ASPIRE Obstetric Anesthesia Subcommittee Meeting

February 2, 2022

Agenda

• Announcements

• November 2021 Meeting recap

• PONV 05: Obstetric Considerations

• Unblinded data review: PONV Measures

• 2021 Recap and 2022 Planning

Announcements

• OB Subcommittee Virtual Meetings

– August 3rd, 1pm EST

– December 7th, 1pm EST

• MPOG Retreat in New Orleans, LA

– October 21, 2022

November Meeting Recap

• Reviewed unblinded site performance for ‘general anesthesia in cesarean

delivery’ measures (GA 01/02)

– Subcommittee expressed interest in separating elective vs. non-elective cesarean

cases

– MPOG can separate ASA ‘E’ cases but not necessarily indicative of elective vs.

non-elective

– Many non-elective c-sections do not have an ‘E’ assigned

– SOAP Centers of Excellence recommends reviewing cases that converted to

general anesthesia at an institutional level

– Follow-up question: Would there be interest in developing a list of considerations

for reviewing these cases at your sites?

November 2021 Meeting Recap

Subcommittee discussed the applicability of existing ASPIRE glycemic management measures

for the obstetric population

– Subcommittee recommended excluding cesarean deliveries from all glucose measures

(GLU 01-05)

– After reviewing cases, Coordinating Center proceeded with excluding cesarean deliveries

from hyperglycemia measures (GLU 01/03/05) as this is typically managed outside of the

OR by obstetrician and nursing

– However, we opted to continue to include cesarean deliveries for hypoglycemia measures

(GLU 02/04) at this time due to potential opportunity to improve health system processes

(outside of OB).

– Plan to revisit with Quality Committee & see if attribution might be removed for obstetric

anesthesiologists in the future

Postoperative Nausea

and Vomiting (PONV)

ASPIRE Measures

New Prophylaxis Measure: PONV 05*

• 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:

– At least two prophylactic pharmacologic antiemetic agents of different classes administered

preoperatively or intraoperatively for patients with one or two risk factors

– At least three or more prophylactic pharmacologic antiemetic agents from different classes preoperatively

or intraoperatively for patients with three or more risk factors

– For cesarean delivery cases only: At least two prophylactic pharmacologic antiemetic agents from

different classes preoperatively or intraoperatively. (per SOAP ERAS 2021 guidelines)

• Excludes: Labor epidurals

• Risk factors not considered for cesarean delivery patients

• Measure time period: Cesarean delivery start for conversion cases, preop start for scheduled c-sections

*Replaces PONV 01 measure

Postoperative Nausea and Vomiting Measures

• There is no risk score for postoperative nausea and/or vomiting (PONV) in parturients.

• Assessed potential parturient and peri-operative risk factors for PONV.

• Non-smoking, history of PONV after cesarean and/or morning sickness increase risk

• All factors were included in an obstetric-specific risk score (Duke score)

• Both Duke and Apfel risk scores performed poorly in prediction of PONV.

PONV 05 Considerations for Cesarean Deliveries

• Agree on the inclusion criteria for cesarean delivery patients

• Agree with measure time period for administration: Preop start - PACU Start?

• Agree on administering 2 anti-emetics, regardless of number of risk factors?

• Agree with giving any 2 antiemetics from separate classes? Specify which classes must

be given (or not given)?

– For example, propofol infusion is currently included as an acceptable antiemetic

• Do current exclusions apply?

– ASA 5 or 6

– Patients <18 years old (a separate pediatric measure is available)

– Patients transferred directly to the ICU

Unblinded Data Review

Reminders

• Per the terms and conditions outlined during the registration process:

– A culture of openness and trust are critical to the development of such a collaborative effort to

improve quality; and a commitment for confidentiality is required to further the goals of ASPIRE.

– The following examples are to be considered privileged and confidential information and should be

discussed only within the confines of the OB Subcommittee Meeting.

– Any and all patient information.

– Any and all patient identifiers/information which are considered privileged and protected

health information as defined by current HIPAA laws.

– Any specific MPOG QI registry case information.

– Any information discussed regarding a specific site outcome.

– Any reference to a specific MPOG site result or analysis.

