Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

OB Subgroup Meeting Minutes – Nov 8, 2023

Attendance:

Abramovitz, Sharon (Weill Cornell)

O'Dell, Diana (MPOG)

Addo, Henrietta (MPOG)

Owens, Wendy (MyMichigan)

Athar, Muhammad (UAMS)

Payne, Patrick (University of Vermont)

Attali, Ami (Henry Ford)

Peace, Jack (Temple)

Barrios, Nicole (MPOG)

Rozek, Sandy (MPOG)

Biggs, Dan (Oklahoma)

Servin, Monica (Michigan)

Buehler, Kate (MPOG)

Shah, Nirav (MPOG)

Cassidy, Ruth (MPOG)

Smiatacz, Frances Guida (MPOG)

Chen, Lee-Lyn (UCSF)

Togioka, Brandon (OHSU)

Coleman, Robert (MPOG)

Vallamkonda, Sushma (MPOG)

Finch, Kim (Henry Ford)

Wade, Meridith (MPOG)

Habib, Ashraf (Duke)

Waldman, Brian (Columbia)

Heiter, Jerri (Trinity)

Zambare, Sonal (Baylor)

Joshi, Wandana (Dartmouth)

Zittleman, Andrew (MPOG)

Malenfant, Tiffany (MPOG)

McKenzie, Christine (UNC)

Mentz, Graciela (MPOG)

Announcements:

1) Welcome New Members

• Jonathan Paul, MD Columbia

• Laurence Ring, MD Columbia

• Muhammed Athar, MD University of Arkansas

• Jack Peace, MD Temple Health

2) Seeking OB Subcommittee Vice-Chair

• 3-year term

• Help shape direction of OB Subcommittee

• Measure performance review, new measure development, measure revision

• Identify and participate in research opportunities

• Work with Nicole and the MPOG team

3) OB Subcommittee Teams Meeting Dates 2024:

• Feb 7, 2024 @1pm EST (Brendan Carvalho, MD - SOAP Stanford)

• May 22, 2024 @1pm EST

• Oct 2, 2024 @1pm EST

• PCRC proposals updates at future meetings:

o PCRC 193

o PCRC 150

May Meeting Recap

• Measure review: ABX 01

-Percentage of cesarean deliveries with documentation of antibiotic

administration initiated within one hour before surgery start.

• At the May subcommittee meeting, members voted to add Placenta Accreta as an exclusion for

the GA measures.

– Score change minimal < 0-3% for sites

– 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.

– GA-03- Percentage of cesarean delivery cases where general anesthesia was used after

epidural.

• Azithromycin measure – Percentage of unscheduled cesarean deliveries in which azithromycin

was administered within 60 minutes before incision or procedure start and anesthesia end.

Discussion:

• Brandon Togioka (OHSU): Too broad of an inclusion criteria. Vote to include all labor epidurals.

• Monica Servin (MPOG Obstetric Subcommittee Chair): If azithromycin was started on nursing

documentation it might be hard to capture that since documented outside of anesthesia record

• Ashraf Habib (Duke): Is the time period 60 minutes before until any time throughout anesthesia

care? Will it capture c-section without epidural?

o Nicole Barrios (MPOG Obstetric Subcommittee Lead): Those cases should be included.

Cesarean Delivery and conversions are included. Hysterectomy c-sections are excluded.

• Dan Biggs (U. Oklahoma): 90% of antibiotics are started by nursing, so it won’t impact

anesthesiologist here.

• Monica Servin (MPOG Obstetric Subcommittee Chair): Can we get the data if started by nursing?

o Nicole Barrios (MPOG Obstetric Subcommittee Lead): If not documented by anesthesia,

we won’t have the data in MPOG

• Monica Servin (MPOG Obstetric Subcommittee Chair): Azithromycin does have a longer half-life

• Sonal Zambare (Baylor University): Is this only for azithromycin?

o Monica Servin (MPOG Obstetric Subcommittee Chair): Yes, this measure is currently only

considering azithromycin but we could consider adding other medications. Speaking for

UofM, it’s based on OB preference - do other institutions give all of these antibiotics

(Clindamycin and Gentamycin).

 Ashraf Habib (Duke): We do give all of those

 Sharon Abramovitz (Weill Cornell): All four are not administered at our

institution.

 Brian Waldman (Columbia): We exclude patients on antibiotics

• Brandon Togioka (OHSU): What about excluding patients that receive clindamycin? Thought is

clindamycin might be an indicator that patient has chorioamnionitis

o Monica Servin (MPOG Obstetric Subcommittee Chair): Is it possible to get these data?

 Nicole Barrios (MPOG Obstetric Subcommittee Lead): Will investigate a bit more

with programmer and Kate to see what data we can pull for

• Ami Attali (Herny Ford): Is the threshold set at 90% - is that appropriate for this measure?

o Monica Servin (MPOG Obstetric Subcommittee Chair): Speaking for the University of

Michigan, our practice is to give azithromycin to all patients requiring an unscheduled

cesarean delivery. I believe that’s what the literature supports also – not sure what

other sites are doing.

Vote: Skipping poll for now to see what additional data we may have and will vote in February

In the news segment

Event

- Healthy 27 y/o G2P1 laboring:

• Epidural

• Abnormal presentation: Arm above head

• Cord prolapse  taken to OR to deliver: 10 minutes

• Mom emergently intubated d/t pain. Fluid suctioned from lungs.

• Extubated without issue, lab work normal postoperatively.

