MPOG Cardiac Anesthesia Subcommittee Meeting
September 30th, 2024
Introductions
• ASPIRE Quality Team
– Allison Janda, MD – MPOG Cardiac Anesthesia Subcommittee Lead
– Michael Mathis, MD – MPOG Director of Research
– Kate Buehler, MS, RN – Clinical Program Manager
• Cardiac Anesthesiology Representatives joining us from around the US!
Measure Review Process
• Review literature for given measure
topic and provide review using
MPOG Measure Review Template
• Present review of literature and
recommendations at Cardiac
Subcommittee meetings
• Reviewers names will be added to
measure specifications as well as
MPOG Measure Reviewer website
Upcoming Cardiac-Focused Measure Reviews
Measure Review Date Reviewers
TEMP-06-C: Hypothermia Avoidance February 2025 Mariya Geube, Cleveland Clinic
TEMP-07-C: Hyperthermia Avoidance February 2025 Ashan Grewal, UMaryland
GLU-06-C: Hyperglycemia Management June 2026 Josh Billings, Vanderbilt
GLU-07-C: Hypoglycemia Management June 2026 Rob Schonberger, Yale
GLU-08-C: Hyperglycemia Treatment June 2026 Josh Billings, Vanderbilt
Thank you in advance for ensuring MPOG Cardiac-specific measures remain relevant &
consistent with published recommendations!
Contact Allison with any questions: ajanda@med.umich.edu
Dissemination of Anonymized Performance Data
Background
● At the 9/23 meeting, Quality Committee voted to approve sharing anonymized
multicenter data with AQI.
● Anesthesiology Quality Institute (AQI) had requested approval to receive
screenshots from MPOG to show variation in care for antibiotic redosing in cardiac
surgery (ABX-03-C)
● AQI may submit the following screenshot (next slide) to CMS as part of their QCDR
measure submission
● Demonstrating variation in care could help the AQI measures obtain approval as
QCDR measures
ABX-03-C Performance
Transfusion Measure Cardiac Inclusion Update
Background
• Transfusion measures were due for review in May 2024.
• Measure reviews performed by assigned Quality Champions & Coordinating Center
and presented to Quality Committee
– Jacek Cywinski, MD (Cleveland Clinic) Transfusion Management Vigilance measure review: TRAN-01
– Linda Liu, MD (UCSF) Overtransfusion measure review: TRAN-02
• Quality Committee requested Cardiac Subcommittee review transfusion measure
exclusion of cardiac cases and determine if:
– Only open cardiac cases should be excluded rather than all cardiac cases or,
– Would separate measure(s) for patient blood management in the cardiac population be
appropriate?
TRAN-01: Transfusion Management Vigilance
TRAN-01: Percentage of adult patients receiving a blood transfusion with documented hemoglobin or
hematocrit value prior to administration.
● Exclusions:
○ Age <18 years
○ ASA 5 & 6
○ Postpartum hemorrhage cases
○ Massive blood loss with EBL > 2000mL and/or 4 or more units of blood transfused
○ Labor Epidurals
○ Burn Cases
○ Cardiac Cases
● Success: Documentation of hemoglobin or hematocrit within 90 minutes prior to transfusion*
*See spec for exceptions.
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:
○ Age < 18 years
○ ASA 5 & 6
○ Postpartum hemorrhage cases
○ Massive blood loss with EBL > 2000mL and/or 4 or more units of blood transfused
○ Labor epidurals
○ Burn cases
○ Cardiac cases
● 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
Update
• Cardiac cases are now included in TRAN-01 and TRAN-02
• “Ignore” autologous blood transfusion for cardiac cases - cases with only autologous
units administered are excluded.
• Scores for most sites increased modestly. A few sites had a decrease in performance
scores for both measures, based on site cardiac transfusion practices.
ABX-03-C Update
ABX-03-C: Antibiotic Re-dosing, Open Cardiac Procedures
• Description:
– Percentage of adult patients undergoing open cardiac surgery with an appropriate
antibiotic administered for surgical site infection prophylaxis.
• Timing:
– 120 minutes prior to Anesthesia Start through Anesthesia End
• Attribution:
– All anesthesia providers signed in at the time of Anesthesia Start Time
• Change: the following antibiotics are now excluded from the measure due to
varying half-lives
– Ceftriaxone, Cefotetan, Cefoxitin
Acute Kidney Injury - Open Cardiac Surgery
AKI-02-C: Acute Kidney Injury in patients undergoing Open Cardiac Surgery
Description: Percentage of patients undergoing an open cardiac procedure with a baseline
creatinine increase of more than 1.5 times within 7 postoperative days or the baseline
creatinine level increases by ≥ 0.3 mg/dL within 48 hours postoperatively.
Inclusion: Adult patients undergoing open cardiac surgical procedures (determined by
Procedure Type: Cardiac value code: 1)
Success:
1. The creatinine level does not go above 1.5x the baseline creatinine within 7 days post-op
2. The creatinine level does not increase by ≥ 0.3 mg/dL obtained within 48 hours after anesthesia end.
AKI-02-C: Acute Kidney Injury in patients undergoing Open Cardiac Surgery
Exclusions:
● ASA 6 (including 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 postop 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
determined by Preop EGFR (most recent) or MPOG Complication - Acute Kidney Injury value code -2.
● Open cardiac procedures performed in conjunction with procedures affecting the kidney, bladder, or
ureter (specific anesthesia and surgical CPT codes).
