Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

OB Subgroup Meeting Minutes – Dec 7, 2022

Attendance:

Monica Servin, University of Michigan

Graciela Mentz, MPOG

Jessica Wren, Henry Ford Health System

Tory Lacca, MPOG

Preet Singh, Washington University

Tiffany Malenfant, MPOG

Ashraf Habib, Duke University

Sandy Rozek, MPOG

Sharon Abramovitz, Weill-Cornell

Rob Coleman, MPOG

Wandana Joshi, Dartmouth-Hitchcock

Meridith Bailey, MPOG

Ron George, UCSF

Nicole Barrios, MPOG

Kim Finch, Henry Ford Health System

Kate Buehler, MPOG

Brandon Togioka, OHSU

Nirav Shah, MPOG

Nicole Zanolli, Duke University

Meridith Bailey, MPOG

Dan Biggs, University of Oklahoma

Ronnie Riggar, MPOG

Announcements

● Meeting dates posted to basecamp. Also see website for 2023 meeting schedule

● July meeting recap:

○ presented data capture rates for cesarean delivery cases in MPOG.

○ Subcommittee voted to move forward with GA03-OB.

Temp 01- Active warming

● Background- 1st published in Jan 2020

● Every 3 years each ASPIRE measure is reviewed by Quality Committee

● Should TEMP 01 continue to access fluid warming as active warming for this pt population?

● Literature limited to small studies and no single, fluid warming studies were found.

Warming Literature

● Butwick, Lipman, Carvalho article- Intraoperative Forced air-warming during cesarean

delivery under spinal

● Sultan, Habib, Cho and Carvalho- The effect of patient warming during cesarean delivery

on maternal…

● Horn, Schroeder, Gottshalk- Active warming during cesarean delivery

● Meghana, Vasudevaro, Kamath- THe effect of combination of warm IV fluid infusion and

FAW vs FAW alone on maternal temperature…

● Cobb, Cho, Hilton- Active warming utilizing combined IV fluid and FAW decreases

hypothermia…

Discussion:

○ Nirav Shah (MPOG QI Director): What is the practice for cesarean deliveries at each of

your institutions?

■ Monica Servin (University of Michigan) We use warm blankets and fluid warmers

but do not use forced air. There’s a big emphasis here on skin-skin with mom

and the forced air warmer can be bulky and there’s minimal area between mom

and incision. However, we do not routinely assess patient comfort

■ Sharon Abramovitz (Cornell): Using underbody forced air warming and temp

sensing foley catheters at Weill Cornell Medicine

■ Ron George (UCSF): No active warming here

■ Wandana Joshi (Dartmouth): haven’t been able to convince them to use a bair

hugger. Nursing is opposed to it and says it interferes with skin-skin. We do use

fluid warmers. Great point on how we don’t generally assess the mothers state

of comfort.

● We’ve been trying to place an underbody but not for elective C-sections.

● Preet Singh (Wash U): Patients ask us to turn it off in 10-15% of patients

as they are uncomfortable with the Bair Hugger on

■ Sharon Abramovitz (Weill Cornell): Doesn’t work with patients with a larger BMI

so makes it challenging but we use fluid warmers in that situation

○ Jessica Wren (Henry Ford Health System): Do we have any data correlating TEMP 01 and

TEMP 05?

○ Nirav Shah (MPOG QI Director): I think it makes sense to focus more on the outcome of

hypothermia and exclude Cesarean Sections from TEMP-0. Can re-evaluate when new

literature is available.

○ Poll results

○

GA-03-OB draft

● Description: Percentage of cesarean delivery cases converted to general anesthesia after

epidural

○ GA-03b-OB: Percentage of cesarean delivery cases converted to general anesthesia after

combined spinal epidural

● Inclusion: Cesarean delivery cases with epidural anesthesia administered

○ GA-03b-OB: Cesarean delivery cases with combined spinal epidural

● Exclusion:

○ Cesarean Hysterectomies as determined by the “Obstetric Anesthesia Type” Phenotype.

