MPOG Cardiac Anesthesia Subcommittee Meeting

September 23, 2023

Agenda

• Welcome & announcements

• Discussion of upcoming cardiac-focused measure reviews

• Hypoglycemia outcome measure (GLU-07-C) discussion (counter measure to

GLU-06-C)

• Discussion of hyperglycemia process measure (GLU-08-C)

• Topic brainstorming for next measures and potential antibiotic redose timing and

selection measures

• Summary and next steps

Introductions

• ASPIRE Quality Team

– Allison Janda, MD – MPOG Cardiac Anesthesia Subcommittee Lead

– Michael Mathis, MD – MPOG Director of Research

– Kate Buehler, MS, RN – Clinical Program Manager

• Cardiac Anesthesiology Representatives joining us from around the US!

Upcoming Cardiac-Focused Measure Reviews

• FLUID-01-C review, October 2023

– We are seeking one or two volunteers from

different institutions, to review this measure and

associated colloid use literature

– Commitment:

– Present literature and suggestions at the

October (10/23) Quality Committee meeting

– Reviewers name will be listed on the

Measure Spec

– Template form

• TEMP-06-C & TEMP-07-C reviews in January 2025

Upcoming Cardiac-Focused Measure Reviews

• FLUID-01-C: Minimizing Colloid Use (Cardiac)

– Definition: Percentage of cardiac cases in which colloids were not administered

intraoperatively

– Rationale: Lack of consistent evidence to suggest improved survival with the use of

colloids as compared to crystalloids in the surgical population. Because colloids

are more expensive than crystalloids, it is recommended that anesthesia providers

avoid the use of colloids in most instances.

Hyperglycemia avoidance measure (GLU-06)

• GLU-06 is released and is available on your dashboards!

• GLU-06 Success:

– Percentage of patients, ≥18 years age, who undergo open cardiac surgical

procedures under general anesthesia of 120 minutes case duration or longer for

whom any blood glucose measure did not exceed 180 mg/dL (and not rechecked

within 30-minutes and found to be </=180 mg/dL) was documented.

– Note: open cardiac cases without ANY glucose values documented are flagged

GLU-07 and GLU-08 Discussion & Preliminary

Data

Cardiac Hypoglycemia Avoidance Measure (GLU-07)

• GLU-07:

– Percentage of adult patients, undergoing open cardiac surgery with any

intraoperative blood glucose value < 70 mg/dL.

– Note: open cardiac cases without ANY glucose values documented are flagged

• Timing:

– Start: Anesthesia Start

– End: 15 minutes after Anesthesia End

Cardiac Hypoglycemia Avoidance Measure

• Concepts Queried:

• Attribution:

– The provider signed in at the first blood glucose of <70 mg/dL.

– In the event that two or more providers in the same role are signed in, both will

receive the feedback.

Glucose MPOG Concept IDs

3361 POC- Glucose (Fingerstick)

3362 POC- Glucose (Unspecified Source)

3405 POC- Blood Gas - Glucose

5003 Formal Lab-Glucose, Serum/Plasma

5036 Formal Lab-Blood Gas, Glucose

Cardiac Hypoglycemia Avoidance Measure

• Inclusions:

– All patients, 18 years of age or older, both with and without diabetes, who

undergo open cardiac surgical procedures (as determined by Procedure Type:

Cardiac phenotype) under general anesthesia of 120 minutes duration or longer.

• Exclusions:

– ASA 6

– Organ harvest (CPT: 01990)

– Non-cardiac cases as defined as those cases not meeting criteria for the cardiac

case type phenotype

– Within the general cardiac case type phenotype, exclude:

Transcatheter/Endovascular, EP/Cath groups and Other Cardiac

– Cases with age <18

Considerations

● Evaluate each low glucose between anesthesia start and end:

○ If blood glucose <70mg/dL is rechecked within 15 minutes and found to be <70mg/dL =

flagged.

○ If blood glucose <70 mg/dL is not rechecked within 15 minutes = flagged.

○ Any case with a glucose <70mg/dL that was rechecked within 15 minutes and found to be

>/=70mg/dL = pass.

○ If no low glucose values <70 mg/dL are documented between anesthesia start and end,

case is passed.

○ If two blood glucose levels are documented in the same minute, the higher blood glucose

will be considered for this measure (in the case of spurious values that were rechecked)

○ If no blood glucose values are documented for a case, then the case will be flagged

Preliminary Performance: GLU-07 (hypoglycemia avoidance measure)

Cardiac Hypoglycemia Avoidance Measure

• Limitations:

– Any glucose checks not entered into the EHR will not be captured

• Remaining Questions:

– Is the 15 minute recheck window appropriate?

– Should we amend GLU-06 to shorten the recheck window to 15 minutes as well?

(currently 30 minute recheck window for GLU-06)

Cardiac Hyperglycemia Treatment Measure (GLU-08)

• GLU-08:

– Percentage of patients, ≥18 years age, who undergo open cardiac surgical

procedures under general anesthesia of 120 minutes case duration or longer for

whom any blood glucose measure >/=180mg/dL was either treated with insulin or

rechecked and found to be <180mg/dL within 30 minutes.