– All anesthesiology data presented including but not limited to outcome reports.

– Taking screenshots, pictures or videos of data slides is prohibited.

Site Participation

• All sites that perform cesarean deliveries are presented on the slides to follow (sites

without PACU data excluded)

• Only those sites who have a participant registered for today’s meeting are unblinded

• Quality and OB Champions were notified that unblinded data would be shared and

were given the opportunity to opt out

• No sites emailed us to express a desire to be excluded from this review

Current Outcome PONV Measure: PONV 03

• Percentage of patients, regardless of age, who undergo a procedure and have a

documented nausea/emesis occurrence OR receive a rescue antiemetic in the immediate

postoperative period

• Time period: Recovery room in through 6 hours after Anesthesia End

• Inclusion: Cesarean Deliveries

• Exclusion: Labor Epidurals

• Success: Patient does not report nausea, have an emesis event or receive an antiemetic

during the immediate postoperative period.

• Displayed as an inverse measure: lower is better

Note: Performance for PONV 03/03b was shared with the subcommittee- this was a

confidential session; unblinded data was removed from the presentation before posting.

General discussion topics are noted in the minutes - any comments specific to a site's

performance were omitted from the minutes.

Current Measure: PONV 03b

• Percentage of patients, regardless of age who undergo a procedure and have a documented

nausea/emesis occurrence with or without receiving an antiemetic in the immediate

postoperative period.

• Time period: Recovery room in through 6 hours after Anesthesia End

• Inclusion: Cesarean Deliveries

• Exclusions: Vaginal Delivery Cases & Patients transferred to ICU

• Success: Patient does not report nausea or have an emesis event during the immediate

postoperative period.

• Displayed as an inverse measure: lower is better

PONV 03 and PONV 03b

• Both are already available on the OB Dashboard displayed as filtered to OB

• Recommended modifications for OB?

2022 Planning

Progress in 2021

• Created new postop temperature measure for cesarean deliveries:

TEMP-05-OB

• Created measures focused on general anesthesia rates for cesarean

deliveries

– GA 01: Percentage of cesarean delivery cases where general anesthesia was used

– GA 02: Percentage of cesarean delivery cases where general anesthesia was

administered after neuraxial anesthesia

• Added specific criteria for cesarean deliveries in new PONV prophylaxis

measure: PONV 05

Recap of 2021 Plans

• Sent out survey in late 2020: 9 responses

2021 Planning Survey ‘Write-In’ Measure Suggestions

Rating: ‘Extremely Important’

Topic MPOG Data Availability

Appropriate addition of azithromycin for cesarean sections

Yes

Regular patient checks for parturients with labor epidurals

Maybe - Pain scores from

some sites; need more info

GA for elective and urgent/emergency cases

Emergency cases - Yes

Elective - No

Pain >= 3 during labor with epidural (within 60 minutes of initiation)

Maybe - Pain scores from

some sites

Incidence of dural puncture with epidural

Accidental Dural Puncture / PDPH

Incidence of blood patch

2021 Planning Survey ‘Write-In’ Measure Suggestions

Rating: ‘Very Important’

Topic MPOG Data Availability

Need for blood product transfusion if intra-procedure PPH

Yes

Failed extension of epidural for Cesarean Delivery

Yes - Subset of GA 02

Antiemetics administered preop/intraop

Yes - PONV 05

Phenylephrine infusions and regulatory requirements

Presence of Infusion - Yes

Regulatory requirements?

Adherence to ERAS/ERAS milestones

Maybe - Need more info

Rate of epidural replacement in labor

Next Steps

• Modifications to PONV outcome measure for obstetric population?

• New Measure Options:

– Multimodal analgesia for cesarean deliveries

– Azithromycin use

– Phenylephrine infusion use

– ERAS area of focus?

• MPOG Coordinating Center to send out new survey to assess and prioritize

topics of interest for OB Subcommittee next steps

THANK YOU!

Kate Buehler MS, RN

MPOG Clinical Program Manager

kjbucrek@med.umich.edu

Monica Servin, MD

MPOG Obstetric Anesthesia

Subcommittee Chair

monicar@med.umich.edu