Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

OB Subgroup Meeting Minutes – May 24, 2023

Attendance:

Sharon Abramovitz, Weill Cornell

Tiffany Malenfant, MPOG

Henrietta Addo, MPOG

Graciela Mentz, MPOG

Nicole Barrios, MPOG

Umma Munnur, Baylor

Dan Biggs, University of Oklahoma

Diana O'Dell, MPOG

Kate Buehler, MPOG

Sandy Rozek, MPOG

Ruth Cassidy, MPOG

Denise Schwerin, Bronson Battle Creek

Johanna Cobb, Dartmouth

Monica Servin, University of Michigan

Rob Coleman, MPOG

Nirav Shah, MPOG

Carlos Delgado Upegui, Washington

Preet Singh, Washington University

Kim Finch, Henry Ford Health System

Frances Guida Smiatacz, MPOG

Ron George, UCSF

Kathleen Smith, University of North Carolina

Josh Goldblatt, Henry Ford Health System

Brandon Togioka, OHSU

Ashraf Habib, Duke University

Sushma Vallamkonda, MPOG

Wandana Joshi, Dartmouth-Hitchcock

Christine Warrick, Utah

Rachel Kacmar, Colorado

James Xie, Stanford

Tom Klumpner, University of Michigan

Andrew Zittleman. MPOG

Tory Lacca, MPOG

Announcements

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

● Feb meeting recap:

○ Last meeting was held on February 15th. Slides and recording posted to basecamp.

○ ABX-01 QI story shared by Dr. Robert Nicholson from Bronson-Kalamazoo.

○ Dr. Mike Mathis, MPOG Research Director shared a brief overview of the PCRC process

for those interested in conducting research using MPOG data. Please visit the MPOG

website for steps to begin your proposal: https://mpog.org/write-a-research-proposal/

○ Reviewed oxytocin survey results and determined there is wide variation in oxytocin

dosages and rates of administration across sites. More research is needed in this area

before standardization can occur.

Measure Updates:

● GA-03-OB is on your dashboard now. Percentage of cesareans where GA was administered after

epidural injection.

● Contact nicbarri@med.umich.edu regarding access to the QI Reporting Dashboard

● Anonymized site performance shared with the group

Discussion:

● Dr. Ashraf Habib (Duke): Are DPE cases included in the GA-03 measure?

○ Kate Buehler (MPOG Coordinating Center): Not sure…would assume they are included

in this measure as epidurals but we haven't tested this out. May need to develop a new

phenotype.

● James Xie (Stanford): The denominator does NOT include epidurals that ended up vaginally

delivering right? Only epidurals that went to c-section AND converted to GA

● Ron George (UToronto): I would hope DPE and CSE are included in all epidurals. failure of

epidural service? not necessarily the technique

● Dan Biggs (UOklahoma): Most common reason for conversion to GA following epidural at our

institution is emergent C-section. Inadequate time to bolus epidural.

● James Xie (Stanford): I can speak offline to how DPEs are charted in Epic - totally depends on

how you set it up (as part of CSE vs epidural procedure note) and whether you have a custom

smart data element to flag that it was a DPE. At the last two institutions I’ve worked in, DPE was

counted as an epidural (not a CSE)

In the news: Oxytocin labeling practice was the topic of a recent Twitter discussion focused on patient

safety in obstetrical anesthesia practice

● What color are your labels?

Discussion

● Christine Warrick (Utah): We recently updated the color tubing to yellow

● Kathleen Smith (UNC): We could also benefit from that as the bag has recently changed and

caused some confusion

● Carlos Delgado Upegui (University of Washington) : Pink oxytocin labels on tubing

● Brandon Togioka (OHSU): We are putting a “hazardous medication” sticker on each bag. OHSU

considered creating greater restriction, which we fought. I gathered a group at OHSU and wrote

this letter to ensure continued easy access to oxytocin on labor and delivery.

GA-01 & GA-02 Measure exclusion: Placenta Accreta

● Recent request for placenta accreta cases to be excluded from GA measures.

● Would rely on ICD-10 codes to exclude placenta accreta

Discussion

● Christine Warrick (U. Utah): I do think these cases should be excluded as many of these cases will

go to GA and it will trigger these cases to be flagged.

● Kathleen Smith (UNC): I agree with excluding accreta cases. At least from GA-02. It is usually our

plan for NA then GA in accreta

● Sharon Abramovitz (Weill Cornell): I agree with excluding PAS from GA-02 too

● Ashraf Habib (Duke): No consensus on this practice so would also recommend excluding placenta

accreta from these measures

● Ron George (U.Toronto): Question - do we want to exclude placenta accreta cases that did not

require hysterectomy? I’m worried we may be over excluding cases

○ Kathleen Smith (UNC): I did not realize these measures already exclude c-section

hysterectomy cases

○ Ashraf Habib (Duke): We have used these codes for our MPOG study and there are

different degrees of accreta. We use neuraxial anesthesia for our placenta accreta cases

but there isn’t consensus across the country about the appropriate anesthesia technique

for these cases.

■ Kate Buehler (MPOG Coordinating Center): We can apply the exclusion to the GA

measures at the coordinating center and determine how many cases would be

excluded as a result. Not sure how well our codes will capture this and properly

exclude. Based on that analysis, we can bring it back to the subcommittee and

determine if this exclusion makes sense to the group based on counts.

Measure Review: ABX-01- Drs. Monica Servin and Brandon Togioka

Discussion:

● Should the measure end time for emergent cases align with non-emergent cases? Is the current

measure too lenient?

● Should patient weight be considered in antibiotic dosing?

● Should azithromycin be required for unscheduled cesarean delivery?

● Potential inclusion criteria for adjunctive azithromycin are ruptured membranes or high BMI (>

35 kg/m2). Perhaps another measure?

● If clindamycin was administered, should success require co-administration of an aminoglycoside?

● Josh Goldblatt (HF Allegiance): Should our measure align with other SSI standards around

assessing if the antibiotic is fully administered within 15 minutes?

● Ron George (U. Toronto): Would argue that this is getting a little too detailed as far as discussion

around a measure. I would think we could spend committee time focusing on building new

measures rather than getting into the weeds on existing measures. I would argue this measure

performance across sites is not as successful as it should be given how simple this measure

should be.

● Brandon Togioka (OHSU): What are the group’s thoughts around administering an

aminoglycoside if clindamycin was given?

○ No comments.

● Brandon Togioka and Monica Servin’s Recommendation: Continue Measure As Is

VOTE:

Conclusion:

- Continue Measure as is - no changes

Measure Review Schedule

BMI Stratification & Use of Second Line Uterotonic Agents

WILL PRESENT AT NOV MEETING

Meeting End Time: 1401