Quality Committee
Meeting
July 25, 2022 @10:00 ET
Announcements
● Matters arising
● PONV Toolkit
● Subcommittee Updates
Measure Review
● Drs Sunny Chiao (UVa) and Shafeena Nurani
(Beaumont), TEMP 01
● Dr. Jonathan Kaper (Beaumont Trenton), TEMP 02
App Discussion
● WebCaseviewer
● Data Direct
Agenda
Meeting Minutes
February 2022
Roll Call – via Zoom or
contact us
Announcements
ASPIRE Collaborative Meeting
• Business and Updates
• QI Stories
– Dr. Ben Stam (UM Health West)
– Dr. Meredith Hall (Bronson Health)
• Hypotension Associated Outcomes
– Dr. Kamal Maheshwari (Cleveland Clinic)
• Rational Vasopressor Selection
– Dr. Allison Janda (UM Health Ann Arbor)
• ASPIRE Performance Review
Upcoming Events
December 7th
September 26th
August 17th
August 22nd
ACQR Annual Retreat
September 16, 2022
DoubleTree Hotel, Ann Arbor
In person Only
MPOG Annual Retreat
October 21, 2022
New Orleans, LA
In person + virtual
PONV Toolkit is
complete!
Existing Toolkits
Subcommittee
Updates
Obstetric Anesthesia Subcommittee Updates
Met this past week with 20 participants in attendance
Slides, minutes, and recording posted on the website
■ Reviewed results of the measure build survey that was sent in February
■ Subcommittee voted to build a measure examining the percentage of
cesarean delivery cases that converted to GA from an epidural
(GA-03-OB)
Next meeting: December 7, 2022 1pm EST
If interested in joining the Obstetric Subcommittee, please contact Kate Buehler
(kjbucrek@med.umich.edu)
Temp 01 Vote
1 vote/ site
Continue as is/ modify/ retire
Need > 50% to retire measure
Coordinating center will review all votes after
meeting to ensure no duplication
Temp 02 Vote
1 vote/ site
Continue as is/ modify/ retire
Need > 50% to retire measure
Coordinating center will review all votes after
meeting to ensure no duplication
WebCaseviewer
Updated Version of Web Case Viewer - A new version of Web Case Viewer will be
released by August provider feedback emails
Web Case Viewer
Measure Details
The result breakdown for the
measure is brought to the
top above the notes section
for easy review
Web Case Viewer - H & P
Record Search and Administrative Sections
MPOG QI
Tools
Measure Case Report
• Standard columns for patient, procedure and anesthesia type
• Predetermined columns specific to measure to assist in flagged
case review
• Not customizable by the end user
Data Direct - Quality Mode
• All measures now available as
filters and outputs
• Customizable columns
Current Limitations:
• Limited to measure result; does
not include other measure details
• Columns limited to phenotypes
and their definitions
• Exports results on multiple
spreadsheets
Next Steps
What modifications would be helpful in Data
Direct?
Are there additional visualizations/filters
that would be helpful in QI Reporting?
In general, are there additional reporting
needs that MPOG could meet?
Thank You!
