MPOG Pediatric
Subcommittee Meeting
June 26, 2023
Agenda
Announcements
TEMP-04-Peds: Survey Results and Discussion
Quality Committee Follow up
Glycemic Management
Oral Morphine Equivalency
Measure Review: Antibiotic Prophylaxis (ABX-02-p)
Sustainability Toolkit Available on MPOG website
● Thank you to Dr. Eva Lu-Boettcher for adding the pediatric sections!
SUS-06-peds Measure Released!
Other Measure Details:
Table: Glenski et al 2022. “Low Flow Anesthesia in Pediatric Patients.”
Provider Attribution: All providers signed in during the induction period of anesthesia
Success Criteria: Mean FGF equal to, or less than the weight-based max FGF (L/min) during
the induction period of anesthesia, as displayed by table below
Weight (kg) Mean FGF
< 20 ≤ 3 L/min
20-30 ≤ 4 L/min
30-40 ≤ 5 L/min
> 40 ≤ 6 L/min
Call for Measure Reviewers!
PAIN-01-Peds: Multimodal Analgesia, Pediatrics
● Initial measure development - December 2020.
● First review due to be presented at the Winter 2023
pediatric subcommittee meeting
MPOG Measure Reviewers are clinical and quality
improvement experts that critique our QI Measures to
ensure they stay relevant.
● Review of New Literature
● Appropriateness of rationale
● Evaluation of inclusion/exclusion criteria
● Evaluation of definition of success criteria
● Recommend to modify, retire or continue measure as is
Upcoming Pediatric Research Proposals
Two multicenter pediatric research proposals will be presented to the MPOG Perioperative
Clinical Research Committee (PCRC) on Monday, August 14th
Must practice at an active MPOG site to join PCRC meetings
PCRC 0145: Prophylaxis Practice in Pediatric PONV: A Retrospective Observational Study
PCRC 0180: The Association of Guideline Directed Prophylaxis with the Incidence of
Postoperative Nausea and Vomiting in Pediatric Patients.
Primary Collaborators: Lucy Everett, Ben Andrew, Wes Templeton, Vikas O’Reilly-Shah,
Lisa Vitale, Brad Taicher, Meridith Wade
TEMP-04
Update
TEMP-04: Pediatric Normothermia, Intraop
Initial publish date: April 2020; Reviewed and presented to Peds committee March 2023
Success: median core/near core body temperature > 36C (96.8F)
Time period: Patient in room → Patient out of room
Exclusions
• Patients ≥ 18yo
• ASA 5 & 6
• Cases < 30 minutes
• Cases without a temperature route documented
• Labor epidurals, Cardiac procedures, MRI
• MAC/Sedation cases
Provider Attribution: Provider present for the longest duration of the case (per staff role)
Thank you for your feedback! - 23 Survey responses
Majority vote to exclude:
• GI cases
• Cases where patient’s baseline temperature was < 35.5C or > 38C
No real consensus on:
• Case duration definition (room duration vs. procedure duration)
• Excluding short duration cases (30 min vs. 60 min)
• Hyperthermia metric
• Measure success criteria
Other Comments:
Though hyperthermia is equally bad, currently we haven't refined our knowledge about hypothermia,
definition and outcomes - once we have achieved this refinement , maybe then we can look at
hyperthermia.
In lieu of an AUC approach, it seems most reasonable to have a duration-based threshold given that the
harm from hypothermia at least in theory should have both a magnitude and duration component (hence
the value of AUC approaches).
How to pick the threshold (both for the definition of hypothermia and for the time) is not
straightforward, and I'm not sure we have adequate evidence to support any one specific threshold, but
the 30 minutes / 36C option seems the most reasonable to me at this point.
Although there is little evidence specifically on this issue, I think this measure (as originally defined) is a
better way to ensure normothermia than our other measures
Quality
Committee
Update
Glycemic Management Measure Review
Hyperglycemia (includes patients ≥ 12y)
GLU 01, 03: Cases with glucose > 200 mg/dL with administration of insulin or lab recheck within 90 minutes.
GLU 05: Cases with glucose > 200 mg/dL with administration of insulin within 90 minutes.
– QC Vote: Modify, Change threshold to 180 mg/dL
– Support for a recheck only measure
Hypoglycemia
GLU 02, 04: Percentage of cases with glucose < 60 mg/dL with administration of dextrose or lab recheck
within 90 minutes.
– QC Vote: Modify, Change threshold to 70 mg/dL
– Reduce time to recheck/treat hypoglycemia to 30 minutes
Discussion
• Should these measures still exclude patients < 12y?
• Are the new thresholds appropriate for patients 12-18y?
• How often should glucose be checked after an abnormal lab?
• Support from this group for a glucose recheck measure?
Oral Morphine Equivalency (OME) Measure Review
OME: Calculated using opioids given between anesthesia start and anesthesia end for each
case. This value is normalized to patient weight (kg) and duration of anesthetic (anesthesia
end – anesthesia start, hours as a decimal).
QC Vote: Modify - Widen time frame to include PACU OR create separate measure for OME in
PACU
Spine (Pediatric)
● Cervical spine and cord (CPT: 00600, 00604)
● Thoracic spine and cord (CPT: 00620,00625,00626)
● Lumbar region (CPT: 00630)
● Extensive spine and spinal cord procedures (CPT: 00670)
Tonsil/Adenoid (Pediatric)
● Cases that return tonsillectomy, adenotonsillectomy or
tonsil bleed from the tonsil/adenoid phenotype
Oral Morphine Equivalency (OME) Measure Review
Discussion
• Would displaying the 'score' as morphine IV equivalency be more valuable
for peds?
