Quality Committee
Meeting
May 23, 2022 @10:00 ET
Announcements
● Matters arising
● Subcommittee Updates
Insulin Pumps
● Jing Tao, MD
Measure Updates - Final specs
● SUS 02
● SUS 03
● SUS 04
● GLU 05
● PONV 05
Agenda
Meeting Minutes
February 2022
Roll Call – via Zoom or
contact us
Announcements
Upcoming Events
ASPIRE Collaborative Meeting
Friday, July 15, 2022
Lansing, MI (in person)
ASPIRE Quality Committee Meeting
Monday, July 25, 2022
Virtual
Release notes at https://mpog.org/2022-may-upgrade/
Subcommittee
Updates
Pediatric Subcommittee
• Met on May 18th - 28 members attended
• New Measures Released
– NMB-03: Neuromuscular blockade dosing in patients < 5yo.
– Pediatric Blood Management (mirror TRAN-01/02)
– TRAN-03: Transfusion Vigilance, Pediatrics
– TRAN-04: Overtransfusion, Pediatrics
• Sustainability in Pediatric Anesthesia
– Workgroup formed; First meeting discussed measure build
– SUS-05: Weight based Fresh Gas Flow
– SUS-06: Nitrous use during induction
• Unblinded Data Review
• Next Meeting, August 17th
Obstetric Anesthesia Subcommittee Updates
• No update since last Quality Committee meeting
• Last meeting held on February 2022: minutes available here
• Next Meeting: July 20, 1pm EST
Cardiac Subcommittee
• April meeting minutes & slides available
• New post-bypass hypothermia avoidance measure has been released to the ‘All
Measures’ and ‘Cardiac’ Dashboards
– TEMP-06-C: 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 pending release:
– TEMP-07-C: Percentage of adult patients who undergo open cardiac surgical procedures
requiring bypass, for whom the temperature did not rise above 37.5 degrees Celsius for over
5 consecutive minutes. Additional measure specification details available here.
• The next measure in development pertains to glucose management
• Next meeting: Scheduling poll to be sent - likely August 2022
New Smoking
Cessation
Measures
Smoking Cessation Measures
Created for the BCBSM value-based reimbursement (VBR) program:
1) Improve smoking status documentation within 30 days prior to surgery.
Target: 70%
2) Increase the proportion of smokers who receive treatment/cessation
counseling. Target: 10%
*Will be published & available on the dashboard by the end of June for all sites
Glucose Measures – Role
of Continuous Glucose
Monitors
Jing Tao, MD
Memorial Sloan Kettering Cancer Center
5/23/2022
Conflict of Interest
• I have nothing to disclose
ASPIRE Glucose Measures
Background
• # of CGM users in 2021:
– United states – 2 million
– Globally – 5 million
• 2020 FDA emergency
authorization for inpatient
setting
• Medicare coverage
• Some Medicaid coverage
CGM: Mechanics
• Age ≥2 yrs
• NO fingerstick
calibration needed
• Water resistant
• Age ≥18 yrs
• Implanted sensor
• 2/day fingerstick
calibration needed
• Age ≥18 yrs
• NO fingerstick
calibration needed
• Water resistant
• Age ≥14 yrs
• 2/day fingerstick
calibration needed
• Water resistant
• Patients: 14 yo + 16 yo males
• Surgery: Pancreatectomy,
splenectomy, islet
autotransplantation
• Glucose monitor: Dexcom G6 vs POC
vs ABG
• Results:
• Patients: 200 adults
• Surgery: Abdominal surgery >2 hrs
• Glucose monitor: Dexcom G6 vs POC
• Results:
• Mean difference = 12.7% (+/- 8.4%)
• Median different = 9.9% (IQR
6.3-15.9%)
Tripyla A et al. Performance of a factory-calibrated, real-time continuous glucose
monitoring system during elective abdominal surgery. Diabetes Obes Metab. 2020
Sep;22(9):1678-1682
DiGiusto M et al. Use of Continuous Glucose Monitoring to Facilitate
Perioperative Glycemic Management: A Case Report. A A Pract. 2021 Mar
24;15(3):e01438
Dexcom G6 ABG Glucometer
Patient A 135 mg/dL
(+/- 29 mg/dL)
119 mg/dL
(+/- 26 mg/dL)
102 mg/dL
(+/- 11 mg/dL)
Patient B 126 mg/dL
(+/- 17 mg/dL)
109 mg/dL
(+/- 12 mg/dL)
103 mg/dL
(+/- 14 mg/dL)
Drawback: Lag Time
7-15 min
7-15 min
Drawback:
Interference
• Dexcom G6:
• Acetaminophen >4gm
• Abbot Freestyle Libre:
• Ascorbic acid
Known
• Skin temperature
• Skin edema
• Positioning
Potential
Benefit:
Continuous
Measurement
with Directional
Trend
What the implications for MPOG GLU measures?
How are sites tracking glucose management compliance when these are used? Issues?
Are nurses and providers entering the CGM data into the EHR?
MPOG only receives data from the EHR from our sites. Options include:
1. Ask anesthesia providers to perform POC glucose testing (this is what typically happens at
UM, but no official policy - still relatively rare)
2. The anesthesia provider enters glucose values into the anesthesia record using a newly
created EHR variable (ie Home Glucose Monitor Value). We can create an MPOG concept
to receive this data.
3. Document that a patient’s CGM will be used to monitor glucose values during a case using
a specific field in the EHR. We can map that local variable to an MPOG concept. (NOT
Recommended)
PONV 05
Updates
PONV 05 Revisions
● New Adult PONV prophylaxis measure released in
January
● Upon review, sites have requested several modifications
to PONV 05
● Plan to retire PONV 01/02 once revised version of PONV
05 released
Source: Fourth Consensus
Guidelines for the Management
of PONV
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
Amisulpride
● Antidopaminergic - IV formulation recently approved for management of
PONV
● In a randomized, double-blind placebo-controlled trial (n=1,147), incidence
of PONV significantly lower in the amisulpride group when given with a
standard antiemetic (Kranke et al., 2018, Anesthesiology)
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)