Cardiac Anesthesia Subcommittee Minutes

June 24, 2024

2:00pm – 3:00pm EST

Zoom

Abernathy, Jake (Johns Hopkins)

Korenke, Mark (Michigan)

Addo, Henrietta (MPOG)

Lopacki, Kayla (Trinity Health)

Atwood, Tammy (Henry Ford)

Malenfant, Tiffany (MPOG)

Barrios, Nicole (MPOG)

Mathis, Mike (MPOG)

Bartoszko

, Justyna (Toronto)

Nieter, Don (Michigan)

Benitez Lopez, Julio (MyMichigan)

Nugele, Judy, Trinity Health)

Buehler, Kate (MPOG)

Owens, Wendy (MyMichigan)

Coffman, Traci (Trinity)

Pennington, Bethany (WUSTL)

Coleman, Robert (MPOG)

Schonberger, Robert (Yale)

Dubovoy, Anna (Michigan)

Shaygan, Lida (UT Southwestern)

Finch, Kim (Henry Ford)

Smiatacz, Frances Guida (MPOG)

Gebhardt, Brian (UMass)

Venkataramani, Ran (UCSF)

Grewal, Ashanpreet (Maryland)

Wade, Meridith (MPOG)

Heiter, Jerri (Trinity)

Welle, Erin (Michigan)

Janda, Allison (MPOG)

Wilkens, Eric (Temple)

Keetai, Miklos (Vanderbilt)

Zittleman, Andrew (MPOG)

Meeting Start: 1401

1. Agenda

a. Welcome & announcements

b. FLUD-01-C Measure Review

c. Transfusion Measure Cardiac Exclusion Discussion (TRAN-01/TRAN-02

)

d. Discussion of antibiotic selection measure specification updates (ABX-04)

e. Acute Kidney Injury in Open Cardiac Surgery: Measure Proposal

f. Summary and next steps

2. Introductions

a. ASPIRE Quality Team

i. Allison Janda, MD – MPOG Cardiac Anesthesia Subcommittee Lead

ii. Michael Mathis, MD – MPOG Director of Research

iii. Kate Buehler, MS, RN – Clinical Program Manager

b. Cardiac Anesthesiology Representatives joining us from around the US!

3. FLUID-01-C Measure Review

– Minimizing Colloid Use in Cardiac Surgery

a. Allison Janda, MD – Measure Reviewer

b. Definition: percentage of cardiac cases in which colloids were not administered

intraoperatively

c. Rationale: Lack of consistent evidence to suggest improved survival with the use of

colloids compared to crystalloids in the surgical population. Because colloids are more

expensive than colloids, it is recommended that anesthesia providers avoid the use of

colloids in most instances.

d. Discussion:

i. Allison Janda (MPOG Cardiac Subcommittee Chair): Nice synthesis of the

literature with recommendations from the Chinese Society of Cardiac Surgery –

added to review here. However, no evidence to support colloid use over

crystalloid use, especially in the context of cost. Recommend retiring this

measure.

ii. Justyna Bartoszko (UHN): Thank you for the great review! There were also the

2024 Chest Guidelines directly commenting: In adult patients undergoing

cardiovascular surgery, intravenous albumin is not suggested for priming the

cardiovascular bypass circuit or volume replacement (Conditional

Recommendation, Moderate Certainty of Evidence of Effect).

https://journal.chestnet.org/action/showPdf?pii=S0012-3692%2824%2900285-

iii. Tammy Atwood (Henry Ford Jackson): Do you know if pump prime components

and/or perfusion fluids used were captured in this measure?

1. Allison Janda (MPOG Cardiac Subcommittee Chair): For some sites, it

was captured and for others it wasn’t – just depends on documentation

and mapping.

iv. Don Nieter (MSTCVS): We recently queried the PERForm registry and hetastarch

– type colloids are no longer being used by registry participants.

v. Jake Abernathy (Johns Hopkins): Does it cost MPOG anything to maintain? If not,

then perhaps continuing the measure, that is already built, all information is

good information and is worth keeping around.

vi. Anna Dubovoy (Michigan Medicine): I think it is nice to clean up and retire this

measure.

vii. Eric Wilkens (Temple): In favor of retiring.

viii. Ashan Grewal (UMaryland): We used a similar measure department wide but

have since retired it because of >95% compliance. Vote to continue.

ix. Rob Schonberger (Yale): Would agree with Dr. Abernathy to continue this

measure to help identify any providers who may be outliers in their

performance.

e. Vote – 1 vote per site

i. Continue as is/ modify/ retire

ii. Need > 50% to retire measure

iii. Coordinating Center will review all votes after meeting to ensure no duplication

f. Next Steps: FLUID-01-C: Continue as is (with updates to literature review and rationale

emphasizing that this is an informational measure).

