Quality Committee
Meeting
May 20, 2024
10:00am - 11:00am Eastern Time
Announcements
- Upcoming Events
- Precision Feedback Trial Updates
- MPOG App Suite April 2024 Upgrade
Measure Review
- TRAN-01 - Jacek Cywinski, Cleveland Clinic
- TRAN-02 - Linda Liu, UCSF
Measure Update
- SMOK-02 Provider Attribution Updated
- Glucose Provider Attribution
- SUS-02 Provider Attribution
New Measures (time permitting)
- ABX-02-C/ABX-03-C
- NMB-04
- BRAIN-01
Agenda
Meeting Minutes
February 2024
Roll Call – via Zoom or contact
MPOG
Announcements
Precision Feedback Trial Launching
● Full scale trial launching Wednesday May 22,
2024!
● All eligible sites (46) opted in. Thank you!
● 23 sites to receive the same email. 23 sites to
receive the updated “precisionized email”
● Opt out email to providers sent out
● Thank you in advance for meeting your upload
deadlines, especially during the next 6 months.
Please let the coordinating center know of any
potential upload delays
Sample Email
Subcommittees
Pediatric Subcommittee met 5/13/2024
● Minutes will be posted in Archived Events on the website
Cardiac Subcommittee meeting: June 24, 2024 2-3pm EST
Obstetric Subcommittee meeting: May 22, 2024 1-2pm EST
● Registration required as unblinded data will be shared. Please register by 5pm
EST today if you would like to attend.
● Agenda:
○ Unblinded Measure Review TEMP-05
○ Review BMI Data
○ Two measure revision proposals: BP- 04 and GA-03
○ New measure proposal for azithromycin administration
MPOG Application Suite Upgrade: Now Available!
● Upgrade package sent to each site’s IT contact (if you don’t know
who this is for your site, contact support@mpog.zendesk.com)
● Sites Using Desktop Virtualization (e.g. Citrix)
○ Your site’s IT team will upgrade the App Suite
● Users using the App Suite installed on their PC
○ Your site’s IT team will distribute the installer to all individuals
at their site after the database upgrade has been applied.
● Release Notes
Thank you to the Quality Champions and Technical Analysts that entered
NPI numbers and email addresses into the user management tool. We are
currently at a 77% fill rate, up from 45% in March of this year.
Thank you to all that entered NPI
numbers and email addresses into
the user management tool. We are
currently at a 77% fill rate, up from
45% in March of this year.
April 2023 - February 2024
Performance Range: 0-100%
April 2023 - February 2024
Performance Range: 0-100%
TRAN-01 Performance across MPOG
April 2023 - February 2024
Performance Range: 0-100%
TRAN-01: Transfusion Management Vigilance
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
TRAN-02: Overtransfusion
TRAN-02: Percentage of adult patients with a post transfusion hemoglobin or hematocrit value greater
than or equal to 10 g/dL or 30%.
● Exclusions:
○ ASA 5 & 6 including Organ Procurement
○ Cesarean delivery cases with EBL >1500cc or HR >110, SBP < 85, DBP <45, O2Sat < 95%
○ Massive blood loss with EBL > 2000mL and/or 4 or more units of blood transfused
● Success: Hematocrit value documented as < 30% and/or hemoglobin as < 10 g/dL OR
○ No hematocrit or hemoglobin checked within 18 hours of Anesthesia End
TRAN-02 Performance across MPOG
April 2023 - February 2024
Performance Range: 0 -100%
TRAN-02: Overtransfusion
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
Measure Updates
PAIN-02 Exclusion
● PAIN-02: Administration of non-opioid adjunct
○ Description: Percentage of adults receiving at least one non-opioid adjunct preoperatively or
intraoperatively
○ Measure Time Period: Preop Start to Anesthesia End
○ Success Criteria: At least one non-opioid adjunct (medication, regional block, neuraxial
block, or local injection) was administered to the patient during the measure time period
● Note: we are updating this measure to include complex bronchoscopy cases that
previously were not assigned as bronchoscopy cases
PAIN-02 Exclusion
● Current exclusion for patients transported to ICU intubated. However, more liver transplant cases
with OR extubations. Received feedback from sites that adjuncts (acetaminophen, regional, etc)
may not always be appropriate for these patients
● Consider adding the following exclusion: Procedure Type: Liver Transplant
● Current exclusion for endoscopy cases, but ERCPs are not part of these exclusions.