GLU 05 Update
● Percentage of cases with a blood glucose >200 mg/dL with documentation
of insulin treatment
● Previously identified issue: Inappropriate flagging of cases where
subcutaneous insulin administered, glucose recheck > 200 mg/dL, but no
additional insulin sq given within 90 minutes because still within the 2-3
hour window of peak insulin effect
Updates
● Insulin administrations within 90 minutes after high glucose value -> PASS
● If not treated, measure will assess if insulin sq was administered within 180 minutes prior to high
glucose value
○ If yes, will ‘ignore’ that value
○ If no, then case will be flagged
● Only applies if MPOG is receiving insulin administration data at least 4 hours before anesthesia
start (ie preop holding)
● These updates will improve measure scores to reflect treatment of hyperglycemia. However, there
may still be gaps in which cases with poor glycemic control are now passed or excluded
● Also updated GLU to account for sq insulin administration
New Measure:
BP 05
New Measure: BP 05
Percentage of cases where severe hypotension during anesthesia induction (defined as MAP < 55 mmHg)
was avoided
Informational Measure Only
Measure Time Period: Induction Start through Induction End
Inclusions: All patients requiring general anesthesia
Exclusions:
● Patients <18 years old
● ASA 6 cases
● Baseline MAP <60 mmHG
● Labor Epidurals / Obstetric Non-Operative Procedures
Success Criteria: MAP > 55 mmHG throughout induction time period
PONV 05
Updates
Updates In Progress
1. Will now only consider actual CPT codes (not predicted) to
assign procedure type risk factors (cholecystectomy,
laparoscopy, gynecologic procedures)
2. ERCP (only) procedures will not trigger the cholecystectomy
risk factor
3. Amulsipride will be added as an acceptable antiemetic agent
Obstetric Population Updates (per OB Subcommittee)
● Include all cesarean delivery cases, regardless of age
● Adjust measure start time for labor epidural cases that convert to cesarean
delivery: Include antiemetics given within 1-2 hours before surgery start
time
Requested revisions pending Quality Committee vote
1. Add procedure exclusions for TEE and endoscopy procedures (even if
GA is used)
2. Consider midazolam as an acceptable ‘antiemetic’
3. Remove intraop fentanyl as risk factor for PONV (part of the opioids for
postoperative pain bucket of risk factors)
Add Procedure Exclusions?
MPOG Analysis:
806,978 Adult PONV 03b cases (05/2021-10/2021)
Overall PONV incidence: 5%
Procedure Type Cases with
PONV
Total Cases % Cases with PONV Recommendation
Cholecystectomy (control) 1453 11504 13% Include
TEE 67 7000 1% Exclude
Endoscopy 511 16891 3% Exclude
Fentanyl as a risk factor
● Remove intraop fentanyl as a risk factor for PONV? (only consider
other “long-acting” opioids?)
● Or, only include intraop fentanyl administrations if they meet a
certain dose threshold for the case?
● Or, do we continue to include fentanyl as a risk factor?
Midazolam
● 4th Consensus PONV Management Guidelines do not recommend
midazolam use due to possibility of sedation-related adverse effects.
● Meta-analysis of 12 RCTs (n=841) found administration of IV midazolam to
be associated with significantly reduced PONV (Grant et al, 2016, Anesth &
Analg)
● No significant difference in PONV between midazolam and ondansetron
given 30 minutes before end of surgery (Lee et al., 2007, Anaesthesia)
Poll
1. Should we add a procedure exclusion for TEE?
2. Should we add a procedure exclusion for endoscopy
3. Should we add midazolam as an anti-emetic?
4. How do we handle fentanyl?
a. Exclude fentanyl as an intraoperative PONV risk factor
b. Include any dose of intraoperative fentanyl as a PONV risk factor (current state)
c. Include dose dependent fentanyl as a PONV risk factor (dose TBD)
Add Procedure Exclusions?
MPOG
Analysis:
806,978
Adult
PONV 03b
cases from
05/2021-
10/2021
Overall
PONV
incidence:
5%
Procedure Type Cases with
PONV
Total Cases % Cases with PONV Recommendation
Cholecystectomy (control) 1453 11504 13% Include
ECT 22 2857 1% Exclude
TEE 67 7000 1% Exclude
Radiology (CT/MRI/IR only) 333 5029 7% ?
Nerve Blocks 2365 126968 2% Exclude
Cataracts 1878 17035 11% Include
Endoscopy 511 16891 3% Exclude
AV Fistula 79 1978 4% Exclude
Cystoscopy 1506 269845 6% ?
Add Procedure Exclusions?
MPOG
Analysis:
806,978
Adult
PONV 03b
cases from
05/2021-
10/2021
Procedure Type Cases with
PONV
Total Cases % Cases with PONV Recommendation
I&D procedures 192 1673 11% Include
Lumbar Puncture/Spinal
tap/Line placement
6 306 4% Exclude
Tympanoplasty 76 881 9% ?
Bronchoscopy/Intubation only 6 914 1% Exclude
Dental Procedures 57 832 7% ?
Dilatation & Curettage (D&C) 173 3211 5% Exclude
Others to consider?
Pediatric Subcommittee
•
Cardiac Subcommittee
