Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Quality Committee Meeting Notes – Monday, July 22

, 2024

Attendance:

Benjamin Stam

Laurence Ring

Bethany Pennington

Linda Liu

Bill Dewhirst

Lorile Greenblatt

Bradford Berndt

Mara Bollini

Brian Reon

Marc Philip Pimentel

Bryan Cohen

Mary McKinney

C.Bowman-Young

Megan Perkaj

Charity Corpus

Mellany Stanislaus

Chris Bourgeois

Merajuddin khan

Chris Wedeven

Meredith Hall

Claire Ostarello

Meridith Wade

Dale Parks

Michael Mathis

Denise Schwerin

Michele Narens

Diana O'Dell

nancy abou nafeh

Diego Bauza

Nicole Barrios

Dieter Adelmann

Nikki Pardo

Douglas Colquhoun

Nirav J Shah

Elizabeth Jewell

Pam Tyler

Eva Lu-Boettcher

Rania Elkhateb

Germaine Cuff

Rebecca Johnson

Hanna Van Pelt

Rebecca Pantis

Heather LaLonde

Ronnie Riggar

Hedi Schroeck

Roya Saffary

Henrietta Addo

Ruth Cassidy

Jacquelyn Goatley

Sachin Kheterpal

Jason Sheffield

Sandra Becker Rozek

Jing Tao

Sarah Kirke

Joe Tandoc

Shu Zhu

Jonathan Kaper

Spiro Spanakis

Jonathan Paul

Stephen Gregory

Joseph J McComb

Tiffany Malenfant

Josh Goldblatt

Tim Harwood

Karen Domino

Tom Joseph

Kate Buehler

Troy Wildes

Kate Hubbert

Victoria A Lacca

Katherine Vitale

Vikram Kumar

Kathleen Collins

Wendy Owens

Kathy Lee Scranton

Yuan Yuan

Katie O'Conor

Yuliana Salamanca

Agenda & Notes

Meeting Start: 1001 EST

(1) Agenda

(2) Roll Call: Via Zoom or contact Coordinating Center (support@mpog.zendesk.com) if you were

present but not listed on Zoom.

(3) Minutes from May 20

, 2024, Quality Committee Meeting

1. Nirav Shah (MPOG Quality Director): Before we get started, I wanted to give a shoutout

and acknowledge the great work of Dr. Dan Biggs from Oklahoma. He retired last month

and was one of the original MPOG QI Champions and PIs that has worked with MPOG

for a long time. He has been a big part of what MPOG has been over the last decade or

so. Best wishes to Dan as he starts his next phase of life. Thank you, Dan!

(4) Announcements

1. Precision Feedback Trial Launched

a. Full scale launching Wednesday May 22, 2024!

b. All eligible sites (46) opted in. Thank you!

c. 23 to receive the same email. 23 sites to receive updated “precisionized email”

d. Thank you in advance for meeting your upload deadlines, especially during the next 6

months. Please let the coordinating center know of any potential delays.

2. Featured Member – July and August

a. Roya Saffary, MD – MyMichigan Health – Stanford University

(5) 2024 Meetings

1. Friday, September 13, 2024: ACQR Retreat, Henry Executive Center, Lansing, MI

2. Friday, October 18, 2024: MPOG Retreat, Philadelphia, Pennsylvania

3. Upcoming Events

(6) Provider Feedback: Student Registered Nurse Anesthetists

a. Provider Feedback Email Groups:

1. Provider feedback emails currently include the following comparison groups:

Attendings, Residents, Fellows, CRNAs, AAs

2. Participating site (Cleveland Clinic) has requested that an additional comparison group

be added for SRNAs

3. Would other sites be interested in this additional comparison group for SRNAs?

4. Do other sites have SRNA sign in and sign out data?

5. Discussion:

(i) Hedi Schroeck (Dartmouth Hitchcock Medical Center) via chat: Dartmouth. Yes,

interested. Yes, we have sign-in and sign-out data.

(ii) Alvin Steward (UAMS) via chat:

UAMS would be interested. Yes, they sign in and out of the case.

(iii) Josh Goldblatt (Henry Ford Health System) via chat: Yes, and Yes for Henry Ford

(iv) Troy Wildes (Nebraska Medicine) via chat:

Interested too. Yes, they sign in here (U of Nebraska)

(v) Marc Pimentel (Brigham & Women’s Hospital) via chat: Yes, SRNAs sign in at BWH

(vi) Mary McKinney (Corewell Dearborn/Taylor) via chat: The SRNA’s that I have seen on

cases at Dearborn do sign and out.