• Day 10: Patient is weak, requiring increased respiratory support -> Intubated, Hypotensive,

WBC count: 40

• Patient codes but is resuscitated. Codes again: resuscitation not successful.

Discussion:

• Monica Servin (MPOG Obstetric Subcommittee Chair): What could they have done differently?

• Brandon Togioka (OHSU): We get a push back about putting patients on NPO. Putting patients

on clear is more beneficial from a nursing standpoint.

• Ashraf Habib (Duke): We insist on patients remaining NPO. We often get push back from

midwives and nursing, but we require the patent to stay NPO.

• Wandana Joshi (Dartmouth): Also get push back from nursing and midwives. It will be

interesting to know what we find in the future research with gastric ultrasound.

o Monica Servin (MPOG Obstetric Subcommittee Chair): Does anyone incorporate gastric

ultrasound in their practice?

o Wandana Joshi (Dartmouth): it will take time, but I can see it being done in the future. it

is pretty unusual that this kind of outcome occurs

o Monica Servin (MPOG Obstetric Subcommittee Chair): Yes, it is sad and very unusual but

shows anything can happen in the obstetric world

BP 04 Measure Review – Link

• Dan Biggs, MD – University of Oklahoma

• Preet Singh, MD – Washington University

Discussion:

• Dan Biggs (U. Oklahoma): Does everyone do BP more than 5 minutes once spinal is placed?

o Ashraf Habib (Duke): I do it every minute

o Wandana Joshi (Dartmouth): 2 minutes

o Muhammad Athar (UAMS) in chat: Every minute till the baby is out, then every 3

minutes

Poll: How frequently do you check a blood pressure after spinal placement?

BP04 Vote Decision: Continue measure as is (100%)

Body Mass Index Stratification

• According to the CDC, in 2020 31.8% of live births with cesarean deliveries – see slide 11 for

national cesarean delivery data from CDC stratified by BMI

• Slide 12: Aggregate MPOG data shared with the committee showing breakdown of patients by

BMI

Discussion:

• Monica Servin (MPOG Obstetric Subcommittee Chair): Do these numbers seem to reflect the

patient population at your sites?

o Ashraf Habib (Duke): Is it possible to look at the super obese, BMI > 40, category?

 Monica Servin (MPOG Obstetric Subcommittee Chair): I think we can look at that

 Nicole Barrios (MPOG Obstetric Subcommittee Lead): Our phenotype doesn’t

group beyond BMI >40 but we can probably assess how many cesarean

deliveries had a BMI >40 vs. >45 vs. >50.

o Sharon Abramovitz (Weill Cornell): We used to consult on patients with a BMI of 40-45

and now only consult for > Anesthesia procedure of BMI greater than 50.

 Ashraf Habib (Duke): Same, we went from 40/45 at our site to consultations for

BMI of 50.

 Monica Servin (MPOG Obstetric Subcommittee Chair): They present more

challenges.

Uterotonic Agents – MPOG data presented:

Administration by agents (see slides 14-15)

Agents and transfusion (see slide 16)

Agents and EBL (see slide 17)

Agents and transfusion stratified by EBL (see slide 18)

Discussion:

• Monica Servin (MPOG Obstetric Subcommittee Chair): Does anyone not use oxytocin as a first

line agent? Or is it pretty much what everyone uses?

o Wandana Joshi (Dartmouth): Yes, that’s our first line agent

o Ashraf Habib (Duke): Agree – our first line agent is also oxytocin

o Sonal Zambare (Baylor University): Yes, first line agent is oxytocin.

• Ashraf Habib (Duke): Unless Canadian sites, but in U.S. oxytocin is likely the first line agent for

most sites

• Brandon Togioka (OHSU): Not surprised that most common agent is Oxytocin. Am surprised to

see Misorostol as second line agent since it’s not as effective as others.

• Kim Finch (Henry Ford Health) in chat: Does anyone use TXA?

o Lee-lynn Chen (UCSF): Yes

• Monica Servin (MPOG Obstetric Subcommittee Chair): Methergine is most common second

medication to add for bleeding.

• Brian Waldman (Columbia): We use Misoprostol as 3

option, given PR by nursing team.

• Wandana Joshi (Dartmouth): We don’t use carboprost so often definitely a further down the

road agent.

• Ashraf Habib (Duke): Typically, Methergine or Carboprost as the second-line agents

• Sharon Abramovitz (Weill-Cornell): Agree with all that, just wondering is anybody or any of the

obstetricians giving misoprostol intra myometrial during the C-section putting the tablets into

the uterus?

o Ashraf Habib (Duke): They do not at our hospital.

o Wandana Joshi (Darthmouth): I haven’t seen that done in years.

o Monica Servin (MPOG OB Subcommittee Chair): Does it seem to work better?

o Sharon Abramovitz (Weill Cornell): No

• Wandana Joshi (Dartmouth): Methergine but not prior to oxytocin. Methergine reduces rates of

transfusion in a journal article I recently read. (Will post to forum when she finds article).

• Monica Servin (MPOG Obstetric Subcommittee Chair): How is transfusion, not MTP, requested?

OBs vs Anesthesiologists?

o Ashraf Habib (Duke): Typically, the anesthesia team

• Sharon Abramovitz (Weill-Cornell): Phenylephrine rates? What’s considered as usual when

higher rates are required? Sparks transfusion conversation. When patients come to OR for spinal

anesthesia, adjustments are made. With ongoing bleeding, when we have to go up on the

infusion, communication to OB team is needed.

o Monica Servin (MPOG Obstetric Subcommittee Chair): Communication with OB team

would be a good area for process improvement.

Meeting End Time: 1355