• Additional OME cohorts of interest for pediatrics?
• Interest in separate PACU opioid equivalency measure for pediatrics? or
combine with intraop?
Measure
Discussion
ABX 02
Background
• Proposed by subcommittee members in previous ‘call for measure’ surveys
• Plans to include in future SSI measure bundle/dashboard
• Allows comparison of antibiotic timing adherence with SSI outcomes for sites
who submit NSQIP-p data
• Currently refining MPOG microbiology data extract - future measures to
include antibiotic susceptibility
ABX-02-Peds
Description: Percentage of patients < 18 years old with documentation of antibiotic administration initiated
before surgical incision.
Measure Time Period: - 3 hours ≤ Procedure Start ≥ 30 minutes
Exclusions:
● ASA 6
● Patients ≥ 18 years of age
● Emergency Cases
● Antibiotics not indicated for procedure. Defined as one of the following:
○ Patients given IV antibiotic treatment > 3 hrs prior to Procedure Start/Incision
○ Case returns value code 0, 2, or 3 for ABXNotes
■ 0 - Not ordered/Indicated per surgeon
■ 2 - Patient on scheduled antibiotics/documented infection
■ 3 - Not administered for medical reasons
● Procedure Type List
Procedures Excluded from NSQIP-p Surgical Antibiotic Prophylaxis
Split-thickness Autograft
15100, 15120
Full Thickness Graft
15200, 15220, 15240, 15260
Muscle, Myocutaneous or
Fasciocutaneous Flap
15733, 15734, 15736, 15738
Free Flap
15756, 15757, 15758, 15842
Excision of chest wall tumor including ribs
19260
Application of External Fixation system
20692, 20696
Bone/Cartilage Graft
20902, 20910, 20970
Excision of Abdominal Wall Tumor
22900
Polydactyly/Syndactyly
26550, 26562, 26587, 28345
Lymph Node Dissection
38542, 38564, 38570, 38724, 38765, 38780
Enterotomy/Enterostomy
44110, 44111, 44227, 44300, 44620 , 44625,
44626, 44640, 44650, 44820
Anoplasty
45499, 46705
Intraperitoneal Cannula Placement
49324, 49421
Craniotomy with elevation of bone flap
61533, 61535
Neuroendoscopy
62161
Creation of Shunt
62192
Ventriculocisternostomy
62200, 62201
Myelomeningocele Repair
63704, 63706
*Limitation: Sites that do not submit billing data could not participate with this measure
ABX-02-Peds
Success Criteria: Patient received IV antibiotics within appropriate timing prior to Procedure Start.
Acceptable Antibiotics and Associated Timing:
45-90 min before incision
● 10048 Azithromycin
● 10126 Ciprofloxacin
● 10190 Fluconazole
● 10202 Gentamicin
● 10245 Levofloxacin
● 10444 Vancomycin
15-60 min before incision
● 10032 Ampicillin
● 10033 Ampicillin/Sulbactam
● 10107 Cefazolin
● 10108 Cefepime
● 10109 Cefotaxime
● 10110 Cefotetan
● 10111 Cefoxitin
● 10114 Ceftriaxone
● 10115 Cefuroxime
● 10131 Clindamycin
● 10299 Metronidazole
Thank You!
MPOG Membership Update
Welcome New Sites!
• University of Alabama Birmingham
• UMASS Memorial Health
• Nebraska Medicine
• Temple Health
In Progress
• Indiana University Health - Riley Children’s Hospital
• Lucile Packard Children’s Hospital
Measure
Discussion
NMB-04
Background – cost containment
• Measure proposed by Dr. Megan Anders (Univ. Maryland)
• Strategies for cost-containment are an area of interest
– Formulary restrictions
– Lower-dosing strategies (0.5 or 1mg/kg)
– Dosing at "adjusted" body weight instead of actual body weight
– IWB + 0.4(Actual – IBW)
– Decision support and email feedback for dosage guideline
• A timely measure – groups may be engaging in discussion of
loosening formulary restrictions given ASA guideline
Pregnall AM, et al. Use of provider education, intra-operative decision support, and an email-feedback system in improving compliance with
sugammadex dosage guideline and reducing drug expenditures. J Clin Anesth. 2022
Measure Specification/Rationale
• Percentage of cases with sugammadex administration where cumulative
sugammadex dose < 200mg OR ≤ 3mg/kg
– Fixed cost of 200mg vial
– Acknowledges dose rounding given small injection volumes
– Encourages judicious use of NMBD to end with at least TOF = 2
– Compliant with FDA approved dosing and ASA 2023 guideline
• Threshold – 90%
– Acknowledges CICV, unexpected discontinuation of surgery, safety margin for
individualized dosing
Measure Specification - Detail
• Time Period: Anes start to Anes end
• Inclusion:
– Sugammadex administered
– Adult patients only?
• Exclusion: No weight documented, ASA 6
– Exclude patients < 2y? < 10kg?
• Attribution options
– Provider(s) signed into case at time of last sugammadex administration
– Provider signed into case at time of last NMBD administration
TEMP 04
1 vote per site
Continue as is / modify / retire
Need > 50% to retire measure
Coordinating center will review all votes after meeting to
ensure no duplication
