Quality Committee
Meeting
February 28, 2022 @10:00 ET
Announcements
● New Cardiac phenotype release
● Precision Feedback announcement
● Subcommittee Updates
ASPIRE Data and Joint Commission Visit
● Sunny Chiao, MD, University of Virginia
New measure discussion
● BP 05 - Rob Schonberger, MD, Yale University
● SUS 02
Measure Updates
● PONV Updates
● GLU 05
Agenda
Meeting Minutes
January 2022
Roll Call – via Zoom or
contact us
Announcements
Upcoming Events
ASPIRE Quality Committee Meeting
Monday, March 28, 2022 (may cancel)
ASPIRE/MSQC Meeting:
Friday April 8th, 2022
2022 Calendar is up
to date at
mpog.org/calendar/
*NEW* Cardiac Procedure Type Phenotype
• New Categories:
– Open Cardiac
– Transcatheter/Endovascular
– EP/Cardiac catheterization
– Other Cardiac
– No/Non-cardiac
– Missing/unknown/unable to determine
• Data Elements Utilized:
– Surgical CPTs (if present)
– Anesthesia CPTs
– Procedural Service IDs
– CPB documentation concepts and phenotypes
– Procedure text phrases
Precision Feedback Study Update - Aim 1
• Plan to conduct interviews over the next couple of months to determine
preferences in feedback emails
• Have reached to Quality Champions to refer potential interviewees
• Criteria included:
– Hospitals both within MI (BCBSM) and outside MI as well
– Hospitals with and without residents
– Community and med school affiliated hospitals
– Range of hospital sizes
• If you are interested in participating in this phase of the project, please
reach out to Allison Janda.
• More detailed information about future phases (trial where we randomize
regular emails vs “precision feedback” emails) coming soon!
Subcommittee
Updates
Pediatric Subcommittee
• Met on February 16
th
- 25 members attended
• Finalized Measure Build for 2022
– NMB-03: Neuromuscular blockade dosing in patients < 1mo.
– ABX-02: Antibiotic Timing, Pediatrics
– FLUID-02: Minimizing Colloid Use, Pediatrics
– TRAN-03/04: Pediatric Transfusion metrics (mirror TRAN-01/02)
• Formation of Workgroups
– Pediatric Mortality (30 day in-hospital)
– Surgical Site Infection
– Normothermia
– PONV
– Pain Management
– Peds Cardiac
• Next Meeting, May 18
th
- Unblinded data review
Obstetric Anesthesia Subcommittee Updates
• Last meeting held on February 2022: 28 attendees
• Introduced unblinded performance review
– GA 01/02 & PONV measures
• Recommends modification to PONV 05: include all cesarean
delivery cases regardless of age
• Modified hyperglycemia measures to exclude cesarean deliveries
• Subcommittee members recently completed survey to determine
future measure focus areas
• Next Meeting: August 3rd, 1pm EST
Cardiac Subcommittee
● December meeting minutes & slides available
● New post-bypass hypothermia avoidance measure is has been released to
the ‘All Measures’ and ‘Cardiac’ Dashboards
○ TEMP 06-C is the percentage of adult patients who undergo open cardiac surgical
procedures for whom the last non-artifact body temperature prior to anesthesia end was
greater than or equal to 35.5 degrees Celsius. Additional measure specification details
available here.
● A countermeasure for on-bypass hyperthermia avoidance is also being
developed and we’re requesting perfusionist input
○ Please reach out to ajanda@umich.edu if you have any perfusionists who would like to join
a subgroup to help develop this measure!
● Additional future measure topics include glucose management and AKI
● Next meeting: Scheduling poll to be sent - likely April, 2022
ASPIRE Data and Joint
Commission Visit
Dr. Sunny Chiao
University of Virginia
Email request
• ”As you may recall, one of the findings […] related to
(moderate) sedation providers and Dr. Y was found not to
have privileges to provide sedation.”
• “I am not surprised a CRNA was pulled (in this light) and I
would anticipate that more APPs will be pulled over time. I
am guessing that quality info was pulled to show compliance
with OPPE/FPPE requirements?”
• What did JC request?
• What was provided
• Anesthesia staff perspectives/opinions
• Recommendations/lessons learned
Overview
JC Ask
• “Provide quality data for a CRNA over a period of a few months.”
Data Provided
JC standard: Ongoing Professional Practice Evaluation (OPPE)
JC standard: Ongoing Professional Practice Evaluation (OPPE)
JC standard: Ongoing Professional Practice Evaluation (OPPE)
• 1. Your credentialing committee must have a process to evaluate
professional practice. What that process is, is up to you.
• 2. What data is collected to make assessment is also up to the
department.
• 3. This info can be used to continue, limit, or revoke privileges.
