Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Pediatric Subcommittee Meeting Minutes – June 26, 2023

Attendance:

Amber Franz, Seattle Children’s

Lucy Everett, MGH

Andrew Zittleman, MPOG

Meridith Wade, MPOG

Ben Andrew, Duke Children’s

Morgan Brown, Boston Children’s

Bishr Haydar, Univ. of Michigan

Nicole Barrios, MPOG

Brad Taicher, Duke Children’s

Nirav Shah, MPOG

Chuck Schrock, St. Louis Children’s

Rahul Koka, Johns Hopkins

Diana O’Dell, MPOG

RK Ramamurthi, Lucile Packard Children’s

Ellen Wang, Lucile Packard Children’s

Ruchika Gupta, Univ. of Michigan

Eva Lu-Boettcher, Univ. Wisconsin

Ruchik Sharma, Univ. of Virginia

Frances Guida Smiatacz, MPOG

Ruth Cassidy, MPOG

Jacques Scharoun, Weill Cornell

Ryan Bradstreet, Bronson Kalamazoo

James Xie,Lucile Packard Children’s

Sushma Vallamkonda, MPOG

Kate Buehler, MPOG

Tiffany Malenfant, MPOG

Kelly Everhart, Dartmouth Hitchcock

Vikas O’Reilly-Shah, Seattle’s Childrens

Kim Taylor, Univ. of Michigan

Yuan Yuan, MPOG

Meeting Summary

Minutes from March 7, 2023 meeting approved - minutes and recording posted on the MPOG website

for review

Announcements

● Sustainability Toolkit available on MPOG Website

○ Thank you to Dr. Eva Lu-Boettcher for adding the pediatric sections!

● SUS-06 Measure Released!

○ Description: Percentage of pediatric cases with a max fresh gas flow (FGF) equal to or

less than a weight-based threshold during the induction phase of anesthesia.

○ Measure is available on the sustainability and pediatric dashboard now. Please view the

measure specification for more information

○ See slides for anonymized institution performance

○ James Xie (Stanford): We changed all our machine FGF defaults to 3L/min since the last

meeting

👍

● 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 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 Intraoperative Antiemetics - DESCRIPTIVE analysis (Dr. Lucy Everett)

○ PCRC 0180 Intraoperative Antiemetics and PONV - OUTCOMES analysis (Dr. Ben Andrew)

TEMP-04-Peds Measure Update: Vikas O’Reilly -Shah (Seattle Children’s/MPOG Pediatric Subcommittee

Co-Chair)

● 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

● DISCUSSION:

○ Brad Taicher (MPOG Pediatric Subcommittee Co-Chair, Duke)- will bring this back to get a

decision on what to do moving forward.

Quality Committee Update Brad Taicher (Duke Children’s/MPOG Pediatric Subcommittee Chair)

● 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

● DISCUSSION:

○ Ruchika Gupta (University of Michigan): Conducted a study about 10 years ago, checking

glucose in all pediatric patients (neonate - 18 years old, majority were 3 years and

younger) and found that though checking glucose is reasonable, would not recommend

treating all hyperglycemia values as patient response to insulin is somewhat

unpredictable in the pediatric population and the risk of hypoglycemia presents as a

patient safety issue.

■ Meridith Wade (MPOG Pediatric Program Manager) -Hyperglycemia measures

include patients greater than or equal to 12 years of age. Hypoglycemia

measures include all ages.

○ Nirav Shah (MPOG Quality Director)- These were some of the first measures we

implemented at MPOG and with the last Quality Committee review, are now looking to

align with hospital policies and national guidelines.

○ Brad Taicher (MPOG Pediatric Subcommittee Co-Chair, Duke) - When we rolled these

measures out at Duke, we started at 200 to achieve buy-in and I think it makes sense to

now move to 180 to align with national guidelines.

○ Nirav Shah (MPOG Quality Director)- having a broad suite of measures would make it

likely for sites to pick and choose what would work for them.

○ Brad Taicher (MPOG Pediatric Subcommittee Co-Chair, Duke) will speak with staff to see

how they are using these measures currently.

● Oral Morphine Equivalency (OME) Measure Review

○ 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

○ DISCUSSION:

■ Brad Taicher (MPOG Pediatric Subcommittee Co-Chair, Duke): One way to use

these measures is to compare institutional performance to other institutions to

obtain some idea of current benchmarks. How are other sites using these

metrics?

● Nirav Shah (ASPIRE Quality Director): That is one way to use these OME

measures - the other way sites are using these metrics to see if any

individual providers prove to be high (or low) outliers

● RJ Ramamurthi (Stanford)- Is valuable to see this on the dashboard.

● James Xie (Stanford) - We created an opioid use dashboard at Stanford:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8942721/ Another

question that has come up is if this data could (or should) be used as a

signal for opioid diversion? How would you deal with extreme outlier

providers?

● Brad Taicher (MPOG Pediatric Subcommittee Co-Chair, Duke) - a lot to

unpack there. We use different software to look at use per provider. But

an interesting thought to use MPOG data for diversion activity.

Discharge from PACU opioid use - way to identify how much pain meds

you get in PACU is due to nursing preference.

■ Interest in a separate PACU opioid equivalency measure for pediatrics? or

combine with intraop?

● Lucy Everett (MGH): I think it would be great to include PACU data but

would want to be able to break out intraop vs. PACU OME use.

○ Brad Taicher (MPOG Pediatric Subcommittee Co-Chair, Duke):

Agree! I think a filter to show intraop vs. PACU vs. periop would

be excellent!

● Ben Andrews (Duke) - Alternatively, separating them but also including a

metric comparing them (PACU to intraop OME ratio or something

similar) could be informative

■ Would displaying the 'score' as morphine IV equivalency be more valuable for

peds?

● Brad Taicher (MPOG Pediatric Subcommittee Co-Chair, Duke)- Please

clarify what the change would mean.

○ Meridith Wade (MPOG Pediatric Program Manager) - currently

displayed as oral equivalents but can change to IV if more

helpful.

● Ruchik Sharma (Univ. of Virginia): IV morphine

● James Xie (Stanford): IV morphine equivalents would be more readily

relatable

● Charles Schrock (WashU): If equivalence is indeed reliably calculable,

maybe the dashboard can toggle to whatever norm the user wants, oral

or IV, with morphine, hydromorphone, or fentanyl as the calculated

standard

■ Additional OME cohorts of interest for pediatrics?

● Brad Taicher (Duke) - Cardiac could be an area of interest.

● Ruchik Sharma (Univ. of Virginia) : Pectus

○ James Xie (Stanford) and Ruchika Gupta (University of

Michigan): Agree!

Antibiotic Timing Measure Discussion: ABX-02-peds

● Background

○ Proposed by subcommittee in previous ‘call for measure’ surveys

○ Plan 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

● 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

● Inclusions: Patients < 18 year of age

● Exclusions

○ ASA 6

○ Patients ≥ 18 years of age

○ Procedure Type List: *see below

○ 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: Same procedures excluded from NSQIP-p Surgical Antibiotic Prophylaxis

● DISCUSSION:

○ Ruchik Sharma (UVA) - Please elaborate on MPOG/NSQIP merger.

■ Brad Taicher (MPOG Pediatric Subcommittee Co-Chair, Duke) - Sites can upload

NSQIP data to MPOG and look at outcomes data.

■ (MPOG Pediatric Program Manager) - We are working to get

Meridith Wade

the congenital heart registry for adults up and running and work out any kinks

before opening up to Peds.

Meeting Concluded @ 1651