Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)
OB Subgroup Meeting Minutes – Feb 15, 2023
Attendance:
Meridith Bailey, MPOG
Tiffany Malenfant, MPOG
Nicole Barrios, MPOG
Michael Mathis, MPOG
Dan Biggs, University of Oklahoma
Graciela Mentz, University of Michigan
Kate Buehler, MPOG
Diane O’Dell, MPOG
Laurie Chalifoux – Corewell West
Monica Servin, University of Michigan
Ruth Cassidy, MPOG
Denise Schwerin, Bronson Healthcare
Rob Coleman, MPOG
Nirav Shah, MPOG
Kim Finch, Henry Ford Health System
Preet Singh, Washington University
Josh Goldblatt, Henry Ford Health System
Frances Guida Smiatacz, MPOG
Daniel Grutter, Trinity Health
Brandon Togioka, OHSU
Ashraf Habib, Duke University
Rachel Toonstra, Corewell Health West
Jerrilyn Heiter, Trinity Health
Sushma Vallamkonda, MPOG
Wandana Joshi, Dartmouth-Hitchcock
Christine Warrick, University of Utah
Sachin Kheterpal, MPOG
Yuan Yuan, University of Michigan
Tory Lacca, MPOG
Sarah Zhao, University of Michigan
Announcements
● Meeting dates posted to basecamp. Also see website for 2023 meeting schedule
● December meeting recap:
○ Subcommittee voted to exclude Cesarean Deliveries from TEMP-01 data. This change
has been implemented: score changes minimal (-2.2-+5 points).
○ Discussed Oxytocin dose ranges at MPOG sites. A survey was sent out to gather
information from sites – will share later in meeting.
○ Dr. Ashraf Habib and Nicole Zanolli presented the research project on placenta accreta.
Measure Updates
• GA-03-OB – Will likely go live by end of March. The Neuraxial and Obstetric Anesthesia Type
phenotypes need revisions before we make this measure public on dashboards.
• TEMP-01 - Cesarean deliveries now excluded from this measure.
Temp 05- Measure Review
• TEMP-05 is the first obstetric-specific measure due for review in early 2023.
• We are seeking one or two volunteers, from two different institutions, to review this measure
and associated normothermia literature.
• Reviewers name will be in Measure Spec webpage.
• Template form
Discussion: Nirav Shah, (MPOG QI Director) via chat - Thanks everyone for considering a
measure review! so important to keeping our measures relevant!
PCRC Overview
• OB-related Research Questions Answerable with MPOG
• Steps to Develop Research Proposal
• Tips and Tricks Research Modules
• Importance of Preparation
• MPOG Research consultations
• Discussion:
o Preet Singh – What are the permissions to gaining access to DataDirect?
▪ The DataDirect affidavit can be found on our website. Once signed and returned
to the coordinating center and your access will be updated.
QI Story: ABX-01 Bronson Kalamazoo, Dr. Rob Nicholson
• Anesthesia staff education surrounding antibiotic administration prior to spinal and reminders
posted in each L&D operating room
• Labor epidurals converting to C-section
o L&D nurse start azithromycin in patient room (ruptured/in labor)
o L&D nurse may also start cefazolin
• Having the ability to view the entire patient encounter via MPOG provided the opportunity to
review this data and plan our intervention
Discussion:
• Nirav Shah, (MPOG QI Director)I: What was the biggest success and challenges of this project?
• Rob Nicholson (Bronson Kalamazoo): Intervention was early 2019, by Q2 of 2020 we had
improved 5% due mostly to our general staff education process. Challenges now surround
maintaining that performance. We have had a lot of staff turnover so educating new staff will be
important.
Oxytocin Survey Results
● Survey sent out Jan 3rd, 2023, and was active for 10 days.
● Questions were aimed at oxytocin administration following delivery of neonate: describe bolus
dose ranges and infusion amounts as well as duration of infusions following labor.
● Asked the group to share policies related to oxytocin administration at their site.
● Requested any additional topics for the subcommittee to discuss throughout the year.
● Received 10 responses out of a possible 26.