(vii) Joseph Tandoc (Henry Ford Health System Macomb) via chat: Yes, and Yes Henry

Ford Macomb

(viii) Bradford Berndt (Bronson Kalamazoo) via chat: Yes, we would be interested at

Bronson Methodist. They sign in here too

(ix) Charity Corpus (Corewell Royal Oak) via chat: Both yes for RO Corewell

(x) Tom Joseph (UPenn) via chat: Interested. They sign in sometimes, but we would

standardize 100% sign in

(xi) Stephen Gregory (WashU) via chat: Yes, for Wash U

(xii) Katie O’Connor (Johns Hopkins) via chat: JHM interested

(7) QI Reporting Tool Updates

a. Site Selected Dashboard – Updated

1. View measures on emails alongside other measures of interest

2. “Star” measures of departmental interests are not on emails

b. Updated Result Reasons

c. Updated Breakdown by location graph

d. Release nots not available on our website.

e. Discussion:

i) Mary McKinney (Corewell Dearborn/Taylor) via chat: Really like the new functionality! Great

work!

ii) Marc Pimentel (Brigham & Women’s Hospital): I think this is great. It’s always good having to

look back and see which measures we are tracking, but I didn’t want to send emails to everyone

just because I was looking at it. These are very welcome changes. Thank you.

iii) Nirav Shah (MPOG Quality Director): Thank you, Marc. As you’re starting to navigate the QI

Reporting tool, now that we’ve hopefully gotten some underlying performance issues resolved,

please let us know if there are any other features that you think will be helpful. If you are still

having performance issues for the standard display, anytime you click on the query buttons or if

you’re filtering for more than 2 years of data, then essentially, we need to re-query the

database. If you’re within 2 years and still having significant performance issues, let us know so

we can address it.

(8) Measure Review: PAIN-02: Dr. Roya Saffary, Stanford University

1. Description: Percentage of adult patients receiving at least one non-opioid adjunct

preoperatively or intraoperatively.

2. Exclusion criteria:

a. Age < 18 years

b. ASA 5 & 6

c. Patients who remained intubated postoperatively

d. 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

3. Success criteria: At least one non-opioid adjunct (medication, regional block, or local

injection) was administered to the patient during the measure time period.

4. Other Measure Details

a. Dexamethasone given alone is not considered a non-opioid adjunct to prevent

multiple false positives that may skew measure performance.

b. Opioid Sparing Medications must be administered between Preop Start and

Anesthesia End via a valid route. Lidocaine given IV is not considered.

c. Local Anesthetic Considerations: Documentation must occur between Preop

Start and Anesthesia End

d. Regional/Neuraxial Block is determined by the Peripheral Nerve Block and

Neuraxial phenotypes respectively. Documentation considered from Preop Start

through PACU end.

5. Discussion:

(i) Roya Saffary (Stanford University): I was concerned about local injection and how

well that is documented. I personally find it difficult to find where it is documented

and how to obtain the data.

(ii) Nirav Shah (MPOG Quality Director): As long local injection is documented in the

MAR; we will get the local information that is administered by the local team.

Assuming the circulating nurses documented it. There may be a couple sites where

the anesthesia team documented, but the data we receive shows it is being

documented by circulating nurses, and we are including that in.

(iii) Roya Saffary (Stanford University): For other feedback, we have a lot of patients to

that get blocks and catheters placed outside of the OR. So, either in the ER or on the

floors and they may come to the OR with them in and I do not know if they are

being properly captured. From personal experience, when I have patients that I care

for in the OR who come in with a catheter, I do not document that the catheter is

running. I assume it’s the nursing report and nursing chart, but unsure if that crosses

over to the MPOG data. To avoid false positives, we must figure out how to capture

that data, but not include patients that simply get a block without an operative

procedure.

(iv) Nirav Shah (MPOG Quality Director): Not just at Stanford, but I know there are other

hospitals where those blocks are being pushed as early as possible. If the local

anesthetic that is being administered through that block, if it’s a catheter, if that

was documented by the anesthesia tea or the circulating nurse team as being

administered or being infused during the procedure, then we will likely get it, but

we are not looking at the procedure documentation that’s happening in the

emergency room. If it happens to fall within the period in which we are pulling block

information, then we may be getting the data. I am leery of extending and including

the procedure notes obtained in the emergency room. We may include blocks that

we did not intend to. So, I think we can investigate this and see if we can be better

at capturing what we need and see if we are missing a lot of blocks that should be

included as well.

(v) Roya Saffary (Stanford University): Will it be possible to link cases that are in the OR

to previous blocks. If they had a block, they include those blocks, versus patients

who had a block but with no operative procedures afterwards. I do not know how

feasible it will be.

(vi) Nirav Shah (MPOG Quality Director): We could extend the period between when the

block was performed and the procedure. For example, 4, 12, or 24 hours and

potentially include many of those. If we did that, we would have to see if there are a

lot of blocks that we are including that we do not intend to. We can at least extend

the look back period for procedure notes.

