Quality Committee
Meeting
July 22, 2024
10:00am - 11:00am Eastern Time
Announcements
- Upcoming Events
Provider Feedback Emails - Adding SRNAs
Measure Review
- PAIN-02 - Roya Saffary, MD - Stanford University
Measure Update
- SMOK-02 Provider Attribution
- Glucose Provider Attribution
New Measures (time permitting)
- ABX-02-C/ABX-03-C
- NMB-04, NMB-05
- BRAIN-01
Agenda
Announcements
Precision Feedback Trial Launched!
● Full scale 6 month trial launched on Wednesday
May 22, 2024!
● All eligible sites (46) opted in. Thank you!
● 23 sites receiving the same email. 23 sites
receiving the updated “precisionized email”
● Thank you for meeting your upload deadlines,
especially during the next several months. Please
let the coordinating center know of any potential
upload delays
Provider Feedback - SRNAs
(Student Registered Nurse
Anesthetists)
Provider Feedback Email Groups
● Provider feedback emails currently include the following comparison groups:
○ Attendings, Residents, Fellows, CRNAs, AAs
● Participating site (Cleveland Clinic) has requested that an additional comparison
group be added for SRNAs
● Would other sites be interested in this additional comparison group for SRNAs?
● Do other sites have SRNA sign in and sign out data?
QI Reporting Tool
Updates
Site Selected Dashboard - Updated
11
View measures
on emails
alongside
other measures of
interest
"Star" measures
of departmental
interest not on
emails
Updated Result Reasons
Updated Breakdown by location graph
13
PUL-01: Protective Tidal Volume, 10 mL/kg PBW
Description: Percentage of patients with medial tidal volumes < 10 mL/kg (predicted body weight)
Threshold: 90%
Exclusions:
● Age < 12
● Age 12-17 with height <91.4 cm or > 213.4 cm
● Age > 18 years with height < 121.9cm or > 213.4 cm
● ASA 5 & 6 cases including Organ Procurement
● Cases in which patients are mechanically ventilated for < 45 cumulative minutes
● Cases without a documented height or sex
● One lung ventilation cases
● Weight < 20 kg
Success criteria: Intraoperative median tidal volume < 10 mL/kg predicted body weight.
PUL-01: Protective Tidal Volume, 10 mL/kg PBW
Other Measure Details:
● For a given case, this measure will exclude periods when patients are not under positive pressure
ventilation
○ Peak Inspiratory Pressure is determined by values mapped by MPOG Concept 3185. If no
PIP documented, PIP is considered null and tidal volume is included.
● For a case to be included for the measure, it must have at least 45 valid values of actual tidal
volume or set tidal volume.
PUL-01 Performance
June 2023 - May 2024
Performance Range: 65% - 100%
PUL-01: Protective Tidal Volume, 10 mL/kg PBW
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
PAIN-02: Multimodal Analgesia
Description: Percentage of adult patients receiving at least one non-opioid adjunct preoperatively or
intraoperatively.
Threshold: 85%
Exclusion criteria:
● Age < 18 years
● ASA 5 & 6
● Patients who remained intubated postoperatively
● Procedures such as open cardiac, obstetric procedures, ECT, TEE/Cardioversion, Endoscopy,
Bronchoscopy, Intubation only cases, Diagnostic imaging, Non-operative procedures, central line
placement, lumbar puncture, otoscopy, eye procedures
Success criteria: At least one non-opioid adjunct (medication, regional block, or local injection) was
administered to the patient during the measure time period.
PAIN-02: Multimodal Analgesia
Other Measure Details:
● Dexamethasone given alone is not considered a non-opioid adjunct to prevent multiple false
positives that may skew measure performance.
● Opioid Sparing Medications must be administered between Preop Start and Anesthesia End via a
valid route. Lidocaine given IV is not considered.
● Local Anesthetic Considerations: Documentation must occur between Preop Start and Anesthesia
End
● Regional/Neuraxial Block is determined by the Peripheral Nerve Block and Neuraxial phenotypes
respectively. Documentation considered from Preop Start through PACU end.
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 Procedure Type: Liver Transplant as exclusion.
● Current exclusion for endoscopy cases, but ERCPs are not part of these exclusions. We are
adding ERCP as part of the endoscopy case type exclusion for PAIN 02
PAIN-02 Performance
June 2023 - May 2024
Performance Range: 46% - 100%
PAIN-02: Multimodal Analgesia
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
SMOK-02: Provider Attribution
● Description: Percentage of adult patients who are documented as current tobacco
smokers and also receive an approved smoking cessation intervention from an
anesthesia provider
● Updated measure to attribute only those providers signed in at anesthesia start rather
than all providers signed into case (as originally specified)
● No change to departmental performance
● Minimal performance changes for individual providers
Provider Attribution
Glucose Measures
Provider Attribution Overview
● Measures are assigned a result (passed/flagged/excluded) at the case
level.
● Each provider signed into the case is also assigned a result - may differ
from case-level result.
● Provider attribution criteria is developed by the Quality Committee when
the measure is initially developed, and is specific to each measure.
