Quality Committee
Meeting
September 23, 2024
10:00am - 11:00am Eastern Time
Topics
- Interest in QI Features for learners - feedback
- Sharing Anonymized Performance Data outside MPOG - vote
- Including “Notable Events” in the MPOG extract - feedback
- Removing individual provider access to specialty dashboards in
MPOG QI Reporting Tool - update (time permitting)
Measure Updates
- ABX-03-C: Antibiotic redosing, Open Cardiac
- SUS-02: Global Warming Footprint, Maintenance
- TOC-02: Transfer of Care to PACU
- TRAN-01/TRAN-02: Transfusion Management
Vigilance/Overtransfusion
New Measures (time permitting)
- AKI-02-C
- ABX-04-C
- ABX-05-C
Agenda
Announcements
MPOG Retreat - Please register!
Friday, October 18, 2024
Philadelphia, Pennsylvania
Virtual option
QI features for learners - request for feedback
● Background: MPOG’s ABA MOCA Part IV program has now enrolled ~1000
anesthesiologists over the last several years
● We have received feedback that it would be helpful for learners to have a
similar program
MOCA program built off provider feedback email
Click button in email to get to case list
Review case
Attest that cases were reviewed
Would a similar program for learners be useful?
● Allow residency program leaders to assess engagement in practice
improvement
● Can help fulfill the practice based learning and improvement components of
residency training
● Helps build lifelong practice reflection skills
● Are there other programs that enable this? Is there a current gap?
Dissemination of anonymized
performance data for non
research purposes (vote required)
Background
● 9/9 PCRC discussed review process for disseminating aggregate anonymized
multicenter data
● Recent Requests from Research Teams:
○ Table showing the # of times ketorolac was administered for pediatric
tonsillectomies at each anonymized MPOG site
○ Line graph showing monthly performance trend for NMB-05 (use of
quantitative twitch monitoring) for all MPOG institutions
Previous use case supported by QC
Rationale for MPOG QI & Research Committee Review
● Scientific Rigor – ensure robust development of research products & QI measures
reflecting a diverse expertise & applicability across a range of patient populations
● Participation in data use decisions – ensure decisions to provide access to
multicenter data are made in democratic fashion
● Transparency – provide forum for establishing shared understanding of how
MPOG data is used
Proposed Policy: Expedited Review Pathway
Expedited Review Pathway QC Review Pathway
Data Sensitivity Low-risk (anonymized, aggregate data)
Anything not satisfying all
Expedited Review Pathway
criteria
Data Quality Curated phenotype, QI measure, or
commonly used MPOG concept
Complexity No coordinating center programmer
effort required
Analysis
Complexity
Descriptive statistics only (counts, %,
mean/SD, median/IQR), typically
resulting in a single table or figure
Specific Use Case
● Anesthesiology Quality Institute (AQI) has requested approval to receive
screenshots from MPOG to show variation in care with elderly patients receiving
midazolam (BRAIN-01), and antibiotic redosing for cardiac surgery (ABX-O3-C)
● AQI may submit these screenshots to CMS as part of their QCDR measure
submission
● Demonstrating variation in care could help the AQI measures obtain approval as
QCDR measures
BRAIN-01
ABX-03-C
Vote
1. Should the MPOG Coordinating Center be able to address
low risk / low complexity requests for anonymized
performance data without explicit approval from Quality
Committee? (yes / no)
2. Do you approve sending the anonymized BRAIN-01 and
ABX-03-C graphs to AQI for possible inclusion in future
QCDR measure submission to CMS? (yes / no)
Inclusion of “Notable Events” in MPOG extract
from sites - interest from sites?
● Background: Notable Events is a form in Epic that enables documentation of complications and
are included part of the medical record
● We have received feedback that it may be helpful to enable sites to analyze this data within and
across MPOG sites for QI and research.