(vii) Rania Elkhateb (UAMS) via chat: Can there be a separate quality metric for cardiac

cases?

a. Nirav Shah (MPOG Quality Director): This is a valid perspective. We plan to

share this feedback with the Cardiac Subcommittee, Dr. Janda and others,

to bring it up at the next meeting and see what their approach could be.

Should they try and include it in this measure or create a new cardiac

measure? Assuming there is more variation in administration in non-opioid

adjuncts and cardiac cases, they could skew or change overall performance

for PAIN-02. The Cardiac Subcommittee needs to figure out how they would

like to implement it and if the rules of implementation are a little bit

different.

(viii) Josh Goldblatt (Henry Ford Health System): Most EMRs that I have seen do include

and administration mode of “Rate Verify.” If anyone in the periop team documents

this on a pain catheter, this should be captured by MPOG. The places I have worked

at consider it policy anytime there is a handoff that the receiving nurse would

document it. I am unsure of the individual practices at other sites. It may be worth

visiting to ensure that data is captured and that those procedures are captured.

a. Nirav Shah (MPOG Quality Director): I am not 100% sure if the rate and

verify crosses into MPOG extract.

6. PAIN-02 Exclusion:

a. 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.

1. Consider adding Procedure Type: Liver Transplant as exclusion.

b. 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.

c. Discussion:

(i) Ketan Chopra (Henry Ford Health System) via chat: We have a lot of patients

with popliteal catheters who come down for repeat procedures, is there

anything we can do to document this now or just hold off until it is

investigated?

a. Nirav Shah (MPOG Quality Director): We need to see if those are

being included right now, or if we are not capturing those, let us

know. We can investigate further to see why they are not being

captured. If it is the time window or some other reason.

(ii) Rania Elkhateb (UAMS): Are repeated procedures not excluded from the

metrics? If the same patient has 2 surgeries, will they both be captured?

a. Nirav Shah (MPOG Quality Director): Both are being captured and

both are being looked at individually. The thought behind this

measure was that if a patient has an index procedure, then returned

a couple of days later for a re-operation, then the re-operation

should still get an opioid sparing adjunct unless it met one of the

exclusion criteria.

d. MPOG Coordinating Center Comments on PAIN-02:

1. Consider additional exclusion for cases without any analgesia (opioids or

opioid sparing agents) administered between preop start and

anesthesia end.

2. Consider additional exclusion for anesthesia block only cases

3. Update organization of exclusion list to be similar to PAIN-01

4. Performance across MPOG – June 2023 – May 2024

a. Performance range: 46% - 100%

e. PAIN-02: Vote

1. Remove exclusion for patients that remain intubated/transferred to ICU

2. Extend look-back period for regional blocks to assess for single-shot

blocks performed on floor or ED before transfer to OR

3. Exclude liver transplants

4. Exclude cases without any analgesic medication or opioid administered

5. Exclude ERCP cases

6. Ask Cardiac Subcommittee to review measure: recommend including

cardiac cases

7. Coordinating center will review all votes after the meeting to ensure no

duplication across sites

7. Measure Updates

a. SMOK-02: Provider Attribution

1. Description: Percentage of adult patients who are documented as current tobacco

smokers and also receive an approved smoking cessation intervention from an

anesthesia provider.

2. Updated measure to attribute only those providers signed in at anesthesia start rather

than all providers signed into case (as originally specified)

3. No change to departmental performance

4. Minimal performance changes overall for individual providers

b. Glucose Measures: Provider Attribution

1. Provider Attribution Overview:

2. Measures are assigned a result (passed/flagged/excluded) at the case level

3. Each provider signed into the case is also assigned a result – may differ from case level

result

4. Provider attribution criteria is developed by the Quality Committee when the measure

initially developed, and is specific to each measure

5. Not all measures assign provider attribution – some measures provide departmental

results only (MORT-01)

6. Provider Attribution – Glucose Measures

(a) Current Logic:

(i) For glucose measures looking for treatment or/rechecking within 90 minutes:

Provider(s) who administered insulin or rechecked glucose within 90 minutes

will PASS.

(ii) If no insulin administered or if no recheck occurred: Providers signed in exactly

90 minutes after the glucose result are flagged (Not within 90 minutes, at 90

minutes)

(iii) Issue:

1. 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.

(iv) Example:

8. 1100: Provider A signed in

9. 1200: Glucose – 350 mg/dL

10. 1230: Glucose treated with insulin (Provider A - PASS)

11. 1300: Glucose – 300 mg/dL

12. 1330: Provider A signed out

13. 1330: Provider B (relief provider) signed in

14. 1430: Glucose not treated or rechecked (Case – Flagged; Provider B –

Flagged)

15. 1435: Provider B (relief provider signed out)

16. 1435: Provider A signed in

17. Should both providers be flagged? Only Provider B (signed in at 90

mins)? Or Provider A as well (within 90 minutes)

18. If the 2

high glucose was re-checked or treated, should both providers

PASS, or just Provider B?