– Note: open cardiac cases without ANY glucose values documented are flagged

• Timing:

– Start: Anesthesia Start

– End: 30 minutes after Anesthesia End

Cardiac Hyperglycemia Treatment Measure

• Concepts Queried:

• Attribution:

– The provider signed in at the first blood glucose of >180mg/dL.

– In the event that two or more providers in the same role are signed in, both will

receive the feedback.

Insulin MPOG Concept IDs Glucose MPOG Concept IDs

10229 Insulin Aspart 3361 POC- Glucose (Fingerstick)

10230 Insulin Glargine 3362 POC- Glucose (Unspecified

Source)

10231 Insulin Novolin 3405 POC- Blood Gas - Glucose

10232 Insulin NPH 5003 Formal Lab-Glucose,

Serum/Plasma

10233 Insulin Regular 5036 Formal Lab-Blood Gas,

Glucose

10659 Insulin- Unspecified

Cardiac Hyperglycemia Treatment Measure

• Inclusions:

– All patients, 18 years of age or older, both with and without diabetes, who

undergo open cardiac surgical procedures (as determined by Procedure Type:

Cardiac phenotype) under general anesthesia of 120 minutes duration or longer.

• Exclusions:

– ASA 6

– Organ harvest (CPT: 01990)

– Non-cardiac cases as defined as those cases not meeting criteria for the cardiac

case type phenotype

– Within the general cardiac case type phenotype, exclude:

Transcatheter/Endovascular, EP/Cath groups and Other Cardiac

– Cases with age <18

Considerations

● Evaluate each high glucose between anesthesia start and end:

○ For any blood glucose >/=180mg/dL, at least one of the following interventions are

documented:

■ Treatment with insulin within 30 minutes, or

■ Glucose rechecked and found to be below 180mg/dL within 30 minutes

● If two blood glucose levels are documented in the same minute, the lower blood

glucose will be considered for this measure

Preliminary Performance: GLU-08 (hyperglycemia treatment measure)

Performance for GLU-06 (Hyperglycemia Avoidance Measure)

Cardiac Hyperglycemia Treatment Measure

• Limitations:

– Any glucose checks not entered into the EHR will not be captured

• Remaining Questions:

– Should the recheck window be shortened to 15 minutes?

Progress and Next Steps

• Build 1 cardiac-specific measure in 2021 (completed, published 12/2021)

– Post-bypass hypothermia avoidance (TEMP-06)

• Build 1 cardiac-specific measure in early 2022 (completed, published 11/2022)

– On-bypass hyperthermia avoidance (TEMP-07)

• Plan and build next measure in mid-2022 and publish in early 2023 (completed,

published 4/2023)

– Hyperglycemia avoidance (GLU-06)

– Hypoglycemia avoidance and refined hyperglycemia treatment and measures to

be released soon

• Next measure?

Next Measure Discussion:

• Previous suggested topics include:

– Antibiotic selection and timing

– Neuromuscular blockade reversal

– Pulmonary complication avoidance

– Hypotension avoidance

– Acute kidney injury avoidance

– Handoffs

– Transfusion

– Other ideas?

Next Measure Discussion:

• Previous suggested topics include:

– Antibiotic selection and timing

– Neuromuscular blockade reversal

– Pulmonary complication avoidance

– Hypotension avoidance

– Acute kidney injury avoidance

– Handoffs

– Transfusion

– Other ideas?

Antibiotic selection and timing

Are Perioperative Antibiotics a Solved

Problem?

Median SCIP adherence by Hospital Referral Region

Source: hospitalcompare.gov

MPOG registry data from 31 centers between the dates of

01/01/2014 and 12/31/2018 was extracted to estimate the

adherence to four IDSA guideline metrics (timing prior to

incision, choice, dosing, redosing) for antibiotic

administration.

Methods

Inclusion Criteria: Patients 18 years of age or older who

underwent non-cardiac surgery involving skin incision.

Exclusion Criteria:

American Society of Anesthesiologists score (ASA) 6,

missing documentation for weight, antibiotic dose, or time

of administration.

Percent non-adherence by institution.

Results

Temporal trends in adherence from 2014 to 2018.

Results

But what about Cardiac… Aren’t we

better than that?

Association of adherence to individual components of Society of Thoracic Surgeons cardiac surgery antibiotic

guidelines and postoperative infections J Thorac Cardiovasc Surg.2023 Apr 17;S0022-5223(23)00325-2.

Of the 2829 included patients, 1084

(38.3%) received care that was

nonadherent to at least 1 aspect of

Society of Thoracic Surgeons antibiotic

guidelines. The incidence of

nonadherence to the 4 individual

components was 223 (7.9%) for timing of

first dose, 639 (22.6%) for antibiotic

choice, 164 (5.8%) for weight-based dose

adjustment, and 192 (6.8%) for

intraoperative redosing.

Thank you!!!

