Quality Committee
Meeting
February 26, 2024
10:00am - 11:00am Eastern Time
Announcements
- Upcoming Events
- Precision Feedback Trial Updates
- QI Reporting Tool Updates
Measure Review
- New Measure Proposed: CARD-04 - Dr. Vikram Kumar, MGH
- Vote on CARD-02/03 retirement
Measure Update
- Retiring Measures PONV-01/PONV-02/MED-01/GLU-01-GLU-05
- NMB 02
New Measures (time permitting)
- ABX-02-C/ABX-03-C
- NMB 04
- BRAIN 01
Agenda
Meeting Minutes
January 2023
Roll Call – via Zoom or contact
MPOG
Announcements
Chair: Dr. Mohanad Shukry
Quality Champion: Dr. Kyle Ringenberg
PI: Dr. Troy Wildes
IT Champion: Emily Glaser
2024 Meetings
Friday, April 12, 2024
MSQC/ASPIRE Collaborative Meeting
Schoolcraft College Vistatech Center
Livonia, MI
Friday, July 12, 2024
ASPIRE Collaborative Meeting
Henry Executive Center
Lansing, Michigan
Friday, September 13, 2024
ACQR Retreat
Henry Executive Center
Lansing, Michigan
Friday, October 18, 2024
MPOG Retreat
Philadelphia, Pennsylvania
Upcoming Events
OB Subcommittee
Meeting Summary (2/7/2024):
● Discussed recent studies about reducing bleeding after a
cesarean delivery.
● Dr. Brendan Carvalho joined the subcommittee to discuss SOAP
and the process to apply to become a Center for Excellence
(COE).
● Thank you to Drs Melinda Mitchell and Sharon Abramovitz for
leading the measure reviews of GA-01 and GA-02.
Subcommittee voted to continue this measure as is (no
changes).
Next Meeting: Wednesday, May 22, 2024 at 1pm EST
Precision Feedback Trial Updates
- Plan to launch full study in May, 2024!
- Please opt out (by April 1, 2024) if:
- Not interested in participating
- May have a >2 month gap in uploads between May, 2024 and
October, 2024
- Please meet your upload deadlines :)
QI Reporting Tool
Update
Request from sites to add denominator counts to institution comparison
graphs (departmental view only). Feedback?
*NEW*
Provider
Summary
Page
*NEW* Case Attribute Filters
*NEW* Case Attribute Filters
*NEW* Multi-select Functionality
CARD -04
Measuring the incidence of post- op troponin testing in high risk
population
Background
• CARD-02 & CARD-03
• High sensitivity vs Older Troponin assays
• Troponin T vs Troponin I
• Outcome measure
CARD 04 ( 2022 ESC Guidelines on
cardiovascular assessment before NCS)
CARD 04 ( AHA scientific statement on
management of patients with myocardial
injury after non cardiac surgery Ruetzler et al
2021 )
CARD 04 ( Canadian guidelines)
CARD 04 ( Evidence)
Specific issues
• Patient population
• Specific surgery types
• Pre-op vs intra-op only
Why
• Build knowledge around how to manage these patients
• Change practice patterns
• Improve medication adherence according to guidelines
CARD 04 ( Evidence)
Thank you !
CARD-04: Troponin Testing in High-Risk Cases
CARD-04: Percentage of patients with cardiac risk where troponin levels were checked postoperatively.
Informational only - No threshold
● Measure Time Period: Anesthesia End to 72 hours after Anesthesia End
● Exclusions:
○ ASA 5 & 6 including Organ Procurement
○ Cardiac cases as determined by the Procedure Type: Cardiac (value codes > 0)
○ Outpatient cases
● Success: In cases that meet the inclusion criteria if a Troponin I (or Troponin T) value is found
within 72 hours after Anesthesia End the case will be considered a success.
○ If no Troponin I (or Troponin T) values are available within 72 hours after anesthesia end,
the case will be flagged.