● This information is not part of the standard Epic extract to MPOG
● Would require IT involvement from sites to query their EHR and generate files to add to extract
● MPOG is trying to understand if there is interest in this type of data, as we refine our roadmap
● Please let the coordinating center know if interested
● If there enough interest across sites, we will add to our
roadmap
● Sites interested will likely have to request IT support to
add to the MPOG extract
Interested?
Thank You!
QI Reporting Tool
Update
● Currently individual providers have access to a dashboard (My Measure
Dashboard) that includes measures that are in the monthly provider feedback
emails
● They also have access to the cardiac, pediatric, and OB dashboards filtered to
their own case.
● These dashboards were originally intended for quality champions and
subspecialty practice leaders, not individual providers
● We plan to remove access to the subspecialty dashboard, and then eventually
replacing with functionality to add specific subspecialty measures to the
“My Measure Dashboard”
● While usage of the QI Reporting Tool is low overall among individual providers,
may generate questions to quality champions, so wanted to inform the QC
Removing individual provider access to specialty
dashboards in MPOG QI Reporting Tool
Removing individual provider access to specialty
dashboards in MPOG QI Reporting Tool
Measure Updates
ABX-03-C: Antibiotic Redosing, Open Cardiac
● Description: Percentage of adult patients undergoing an open cardiac procedure
with an antibiotic redose initiated within four hours after initial antibiotic administration
(cephalosporins only)
● Excluded: Three Antibiotics from this measure
○ Ceftriaxone and Cefotetan are excluded due to extended half-lives relative to
other commonly used cephalosporins and therefore, re-dosing is not
recommended for a typical cardiac case (these cases are excluded NOT
flagged).
○ Cefoxitin is also excluded as it is not typically used for cardiac cases and would
require more frequent dosing (these cases are excluded NOT flagged).
SUS-02: Global Warming Footprint, Maintenance
● Description: This measure analyzes the percentage of cases where carbon dioxide
equivalents normalized by hour for cases receiving inhalational anesthetic agents
(desflurane, isoflurane, or nitrous oxide) is less than CO
2
eq of 2% sevoflurane at 2 L
FGF = 2.83 kg CO
2
/hr or the Total CO
2
eq is less than 2.83 kg of CO
2
for the
maintenance period of anesthesia.
● Updated measure and code to allow MPOG to calculate Total FGF from
component FGFs. Significant score changes for 4 sites and they were notified
● Updated measure to include conversion of Nitrous Insp % to Flow of Nitrous.
Minimal score changes
● Will apply to SUS 03 (GWF - Induction) and SUS 06 (FGF Induction, Peds) next
TRAN-01 and TRAN-02:
● TRAN 01 - Percentage of adult patients receiving a blood transfusion with documented
hemoglobin or hematocrit value prior to administration
● TRAN 02 - Percentage of adult patients with a post transfusion hemoglobin or hematocrit
value greater than or equal to 10 g/dL or 30%, as a proxy for overtransfusion
● The approved changes are:
○ Include cardiac cases (previously excluded), as both Quality Committee and
Cardiac Subcommittee members determined that these measures apply to cardiac
procedures
○ “Ignore” autologous blood transfusion, as it is common and acceptable practice to
administer these blood products regardless of hgb/hct values.
● Scores for most sites increased modestly. However, several sites saw drops in
performance scores for both measures, based on site cardiac case transfusion practices.
New Measures
AKI-02-C: Acute Kidney Injury, Cardiac
Description: Percentage of adult patients undergoing an open cardiac procedure with more than a 1.5x increase in
baseline creatinine within 7 postoperative days or the baseline creatinine level increases by ≥ 0.3 mg/dL within 48 hours
postoperatively.
