● Moderate interest: 1 respondents

● High interest: 9 respondents

■ % of cesarean delivery cases with hypotension intervention

● Low interest: 3

● Moderate interest: 3

● High interest: 4

■ Write-in Topics

● In room to induction complete, time from induction to incision, incision

to baby delivered (limited data in MPOG)

● Epidural catheter replacement during labor (data not available in MPOG)

● Labor epidural catheter replacement for cesarean delivery (data not

available in MPOG)

● Appropriate dosing of duramorph Available - prelim data will be shared

later in presentation

b. Preliminary Performance Data of proposed topics

■ This data has been minimally validated

■ Blinded - no site names included

■ Sites with less than 75 cesarean sections in 2021: not represented

■ Topics highlighted:

● Epidural->General anesthesia

● Hypotension & treatment of, in cesarean delivery

● Blood product administration and EBL in cesarean delivery

● Morphine dosing for spinals/epidurals

■ Goal - Provide some preliminary results for the measure topics proposed in

order to guide the subcommittee to:

● Select topics for the next 1-3 obstetric measures

● Facilitate future measure specification discussions for selected topics

c. Discussion: Cesarean Delivery: Vasopressor Use

■ Nirav Shah (MPOG QI Director): Is there any discussion among OB

anesthesiologists that treatment of hypotension should be bolus vs. infusion?

● Josh Younger (HFHS-Detroit): This was a debatable point during

ASA…didn’t want to require centers to only use infusions as it isn’t

realistic for many non-academic centers.

● Monica Servin (University of Michigan): For some sites syringes may be

cheaper than an infusion, though with an infusion, more med may be

wasted

● Ami Attali (HFHS-Detroit): I think it depends on who makes the syringe.

In-house pharmacy making the infusion may be more economical but

some sites may not be set up for that

d. Discussion: Cesarean Delivery: PRBC administration

■ See slide deck for preliminary data for PRBC administration and blood loss across

participating MPOG centers- no additional comments or questions from the

committee

e. Discussion: Cesarean Delivery: Morphine Dosing

■ Most common Epidural dosing is 3mg, Spinal is 0.15mg

■ Nirav Shah (MPOG QI Director): MPOG is getting better at describing variation of

care, if anyone is interested in publishing any of these topics please contact the

coordinating center.

● Angel Martino-Horrall (Beaumont): Could we correlate PONV outcomes

based on dosing of morphine for OB patients?

● Nirav Shah (MPOG QI Director): We could definitely produce these rates

but it would be unadjusted so would be difficult to deduce without

appropriate statistical analysis to limit or at least take into consideration,

the many confounding variables associated with PONV.

f. Survey results regarding meeting frequency showed that 3 meetings per year is

favorable- will continue this cadence for 2023.

F. Vote on measure topics (via Zoom poll)

G. Next Steps

a. Coordinating Center will draft measure specification for % of cesarean cases performed

under GA that also had a labor epidural

b. Measure specification will be posted via Basecamp for subcommittee to provide

feedback

c. Goal:

■ Build one additional obstetric-specific measure by late 2022 - GA 03_OB: % of

cesarean delivery cases performed under GA that had a labor epidural

■ Build 1-2 obstetric-specific measures in early 2023

● Potentially build a measure looking at blood product administration for

cesarean delivery

● After GA 03 is released, will seek out feedback from subcommittee on

next steps

H. Additional Comments

a. Sharon is interested in reporting on morphine dosing

b. Nirav - once this measure is out we can bring this topic back to the group. I would

encourage sites to look at single center analysis for this data.

Meeting concluded at: 1:48pm