Focused/Ongoing Professional Practice
Evaluation Process (FPPE/OPPE)
• At our institution, we have a Professional Practice Evaluation
Subcommittee (PPES) that reports to the Credentialing Committee
• Currently working to establish a Advanced Practice Providers
Subcommittee (APPS) committee to mirror the physician standard
University of Virginia MC Policy
Initial FPPE
FPPE for cause
OPPE Process
Takeaways
• JC more interested that we maintain a process and track it, but do not
care what the specifics are
• MPOG provider dashboard is well equipped to fulfill these
requirements
• Be familiar with your institutional credentialing FPPE/OPPE standard
• What will your credentialing committee do with ASPIRE data?
Where do we go from here?
• Initiating feedback…
• Low-hanging fruit for metrics (process vs outcomes? Things you already do well?)
• Allow staff to become accustomed to this process
• Incentivize anesthesiologists with MOCA Part 2 credit
• Going forward….
• What to do with underperformers?
• Mandatory QI/PBLI?
• Tied with performance bonus?
• Discussion at annual review?
• Triggered FPPE?
New Measure:
BP 05
Context: Measure “sources”
Feedback from Quality Champions, individual providers, and sites
Coordinating Center
Subcommittees
Research projects
Rob Schonberger
Yale University
Prevalent Propofol Dosing
Practices at MPOG institutions
2014-2018
The mean (SD) weight-adjusted propofol
dose was 1.7 (0.6) mg/kg. The mean
prevalent propofol induction dose
exceeded the upper bound of what has
been described as the typical geriatric
dose requirement across every age
category examined. The percent of
patients receiving propofol induction
doses above the described typical geriatric
range was 64.8% (95% CI 64.6-65.0),
varying from 73.8% among patients aged
65-69 to 45.8% among patients aged 80
and older.
Induction medications and dosing are both
attributable and modifiable
• Among 320,585 total patients, 22.6% experienced the outcome of
pre-incision severe hypotension (MAP≤55mmHg).
• 20.7% with non-invasive blood pressure measurements
• 35.0% with invasive blood pressure measurements had the outcome.
• Propofol induction dose (considered both as a continuous variable and as
yes/no >1.5mg/kg) was associated with pre-incision hypotension
(MAP<55mmHg)
• However, a multitude of other factors both captured and not captured
within MPOG may mediate this relationship.
Informational ASPIRE Metric BP-05
Percent of patients age >65 without preoperative hypotension undergoing GA who
had an episode of MAP<55mmHg within 15 minutes of induction and prior to surgical
incision.
New Measure: BP 05 (informational measure)
Percentage of cases where severe hypotension during anesthesia induction (defined as MAP < 55 mmHg)
was avoided
Measure Time Period: Induction Start through Surgery Start
Inclusions: All patients requiring general anesthesia
Exclusions:
● Patients <18 years old
● ASA 6 cases/ Organ Harvest
● Baseline MAP <60 mmHG
● Labor Epidurals / Obstetric Non-Operative Procedures
● Anesthesia Procedures
Success Criteria: MAP > 55 mmHG throughout induction time period
New Measure:
SUS 02
Thank you Dr. Jodi Sherman (Yale University)
Purpose today is to introduce the measure in its current form and discuss how to
approach this measure (specifically, are we targeting “acceptable” or “ideal”
practice.
Questions
Should the threshold be 2 l/min or 1 l/min or something else?
Should the measure start time begin at inhalation agent start or intubation or some other time?
If we include induction, do we exclude or include short cases?
Next Steps
Circulate specification for comment, update measure based on comments
Schedule meeting of interested folks if appropriate for further discussion
Share timeline for measure development
GLU 05 Update
Current State
● Percentage of cases with a blood glucose >200 mg/dL with documentation
of insulin treatment
● Subcutaneous insulin dosing intervals are up to every 3 hours
● Many institutional protocols recommend hourly glucose checks in the periop
time period when insulin is administered
● GLU 05 flags cases with high glucose & no treatment within 90 minutes
● Inappropriate flagging of cases where subcutaneous insulin administered,
follow up glucose > 200 mg/dL, but no additional insulin sq given within 90
minutes because still within the 3 hour window
Proposed Updates
● If insulin SQ is administered, we will not require elevated blood glucose
values to be treated within a 3 hour time frame of the insulin administration
● This update assumes we are receiving insulin administration data up to 4
hours before anesthesia start (ie preop holding)
PONV 05
Updates
PONV 05 Released!
● New Adult PONV prophylaxis measure released last month
● Site Champions and ACQRs actively reviewing cases
● Please continue to submit feedback to the Coordinating
Center
● Will vote on proposed changes at the May Quality
Committee meeting:
○ Add midazolam as a potential antiemetic
○ Add exclusion for endoscopy procedures (regardless of GA)
○ Remove CPT prediction from procedure type risk factor (rely on actual
codes only)
○ Trigger ERCP as cholecystectomy risk factor (or only ‘true’
cholecystectomy)
○ Adjust fentanyl as ‘trigger’ for the opioid administration risk factor
○ Include all cesarean delivery cases, regardless of age
Source: Fourth Consensus
Guidelines for the Management
of PONV
Thank You!