Measure Time Period: Up to 7 days after Anesthesia End
Exclusions:
● ASA 6 including Organ Procurement (CPT:01990)
● Cases where a baseline creatinine is not available within 60 days preoperatively
● Cases where a creatinine lab is not available within 7 postoperative days
● Patients with more than one case in a 7-day period. The first case will be excluded if a post-op creatinine is not documented for that first case. For example, a patient that
has surgery twice in a 7-day period, the first surgery is excluded if a creatinine is not drawn in between cases
● Patients with pre-existing renal (stage 4 or 5) failure based upon BSA-Indexed EGFR < 30 mL/min/1.73m
2
● Liver Transplants
● Open cardiac procedures performed in conjunction with procedures affecting the kidney, bladder, or ureter
Success: The creatinine level does not go above 1.5x the baseline creatinine within 7 days post-op and The creatinine
level does not increase by ≥0.3 mg/dL obtained within 48 hours after anesthesia end.
AKI-02-C Performance
September 2023 - July 2024
ABX-04-C: Antibiotic Selection for Open Cardiac
Procedures
Description: Percentage of adult patients undergoing open cardiac surgery with the recommended
antibiotic agents administered for surgical site infection prophylaxis.
Measure Time Period: 120 minutes prior to Anesthesia Start through Anesthesia End
Exclusions:
● Age < 18 years
● ASA 6 including Organ Procurement
● Patients already on scheduled abx or had a documented infection prior to surgery (determined by ABX Notes
phenotype value code:2)
● Procedures:
○ Lung transplants
○ Non-cardiac, Transcatheter/Endovascular, EP/Cath, and other Cardiac cases
Success: Documentation of appropriate antibiotics administered preoperatively or intraoperatively
ABX-04-C: Acceptable Antibiotics
● Vancomycin + Cephalosporin
● Vancomycin + Aminoglycoside
● Vancomycin Only
● Cephalosporin Only
● Note: Only doses administered via IV route (MPOG Concept ID:2001) will be considered.
● Cases with assigned one of the following results:
○ Passed - Vancomycin + Cephalosporin
○ Passed - Vancomycin + Aminoglycoside
○ Passed - Vancomycin Only
○ Passed - Cephalosporin Only
○ Flagged - Non-standard antibiotic selection
○ Flagged - Prophylactic antibiotic administered (Not documented in MAR)
○ Flagged - Antibiotic not ordered/indicated per surgeon
○ Flagged - Not administered for medical reasons
○ Excluded - Scheduled antibiotics/documented infection
ABX-04-C Performance
September 2023 - July 2024
Performance Range: X - X%
ABX-05-C: Composite Measure: Antibiotic Compliance
for Open Cardiac Procedures
Description: Percentage of adult patients undergoing open cardiac surgery with appropriate antibiotic
selection, timing, and re-dosing administered for surgical site infection prophylaxis
Measure Time Period: 120 minutes prior to Anesthesia Start through Anesthesia End
Exclusions:
● Age < 18 years
● ASA 6 including Organ Procurement
● Patients already on scheduled abx or had a documented infection prior to surgery (determined by ABX Notes
phenotype value code:2)
● Procedures:
○ Lung transplants
○ Non-cardiac, Transcatheter/Endovascular, EP/Cath, and other Cardiac cases
Success: Case must pass all 3 antibiotic prophylaxis for open cardiac procedure measures:
● ABX-02-C/ABX-03-C/ABX-04-C
ABX-05-C: Other Measure Build Details
● Note: Only doses administered via IV route (MPOG Concept ID:2001) will be considered.
● Cases with assigned one of the following results:
○ Passed - Antibiotic Prophylaxis Standards Met
○ Flagged - Timing, Re-dosing, & Section Not Met (ABX-02-C, ABX-03-C, & ABX-04-C flagged)
○ Flagged - Timing & Selection Not Met (BX-02-C & ABX-04-C flagged)
○ Flagged - Re-dosing & Selection Not Met (ABX-03-C & ABX-04-C flagged)
○ Flagged - Timing & Re-dosing (ABX-02-C & ABX-03-C flagged)
○ Flagged - Antibiotic not administered on time (ABX-02-C flagged)
○ Flagged - Antibiotics not appropriately re-dosed (ABX-03-C flagged)
○ Flagged - Non-standard antibiotic selection (ABX-04-C flagged)
○ Excluded - Scheduled antibiotics/documented infection
ABX-05-C Performance
September 2023 - July 2024
Performance Range: X - X %
Antibiotic Bundle for
Cardiac Cases
ABX-02-C: Antibiotic Timing, Open Cardiac
Description: Percentage of adult patients undergoing open cardiac surgery with antibiotic administration
initiated within the appropriate time frame before surgical incision.