● Consider: adding ERCP as part of the endoscopy case type exclusion for PAIN 02
SMOK-02: Provider Attribution
● Percentage of adult patients who are documented as current tobacco smokers and
also receive an approved smoking cessation intervention from an anesthesia provider
● Corrected measure to attribute only those providers signed in at anesthesia start
rather than all providers signed into case
● Minimal performance changes overall for individual providers
● No change to departmental performance
Glucose Measure: Provider Attribution
● GLU-09: Hyperglycemia Management, Intraop (>180 mg/dL)
● If a patient has a glucose value > 180 mg/dL, the providers who start insulin or recheck glucose within 90 mins are
attributed with a pass. If no insulin was started or if no recheck occured, then the providers signed in 90 mins
after the glucose result are flagged
● Feedback: if a handoff occurred between the high glucose result and the intervention (insulin or recheck), then
both the incoming and outgoing provider should pass the measure. If a handoff occurred after the high glucose
result and no intervention occurred within 90 mins, then both the incoming and outgoing providers should flag the
measure
● This reasoning should also apply to
○ GLU 10 (management of hyperglycemia between preop holding and PACU end)
○ GLU 11 (Treatment of hyperglycemia with insulin)
○ GLU 12 and 13 (management of hypoglycemia)
New Measures
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 across MPOG
April 2023 - February 2024
Performance Range: 50-100%
NMB-05: Quantitative Monitoring
NMB-05: Percentage of cases with documentation of train-of-four count or ratio provided by a
quantitative monitor (acceleromyography, electromyography, kinemyography, or mechanomyography)
No threshold - Informational only measure
● Measure Time Period: Patient in Room to Patient Out of Room
● Exclusions:
○ ASA 5 & 6 cases including Organ Procurement
○ Patients not receiving neuromuscular blockade
● Success: Documentation of train-of-four count or ratio provided by a quantitative monitor
(acceleromyography, electromyography, kinemyography, or mechanomyography)
NMB-05 Performance across MPOG
April 2023 - February 2024
Performance Range: 0 -100%
BRAIN-01
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) across MPOG
January 2023 - December 2023
Performance Range: 1- 86%
Antibiotic Bundle for
Cardiac Cases
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
April 2023 - February 2024
Performance Range: 18 - 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 across MPOG
April 2023 - February 2024
Performance Range: 0 - 100%
Thank You!
Measure Updates
SUS-02: Global Warming Footprint During
Maintenance Phase
This measure analyzes efficient (based on global warming potential) use of inhalational anesthetic
agents. The CO
2
equivalent of 2 l/min of 2% sevoflurane is considered efficient use. This is calculated
to be 2.83 kg CO
2
per hour. We have received feedback to refine provider attribution for this measure
and need your input.
Currently, attribution is assigned to all provider(s) signed during during the maintenance phase of a
case where patients are administered an inhalational agent.
SUS 02 - Attribution
● Feedback: measure as currently written means that providers who are giving breaks are being attributed
(both passed and flagged)
● Should we continue to attribute all providers signed in during the maintenance period? So, if a case is
flagged, all providers are flagged. If case is passed, all providers pass OR
● Only attribute results to providers if they are signed in > 30 minutes
● Implications: if no provider is signed in for > 30 minutes, then no provider is attributed (for passed or
flagged cases)
● For short cases where maintenance phase periods less than 30 minutes, no providers attributed (for both
passed and flagged cases)
● For short cases, we could attribute the providers (in room + medically directing) who are signed in the
cases. If there are multiple providers, we can attribute the providers who are signed in the longest.
SUS 02 - Attribution: Other Ideas
● Or only attribute providers that are signed in when inhalational agents are being administered?
● So if a case is included, If a provider is signed in when inhalational agents are being
administered, they are an attributable provider
● If the case passes, then all attributable providers pass
● If a case flags, then flag all providers with mean CO2e greater than or equal to 2.83 kg CO2/hr
are flagged. Providers with a mean CO2e less than 2.83 kg CO2/hr would pass