7. Discussion:

(i) Josh Goldblatt (Henry Ford Health System): I have been working with Kim Finch to

investigate our glucose processes across Henry Ford. We recently audited 200

glucose cases, to see what step happened. We did not concentrate on provider

attribution but noticed treatment issues through handoff in different phases of care

from preop to intraop and then into PACU. While auditing for quality, we laid out a

15-minute hand over window. So, if a provider leaves preop and the recheck is due

within 15 minutes, the departing provider or team should take care of that, so the

receiving team is not left with a 15-minute window. We are also considering

reminder BPAs that remind providers to intervene. So, we are using a 30-minute

window for that. Part of our conversation has been around avoiding over testing. In

the example given, is a handoff that occurred 30 minutes after a high glucose way

too early to consider? I think it is too early. It is less than half of the allocated 90-

minute time frame. Personally, I like the idea of attributing to both providers,

positive and negative.

(ii) Kathleen Collins (Trinity Health Livonia): I am in favor of both providers being

attributed. We had a CRNA who gave a 15-minute break and the 90-minutes

happened during that time. The person who gave the break was attributed, but then

the CRNA that was there before and after the break was not attributed. If it is a

problem with process and handoff, then both providers should be attributed in this

circumstance.

a. Nirav Shah (MPOG Quality Director): The counter point of that could be that

there’s already transfer of care measures that are meant to address that.

(iii) Troy Wildes (Nebraska Medicine) via chat: I do think it is unfair to attribute someone

who signs in right before the glucose/insulin due time (e.g. 10-10 min) as there is no

sufficient time to intervene and would suggest excluding receiving physician in this

scenario (not attributing both) (Seconded by Katie O’Connor (Johns Hopkins))

8. Vote:

a. 1 vote/site – Coordinating Center will review all votes after the meeting to

ensure no duplication

b. Continue as is – no changes

c. Modify – Attribute all providers signed in within 90 minutes after glucose

8. New Measures

a. NMB-04: Variation in Sugammadex Administration

1. Description: Percentage of adult and pediatric (> 3 years) cases with sugammadex

administration where cumulative sugammadex dose < 200 mg OR < 3 mg/kg

2. Threshold: 90%

3. Measure Time Period: Anesthesia Start to Earliest Extubation

4. Exclusions:

a. Age < 2 years

b. ASA 5 & 6

c. Cases < 30 minutes

d. Patients that were not extubated in the immediate postoperative period

5. Success: Cases where cumulative sugammadex dose was < 200 mg OR < 3 mg/kg

6. NMB-04 Performance across MPOG

a. June 2023 – May 2024 Performance range 51% – 100%

b. NMB-05: Quantitative Monitoring

1. Description: Percentage of cases with documentation of train-of-four count or ratio

provided by a quantitative monitor (acceleromyography, electromyography,

kinemyography, or mechanomyography)

2. No threshold – informational only measure

3. Measure Time Period: Patient in Room to Patient Out of Room

4. Exclusions:

i. ASA 5 & 6 including Organ Procurement

ii. Patients not receiving neuromuscular blockade

5. Success: Documentation of train-of-four count, or ratio provided by a quantitative

monitor (acceleromyography, electromyography, kinemyography, or

mechanomyography)

6. NMB-05 Performance across MPOG

iii. June 2023 – May2024 Performance range 0% – 99%

7. Discussion:

(i) Troy Wildes (Nebraska Medicine) via chat: We are finding NMB-05 very useful in

supporting quantitative expansion. Any way to start thinking about provider

attribution for this one so we can look at this data at our sites?

a. Nirav Shah (MPOG Quality Director): We can. Once we have more

confidence in the data quality across all sites and we have interest, we can

think about provider attribution as well.

(ii) Joseph McComb (Temple Health) via chat: Would like to see recovery percentage

with Quantitative monitoring > 90%.

a. Nirav Shah (MPOG Quality Director): Yes, great point. Maybe another

measure related to neuromuscular dosing as well.

c. BRAIN-01: Benzodiazepine use

1. Description: Percentage of patients > 70 years old who received a benzodiazepine

perioperatively.

2. No threshold - Informational only measure

3. Measure Time Period: Pre-op Start to PACU End

4. Exclusions:

a. Age < 70 years

b. ASA 5 & 6

c. Floor/ICU emergent intubation only cases

d. ICU transfer postoperatively

5. Success: Avoiding administration of benzodiazepines for patients > 70 years

6. BRAIN-01 Performance across MPOG (Inverse)

a. June 2023 – May 2024 Performance Range 0% - 86%

Meeting Adjourned: 1102 EST

Next meeting: September 23

, 2024