Discussion:
• How is the success of the infusion measured? Uterine tone grading? Is there opportunity to
standardize oxytocin infusion rates across sites?
o Wandana Joshi, Darmouth: We don’t do anything formal but get feedback from the
surgeon while closing the uterus and sometimes need to initiate that discussion. In
terms of standardizing oxytocin infusion rates I think this would be really challenging.
o Monica Servin (MPOG OB Chair) - At U of M we have tried to standardize but were not
successful. We often find that we tend to ask the questions first to the obstetrician.
o Christine Warrick (University of Utah) – our experience is similar; either tone is good or
tone is not good and we adjust our rate based on that answer
▪ We use the standardized infusion described by ______ 300milliunits/hr then
escalate to secondary uterine tone agents if needed
o Mike Mathis (MPOG Research Director) – has this group looked at these second line
agents and how often its happening and whether there is a need for rescue agents?
▪ Monica Servin (MPOG OB Chair) - Not that I’m aware of
▪ Mike Mathis (MPOG Research Director) – without a structured process for
rating uterine tone, is that even getting into the medical record? What is
documented is the medication administered. Similar to PONV measures looking
at antiemetics given in PACU, but considering an outcome measure looking at
the escalation of uterine tonics
▪ Wandana Joshi, Darmouth – we base our oxytocin infusion based on
postpartum hemorrhage risk. So someone who is at risk we have a low, medium
and high. If we give a low dose it’s a lower bolus (1mL) to high bolus (3mL). It
would be interesting to see which patients are high risk and if they are receiving
these additional agents
▪ Monica Servin (MPOG OB Chair) – infusion is guided for us based on scheduled
vs. conversion c-section. We have a pretty high postpartum hemmorhage rate
so I agree it would make sense to look at this data and see where we could
improve
▪ Mike Mathis (MPOG Research Director) – It sounds like most sites have a site
specific ‘standard’ protocol but maybe the first escalation isn’t an escalation
drug but a dose above the standard oxytocin. Ie define escalated uterine tonics
per site.
• Has anyone experienced adverse effects from oxytocin infusion in their patients?
o Monica Servin (MPOG OB Chair) – very uncommon or atleast mild hypotension which is
manageable but I haven’t seen anything major
o Christine Warrick (University of Utah) – I agree. There seems to be more hypotension
but its time for that to be happening and there is sometimes increased nausea after we
start oxytocin at a higher dose
o Brandon Togioka (OHSU) - I have seen chest tightness with higher doses and if you slow
it down it goes away
▪ Monica Servin (MPOG OB Chair) - I have also heard that but hard to determine
if that’s from oxytocin or uterus externalization
▪ Brandon Togioka (OHSU) – we are trying to transition away from externalizing
but most OB/GYNs are still doing it
▪ Wandana Joshi (Darmouth) – we have recently gotten our OB/GYNs together to
have a more family centered approach and we decided to have the partner
present for spinal, stop externalizing uterus and have seen great results: less IV
meds, less nausea…
Future Topics:
• Topics the OB Subcommittee would like to discuss in 2023 per January 2023 OB Subcommittee
Survey:
o NPO for labor epidural (not possible with MPOG data) Can send out survey if interested.
o Reducing the wet tap rate (not possible with MPOG data)
o Chloroprocaine spinals for short OB procedures (Can send out survey if interested)
o Epidural monitoring and labor analgesia (not possible with MPOG data)
o BMI Stratification across sites
o Transfusion and EBL
Discussion:
• Wandana Joshi (Darmouth) – when you talk about the epidural monitoring, we have created a
way to put in epidural monitoring into our EDH. We have put in this epidural rounding so the
residents are required to see the patients every 3-4hours to see how the epidural is doing. It
goes through the stepwise blockade assessment and then document any intervention that was
done. With a second intervention an alert goes to the anesthesiologist to suggest replacing the
epidural. Also interested in the use of tranexamic acid. Some of our OB/GYNs request it
prophylactically but there doesn’t seem to be any reason behind it. Are any other sites
documenting this?
• Monica Servin (MPOG OB Chair) – at U of Michigan anything over 1L of blood loss we use TA.
PONV Updates
● Question posted to Basecamp regarding data on the use of two agents for preventing PONV
during a cesarean delivery.
● Question also raised at previous meetings via chat in Zoom meetings.
● Information presented during the February 2022 meeting.
OB Dashboard Tutorial
Dashboard and Live Demo from Monica Servin.
*Of note, the obstetric dashboard automatically filters to cases that were categorized an obstetric case.
However, some measure excludes labor epidurals so performance is mostly based on cesarean deliver
cases.
Meeting End Time: 1402