○ Non-cesarean delivery cases, including labor epidural only cases

○ Cesarean delivery cases without epidural placement (or CSE for GA-03b)

● Was posted to basecamp for comments/review for those unable to attend the meeting today

● Considerations:

○ Exclusion for cases converted to GA >= 75 min after neonate delivery.

○ Cases converted to GA before neonate delivery and after epidural placement will be

included.

○ Documentation is not standardized enough to detect medical reason vs. failed epidural

● Review performance for existing GA measures for cesarean delivery (See slides for GA-01, GA-02,

and GA-03 performance across MPOG sites)

● GA 03-OB next steps- neuraxial and obstetric anesthesia type need some revisions before this is

public on dashboards

○ Would the group like to move forward with this measure?

● Discussion:

○ Nirav Shah (MPOG QI Director): Lots of variation where half the sites are converting

epidural cases to GA. Was that surprising? Are there places where you typically just

convert to a GA immediately rather than converting the epidural to be used for the

cesarean?

○ Melinda Mitchell (HFHS - Allegiance): Physicians previously were less hands on where

CRNAs would start without their presence to get the baby out. We started leading an

effort after joining MPOG to change the culture where if the epidural was working that

the CRNAs would bolus the epidural and then proceed to GA at that point if needed

which has lowered our numbers. I think its driven by the Obstetricians at each sites

■ Monica Servin (University of Michigan): for sites with lower number of

C-sections with higher rates of GA conversions. Is that due to anesthesia

providers being more comfortable with GA?

■ Kate Buehler (MPOG Clinical Program Manager): I hope some of this variation

will improve a little. For example, a site that has 60% conversion with only a few

c-section cases included. As our phenotypes are cleaned I'm confident we will

improve this capture.

○ Do we want to move forward with building GA-03 measure and push to a dashboard?

■ Melinda Mitchell (HFHS-Allegiance): I think we should leave it in place because

this measure had a positive impact on my practice

■ Brandon Togioka (OHSU): I like this measure. I thought our performance

would’ve been higher but it wasn’t. This is also a hot topic with SOAP currently.

Oxytocin

● Basecamp discussion July 2022:

○ post regarding oxytocin design at other sites for cesarean delivery.

○ range of practices reported on forum.

● Literature review:

○ Heesen, Carvalho, Duvekot- International consensus statement on the use of uterotonic

agents during cesarean section.

○ Duffield, McKenzie, Carvalho- The effect of high rate vs low rate of oxytocin infusion for

maintaining uterine contractility during elective cesarean

● MPOG coordinating center review:

○ 238 cesarean cases across 49 sites

○ No standard bolus amount found: 1-6 units found in documentation in MPOG

○ No standard infusion rate was found among sites

○ Does your site have a standard practice around oxytocin dosing for cesarean delivery?

Poll Results:

Anesthetic Management of Cesarean Hysterectomy for Placenta Accreta Spectrum

Nicole Zanolli and Dr. Ashraf Habib

● Background

● Gaps

● Primary objective of study

● Secondary objective

● Study Design- retrospective cohort study

○ Inclusion criteria-

■ January 1, 2015- December 31, 2021

■ “Cesarean Hysterectomy” in OBAT phenotype

■ MPOG case reviewer to insure will manually reviewed

○ Exclusion criteria-

■ Patients <13 years of age

■ Length of procedure <15 minutes

■ Procedures occurring after cesarean hysterectomy

● Progress

○ completed single center review of PAS at Duke

○ received PCRC approval

○ Planning for individual case review

● Discussion:

○ Nirav Shah: You presented a primary and secondary analysis- are you planning to submit

the descriptive analysis first as one paper and then a secondary paper based on

outcomes based on different techniques?

■ Ashraf Habib: Not sure what we’ll get based on the data but we do think we’ll

end up with two main projects. Will depend on how many instances we find

within each group to know how to proceed.

■ Nirav: could narrow it down to the centers who perform the most cesarean

hysterectomies first

■ Ashraf: Agree! There are many ways we slice this data- we are excited to see the

results and begin our analysis. The benefit of MPOG is the rich intraoperative,

minute-to-minute data from many centers.

Meeting End Time: 1354