Rob Schonberger, Yale School of Medicine

Amit Bardia, MGH

Cardiac Anesthesia Subcommittee Membership

• Open to all anesthesiologists or those interested in improving cardiothoracic

measures

– Do not have to practice at an active MPOG institution

• Proposed 2023 Meeting Schedule

– April 2023

– August/September 2023

– November or December 2023

• Thank you for using the forum for discussion between meetings

Thank you!

Allison Janda, MD

MPOG Cardiac Anesthesia

Subcommittee Chair

ajanda@med.umich.edu

Glucose Measure Literature/Guidelines:

• In a study of 510 patients undergoing cardiovascular surgery and found the incidence

of AKI to be higher in patients with high HbA1c levels preoperatively; Every 1%

increase over 6% in HgA1c levels increased the risk of renal complications by 24%

• Glycemic variability, a standard deviation of all POC-BG readings, is associated with

increased postoperative LOS-ICU, rise in creatinine, and AKI

• A study including 761 cardiac surgery patients and found that diabetics were at

increased risk of infection and glucose control (120-160 mg/dL) reduced the risk of

wound infection in diabetics

• In a randomized controlled trial, moderate glucose control defined as 127-179 mg/dl

was found to be preferable to tight control ≤ 126 in patients undergoing CABG

Glucose Measure Literature/Guidelines Continued:

• Incidence of AKI was higher in patients with time-weighted average intraop glucose

of >150mg/dl (8%) as compared to patients with blood glucose 110-150 mg/dl (3%)

• KDIGO - recommends maintaining blood glucose between 110 - 149 mg/dL in

critically ill patients

• Tight glucose control (<150mg/dl) is seen as controversial as risks of hypoglycemia

are significant: NICE-SUGAR meta-analysis

• Society of Thoracic Surgeons (STS) Practice Guidelines recommend maintaining

serum glucose levels ≤ 180 mg/dL for at least 24 hours after cardiac surgery

• Guidelines for Perioperative Care in Cardiac Surgery from the Enhanced Recovery

After Surgery Society recommends treatment of blood glucose >160-180mg/dL

with an insulin infusion

References

1. Gumus F, Polat A, Sinikoglu SN, Yektas A, Erkalp K, Alagol A: Use of a lower cut-off value for HbA1c to predict

postoperative renal complication risk in patients undergoing coronary artery bypass grafting. J Cardiothorac

Vasc Anesth 2013; 27:1167–73

2. Bansal B, Carvalho P, Mehta Y, Yadav J, Sharma P, Mithal A, Trehan N: Prognostic significance of glycemic

variability after cardiac surgery. J Diabetes Complications 2016; 30:613–7

3. Hruska LA, Smith JM, Hendy MP, Fritz VL, McAdams S. Continuous insulin infusion reduces infectious

complications in diabetics following coronary surgery. Journal of cardiac surgery. 2005;20(5):403-407.

4. Bhamidipati CM, LaPar DJ, Stukenborg GJ, Morrison CC, Kern JA, Kron IL, Ailawadi G: Superiority of moderate

control of hyperglycemia to tight control in patients undergoing coronary artery bypass grafting. J Thorac

Cardiovasc Surg 2011; 141:543–51

5. Song JW, Shim JK, Yoo KJ, Oh SY, Kwak YL: Impact of intraoperative hyperglycaemia on renal dysfunction after

off-pump coronary artery bypass. Interact Cardiovasc Thorac Surg 2013; 17:473–8

References

6. KDIGO. 2012. “KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney

Disease.” https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf.

7. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY-S, Blair D, Foster D, Dhingra V, Bellomo R, Cook D,

Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA,

Norton R, Potter J, Robinson BG, Ronco JJ: Intensive versus conventional glucose control in critically ill patients.

N Engl J Med 2009; 360:1283–97

8. Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR, Bridges CR, Haan CK, Svedjeholm R,

Taegtmeyer H, Shemin RJ, Society of Thoracic Surgeons Blood Glucose Guideline Task Force: The Society of

Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann

Thorac Surg 2009; 87:663–9

9. Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M,

Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM: Guidelines for

Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg

2019 doi:10.1001/jamasurg.2019.1153

Current Cardiac-Specific Measures Developed

by the Subcommittee

TEMP-06

Success:

Percentage of patients, ≥18 years age, who undergo an open cardiac surgical

procedure under general anesthesia of 120 minutes duration or longer for whom the

last non-artifact body temperature measure at the end of the case was greater than or

equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit).

Reported as an inverse measure (lower = better)

TEMP-07

Success:

Percentage of patients, ≥ 18 years age, who undergo an open cardiac surgical

procedures using cardiopulmonary bypass under general anesthesia of >120

minutes for whom the temperature was > 37.5 degrees Celsius while on bypass for

over 5 consecutive minutes

Reported as an inverse measure (lower = better)

GLU-06

• Success:

– Percentage of patients, ≥18 years age, who undergo open cardiac surgical

procedures under general anesthesia of 120 minutes case duration or longer for

whom any blood glucose measure did not exceed 180 mg/dL (and not rechecked

within 30-minutes and found to be </=180 mg/dL) was documented.

– Note: open cardiac cases without ANY glucose values documented are flagged