AKI-02-C Performance Across MPOG
September 2023 - August 2024
0 - 100%
Antibiotic Selection Measure
ABX-04 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.
• Timing:
– 120 minutes prior to Anesthesia Start through Anesthesia End
• Attribution:
– All anesthesia providers signed in at the time of Anesthesia Start Time
ABX-04 Antibiotic Selection Considerations
• Inclusions:
– Adult patients undergoing open cardiac surgical procedures
• Exclusions:
– Age < 18 years
– ASA 6 including Organ Procurement
– Patients already on scheduled antibiotics or had a documented infection prior to
surgery, as determined by “Patient on Scheduled Antibiotics/Documented Infection”
(value: 2) of the ABX Notes Phenotype
– Non-cardiac, Transcatheter/Endovascular, EP/Cath groups and Other Cardiac cases as
determined by the Procedure Type: Cardiac phenotype
– Lung Transplant cases as determined by the Procedure Type: Lung Transplant
phenotype
ABX-04 Antibiotic Selection Considerations
• Acceptable antibiotic combinations for Open Cardiac Procedures:
– Vancomycin + Cephalosporin
– Vancomycin + Aminoglycoside
– Vancomycin Only
– Cephalosporin Only
ABX-04 Antibiotic Selection Considerations
• Cases will be assigned one of the following result reasons:
– Passed - Vancomycin + Cephalosporin
– Passed - Vancomycin + Aminoglycoside
– Passed - Vancomycin Only
– Passed - Cephalosporin Only
– Flagged - Non-standard antibiotic selection
– Flagged - Prophylactic antibiotic not administered (Not documented in MAR)
– Flagged - Antibiotic not ordered/indicated per surgeon
– Flagged - Not administered for medical reasons
– Excluded - Scheduled antibiotics/documented infection
ABX-05 Composite Antibiotic Compliance for Open Cardiac
• Description:
– Percentage of adult patients undergoing open cardiac surgery with appropriate
antibiotic selection, timing, and re-dosing administered for surgical site infection
prophylaxis.
• Timing:
– 120 minutes prior to Anesthesia Start Time through Anesthesia End Time
• Attribution: Departmental Only
– Case level attribution, viewable on the dashboard at the case level, not provided
to individual clinicians
• Success:
– Case must pass all 3 antibiotic prophylaxis for open cardiac procedure measures
– ABX-02-C / ABX-03-C / ABX-04-C
ABX-05 Composite Antibiotic Compliance Considerations
• Inclusions:
– Adult patients undergoing open cardiac surgical procedures
• Exclusions:
– Age < 18 years
– ASA 6 including Organ Procurement
– Patients already on scheduled antibiotics or had a documented infection prior to
surgery, as determined by “Patient on Scheduled Antibiotics/Documented Infection”
(value: 2) of the ABX Notes Phenotype
– Non-cardiac, Transcatheter/Endovascular, EP/Cath groups and Other Cardiac cases as
determined by the Procedure Type: Cardiac phenotype
– Lung Transplant cases as determined by the Procedure Type: Lung Transplant
Phenotype
ABX-05-C - Other Measure Build Details
• Cases will be assigned one of the following result reasons:
– Passed - Antibiotic Prophylaxis Standards Met
– Flagged - Timing, Re-dosing, & Selection Not Met (ABX-02-C, ABX-03-C, & ABX-04-C
flagged)
– Flagged - Timing & Selection Not Met (ABX-02-C & ABX-04-C flagged)
– Flagged - Re-dosing & Selection Not Met (ABX-03-C & ABX-04-C flagged)
– Flagged - Timing & Re-dosing Not Met (ABX-02-C & ABX-03-C flagged)
– Flagged - Antibiotic not administered on time (ABX-02-C flagged)
– Flagged - Antibiotic not appropriately re-dosed (ABX-03-C flagged)
– Flagged - Non-standard antibiotics selection (ABX-04-C flagged)
– Excluded - Scheduled antibiotics/documented infection
Specific Aims
Next Measure Discussion:
Previous suggested topics include:
– Antibiotic selection and timing Complete! (ABX-04-C and ABX-02-C)
– Neuromuscular blockade reversal
– Pulmonary complication avoidance
– Hypotension avoidance
– Acute kidney injury avoidance Complete! (AKI-02-C)
– Handoffs
– Transfusion Update - added cardiac cases to TRAN-01/TRAN-02
– Other ideas?
Cardiac Anesthesia Subcommittee Membership
• Open to all anesthesiologists or those interested in improving cardiothoracic
measures
– Do not have to practice at an active MPOG institution
• Upcoming Meetings
– December 2024 (unblinded data review)
– February 2025
– June 2025
– November 2025
• Thank you for using the forum for discussion between meetings
Summary/Next Steps
• Cardiac cases are now included in TRAN-01 and TRAN-02 measures
• Cefoxitin, Cefotetan, and Ceftriaxone are now excluded from the ABX-03-C measure
• New measures released!:
– AKI-02-C: Acute Kidney Injury, Open Cardiac
– ABX-04-C: Antibiotic Selection for Open Cardiac Procedures
– ABX-05-C: Composite Measure: Antibiotic Compliance for Open Cardiac Procedures
• CONTRACTION-CS Study
• New measure discussion - next steps
• Please register for the unblinded review of ABX-02-C, ABX-03-C, ABX-04-C, ABX-05-C,
and AKI-02-C measures for our December Subcommittee meeting
• Next Meeting:
– TBD, December 2024