Exclusions:
● Age < 18 years
● ASA 6 including Organ Procurement (CPT: 01990)
● Lung Transplants
● Procedure Type: Cardiac (value codes 0, 2, 3, and 4)
● Patients already on scheduled antibiotics or had a documented infection prior to surgery as
specified by the ABX Notes Phenotype
Success: Documentation of antibiotics administered before Surgery Start Time (‘Other Measure Details’
has time expectations based on antibiotic selection).
ABX-02-C Acceptable Antibiotics and Timing
ABX-02-C Performance
June 2023 - May 2024
Performance Range: 13 - 100%
ABX-03-C: Antibiotic Redosing, Open Cardiac
Description: Percentage of adult patients undergoing an open cardiac surgery with antibiotic redose initiated within four
hours after initial antibiotic administration (Cephalosporins only).
Exclusions:
● Age < 18 years
● ASA 6 including Organ Procurement (CPT: 01990)
● Cases where surgery end time occurs before redose is due
● Cases without administration of a cephalosporin for antibiotic prophylaxis
● Lung transplants
● Other non-open cardiac procedures
● Patients already on scheduled antibiotics or had a documented infection prior to surgery as specified by the ABX Notes
Phenotype
Success:
● Documentation of a cephalosporin redose within 180-255 minutes after each cephalosporin administration.
● For longer cases, a second redose within 180-255 minutes after initial redose is required, unless the last
cephalosporin dose is < 255 minutes before Surgery End. If Surgery End not available, Anesthesia End.
ABX-03-C: Cephalosporin Concepts
ABX-03-C Performance
June 2023 - May 2024
Performance Range: 0 - 100%
SUS-02: Global Warming Footprint, Maintenance
For cases with Nitrous Oxide (N
2
O) reported as percent inspired (%), convert percent
inspired to L/min :
1. If not available. MPOG will determine percentage inspired for Oxygen by subtracting
Nitrous Oxide percent inspired value from 100.
2. Calculate the total Fresh Gas Flow by dividing Oxygen flows (L/min) by Oxygen
percent.
3. Calculate Nitrous flow by subtracting Oxygen flows (L/min) form total Fresh Gas Flow.
SUS-02: Global Warming Footprint, Maintenance
Please note: in rare cases where both Nitrous and Air are delivered, MPOG adjusts these
steps to include both Air and Oxygen in these steps (instead of just Oxygen alone)
Step Step 1 Step 2 Step 3 Step 4 Step 5
Concept Start with N
2
O
inspired %
Determine
O2 inspired if
necessary (1
- N
2
O%)
Use O
2
flow
(L/min)
Determine
total FGF (O
2
flow divided
by O
2
inspired)
Determine
N
2
O flow
(Total FGF -
O
2
flow
(L/min))
Value 34 66 1.3 2.0 0.7
NMB-01: Train of Four Measured
● Description: Percentage of patients with a documented Train of Four (TOF) after last
dose of nondepolarizing neuromuscular blocker
Change in Other Measure Build Details:
● We fixed an issue so that the measure now only accepts TOF values before
extubation. Ie, if there are no TOF values before extubation, the case will flag
● This measure accepts a TOF value of 0, if sugammadex is administered. However,
now, if the sugammadex is administered after extubation, the case will flag. This is
an edge case
NMB-02: Reversal Administered
● Description: Percentage of patients administered neuromuscular blockade reversal
before extubation and after the last dose of nondepolarizing neuromuscular blockade
Change to measure:
● Fixed an issue so that now if sugammadex was administered after extubation, then
case is flagged
● Fixed a minor edge case issue: now NMB doses after extubation are excluded