CARD-04: Troponin Testing in High Risk Cases
1 vote/ site
Continue as is/ modify/ retire
Need > 50% to retire measure
Coordinating center will review all votes after meeting to ensure
no duplication
CARD-02: Troponin Elevation
CARD-03: Troponin Elevation, High Risk Cases
Measure Updates
Retiring Measures
● GLU-01: Hyperglycemia Management, Intraop (> 200 mg/dL)
○ Replaced with GLU-09: Hyperglycemia Management, Intraop (> 180 mg/dL)
● GLU-02: Hypoglycemia Management, Intraop (< 60 mg/dL)
○ Replaced with GLU-12: Hypoglycemia Management, Intraop (< 70 mg/dL)
● GLU-03: Hyperglycemia Management, Periop (> 200 mg/dL)
○ Replaced with GLU-10: Hyperglycemia Management, Periop (> 180 mg/dL)
● GLU-04: Hypoglycemia Management, Periop (< 60 mg/dL)
○ Replaced with GLU-13: Hypoglycemia Management, Periop (< 70 mg/dL)
● GLU-05: Hyperglycemia Treatment, Periop (> 200 mg/dL)
○ Replaced with GLU-11: Hyperglycemia Treatment, Periop (> 180 mg/dL)
NMB-02: Appropriate Reversal
The measure was last reviewed by the Quality Committee in 2021 and the following changes were recommended:
1. Remove cardiac exclusion
2. Remove defasciculating dose exclusion
3. Remove the following success criteria: 3 hours between last dose of NMB and extubation does not require
reversal for adults (2 hours for pediatric patients)
Examples of cases that may have previously passed but are now flagged include:
1. Cases where defasciculating doses were administered, but no reversal administered.
2. Long spine cases where TOF ratio was measured only by neuromonitoring team and not documented in the
anesthesia record.
Score changes ranged from -7% to +1%. As you review cases, please contact the CC with feedback.
NMB-02 Performance
January - December 2023
Performance Range: 76-100%
New Measures
ABX-02-C: Antibiotic Timing, Open Cardiac
ABX-02-C: Percentage of adult patients undergoing open cardiac surgery with antibiotic administration
initiated within the appropriate time frame before surgical incision.
● Measure Time Period: 120 minutes prior to Surgery Start Time through Surgery Start Time
● 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
Associated Timing:
ABX-02-C Performance across MPOG
January 2023 - December 2023
Performance Range: 0 - 100%
ABX-03-C: Antibiotic Redosing, Open Cardiac
ABX-03-C: 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 transplant
○ 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 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
January 2023 - December 2023
Performance Range: 0 - 100%
NMB-04: Sugammadex Dosing
NMB-04: Percentage of adult and pediatric (> 3 years) cases with sugammadex administration where
cumulative sugammadex dose is < 200 mg OR < 3 mg/kg
● Measure Time Period: Anesthesia Start to Earliest Extubation
● Exclusions:
○ Age < 2 years
○ ASA 5 & 6
○ Cases < 30 minutes
○ Patients that were not extubated in the immediate postoperative period
● Success: Cases where cumulative sugammadex dose was < 200 mg OR < 3 mg/kg
NMB-04 Performance
January 2023 - December 2023
Performance Range: 50-100%
BRAIN-01 Released!
BRAIN-01: Percentage of patients > 70 years old who received a benzodiazepine perioperatively.
Informational only - No threshold
● Measure Time Period: Pre-op Start - PACU End
● Exclusions:
○ Age < 70 years
○ ASA 5 & 6
○ Floor/ICU emergent intubation only cases
○ ICU transfer postoperatively
● Success: Avoiding administration of benzodiazepines for patients > 70 years old
BRAIN-01 Performance (Inverse)
January 2023 - December 2023
Performance Range: 0.1-75.4%
Thank You!
CARD-02 Performance (Inverse)
January 2023 - December 2023
Performance Range: 0 - 2.3%
CARD-03 Performance (Inverse)
January 2023 - December 2023
Performance Range: 0 - ~5%