● Most, but not all measures assign provider attribution - some measures
provide departmental results only (MORT 01)
Provider Attribution - Glucose Measures
Current logic:
● For glucose measures looking for treatment or /rechecking within 90 minutes:
Provider(s) who administered insulin or rechecked glucose within 90 minutes will
PASS.
● If no insulin administered or if no recheck occured: Providers signed in exactly 90
minutes after the glucose result are flagged. (Not within 90 minutes, at 90
minutes.)
Potential Issue:
● If transfer of care occurred during the 90 minutes after the high (or low) glucose
value, the measure will attribute a relief provider rather than the primary provider.
Is this appropriate? We are assuming that the handoff happened appropriately.
Provider Attribution - Glucose Measures
Example:
● 1100: Case started and Provider A signed in
● 1200: Glucose - 350 mg/dl
● 1230: Glucose treated with insulin (Provider A - PASS)
● 1300: Glucose - 300 mg/dl
● 1330: Provider A signed out
● 1330: Provider B (relief provider) signed in
● 1430: Not treated or rechecked (Case - Flagged, Provider B - FLAG)
Should both providers be flagged? Only Provider B (signed in at 90 mins)? Or also
Provider A (within 90 mins).
If the 2nd high glucose was re-checked or treated, should both providers PASS, or just
Provider B?
GLU-09: Hyperglycemia Management, Intraop (>180 mg/dL)
Measure Time Period: Preop Start to PACU end
Provider Attribution
● 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)
GLU-10: Hyperglycemia Management, Periop (>180 mg/dL)
Measure time period: Preop start to PACU end
Success Criteria:
● Administration of insulin within 90 minutes (either IV or sub Q
routes) or
● Recheck of glucose level within 90 minutes
Inclusion:
● All patients with glucose level greater than 180 mg/dL
● Patients with and without diagnosis of diabetes
Preop start to Anesthesia Start: The first anesthesia provider(s) signed into the case
Anesthesia Start to Anesthesia End: The provider(s) signed in at the first glucose
recheck or first administration of insulin. If neither occurred, then the responsible provider
is the one signed in 90 minutes after the high glucose measurement.
Anesthesia End to PACU End: The last anesthesia provider(s) signed into the case.
Reasoning will also apply to the following measures:
● 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)
GLU-10: Hyperglycemia Management- Provider Attribution
Case flagged, provider passed/excluded
● GLU cases can pass/flag for a measure AND pass/flag or be excluded on the
provider level.
● If a provider was not signed in during a 90 minute re-check the individual
provider may be excluded/pass for the case.
● We will walk through a case example in the next slide and then open the floor for
discussion before we vote on attribution for these GLU measures.
Important note - attribution for each measure is different based the vote from
Quality Committee or respective subcommittee.
Measure Attribution Case example will apply for Glucose 10 and 11 (hyperglycemia) and 12 and 13 (hypoglycemia)
Preop start 950 Anes start 1132 – Anes end 1510 Blood glucose in preop at 1034 -164
Provider 1- Dr. X In room at anes start Provider 2- Dr. Y In room at anes start Blood glucose at noon- 222
Recheck or insulin due by 1330
If no treatment or recheck, all providers signed in at 90 minutes of high value gets flagged.
Dr. X remains in room Dr. Y remains in room Insulin administered at 1310 - all providers signed in pass for
this time check.
Recheck or insulin due by 1440
Dr. X signed out at 1415
Dr. X signed in at 1450
Dr. Y remains in room No blood sugar rechecks, or insulin given by 1440
Dr. Z (covering) signed in at 1415
Dr. Z signed out at 1450
Dr. Y signed out at 1500 and does not return to case Dr. Z and Dr. Y are flagged for this measure.
Measure Times- Preop Start -- 950 Anes Start -- 1132 Anes end 1510
Providers Blood Sugar checked Recheck/insulin given
Dr. X- in room at Anes Start Preop- 1034 – 164 mg/dL None due- within normal range
Dr. Y- in room at Anes Start Intraop - BG 222 mg/dL Recheck or Insulin due by 1330
If no treatment or recheck, all providers signed in at 90 minutes of high value gets flagged.
Dr. X remains in room
Dr. Y remains in room
BG 241 mg/dL at 1310 Insulin administered at 1315- all providers signed in for this time
check pass.
Recheck or insulin due by 1445
Dr. X signed out at 1415
Dr. X signed in at 1450
No blood sugar checked No blood sugar rechecks, or insulin given by 1445
Dr. Z (covering) signed in at 1415
Dr. Z signed out at 1450
No blood sugar checked
Dr. Y remains in room
Dr. Y signs out and does not return to case
No blood sugar checked
Dr. Z and Dr. Y are flagged for this measure.
Glucose Measure Attribution
1: Continue attribution as is (no changes)
2: Attribute all providers signed in within 90 minutes after
glucose value
1 vote/ site
Continue as is/ modify
Coordinating Center will review all votes after meeting to ensure no
duplication
New Measures
NMB-04: Sugammadex Dosing
Description: 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
June 2023 - May 2024
Performance Range: 51-100%
NMB-05: Quantitative Monitoring
Description: 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
June 2023 - May 2024
Performance Range: 0 - 99%
BRAIN-01: Benzodiazepene Use
Description: 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)
June 2023 - May 2024
Performance Range: 0 - 86%
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%
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