4. Measure Review Process

a. Review literature for given measure topic and provide review using

MPOG Measure

Review Template

b. Present review of literature and recommendations at Cardiac Subcommittee meetings

c. Reviewers' names will be added to measure specifications as well as

MPOG Measure

Reviewer website

5. 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: Hyperglycemia Management

June 2026

Josh Billings, Vanderbilt

GLU-07: Hypoglycemia Management

June 2026

Rob Schonberger, Yale

GLU-08: Hyperglycemia Treatment

June 2026

Josh Billings, Vanderbilt

a. Thank you in advance for ensuring MPOG Cardiac-specific measures remain relevant &

consistent with published recommendations

b. Contact Allison with any questions: ajanda@med.umich.edu

6. Transfusion Measure Discussion

a. Background

b. Transfusion measures were due for review in May 2024

c. Measure reviews performed by assigned Quality Champions & Coordinating Center and

presented to Quality Committee

i. Jacek Cywinski, MD (Cleveland Clinic) Transfusion Management Vigilance

measure review: TRAN-01

ii. Linda Liu, MD (UCSF) Overtransfusion measure review: TRAN-02

d. Quality Committee requested Cardiac Subcommittee review transfusion measure

exclusion of cardiac cases and determine if:

i. Only open cardiac cases should be excluded rather than all cardiac cases or,

ii. Would separate measure(s) for patient blood management in the cardiac

population be appropriate?

e. TRAN-01: Transfusion Management Vigilance

i. Description: Percentage of adult patients receiving blood transfusion with

documented hemoglobin or hematocrit value prior to administration.

ii. Exclusions:

1. Age < 18 years

2. ASA 5 & 6

3. Postpartum hemorrhage cases

4. Massive blood loss with EBL > 200 mL and/or 4 or more units of blood

transfused

5. Labor epidurals

6. Burn cases

7. Cardiac cases

iii. Success: Documentation of hemoglobin or hematocrit within 90 minutes prior

to transfusion

f. TRAN-02: Overtransfusion

i. Description: Percentage of adult patients with a post transfusion hemoglobin or

hematocrit value greater than or equal to 10 g/dL or 30%.

iv. Exclusions:

1. Age < 18 years

2. ASA 5 & 6

3. Postpartum hemorrhage cases

4. Massive blood loss with EBL > 200 mL and/or 4 or more units of blood

transfused

5. Labor epidurals

6. Burn cases

7. Cardiac cases

v. 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

g. Discussion

vi. Maintain exclusion of cardiac cases for TRAN-01 and TRAN-02?

vii. Create new patient blood management measures for the open cardiac

population?

viii. Include specific cardiac procedures in TRAN-01/TRAN-02 measures but

continue to exclude open cardiac procedures?

ix. Anna Dubovoy (Michigan Medicine): Definitely think this measure applies to

cardiac cases and would include them.

x. Lida Shaygan (UT Southwestern): Disagree – hard measure to control with open

cardiac cases. Would not include open cardiac cases. There are other non-

cardiac cases, like non-open cardiac cases like endovascular arch cases where

surgeons what hgb of >=10.

xi. Erin Welle (Michigan Medicine): I worry that some surgeons have very specific

transfusion parameters, if I’m understanding TRAN-02 correctly

xii. Allison Janda (MPOG Cardiac Subcommittee Chair): Can exclude open cardiac

only, endovascular cases only, other cardiac cases or any combination thereof.

What does the group think about that?

xiii. Mike Mathis (Michigan Medicine): I tend to agree with Anna in the spirit of

taking these measures seriously but not personally. Should not aim for 100%

adherence to any of these measures if considering clinical nuance. I think it’s

okay to flag cardiac cases for TRAN-02. May need to consider autologous vs

homologous units.

1. Kate Buehler (MPOG Clinical Program Manager): Would you agree with

including cardiac cases for TRAN-01 too?

2. Mike Mathis (Michigan Medicine): Yes, as long as the same exclusions

apply for massive transfusion, then yes. Think it is appropriate to

include cardiac cases for TRAN-01.

xiv. Ashan Grewal (UMaryland): Can MPOG data differentiate between PRBC vs

autologous blood vs. cell saver vs. pump blood transfusion?

1. Allison Janda (MPOG Cardiac Subcommittee Chair): Yes, as long as sites

have the variables broken out by these different types of transfusions

and have mapped them to the given MPOG corresponding concepts.

2. Don Nieter (MSTCVS): This data is all recorded in PERForm also fyi.

xv. Ashan Grewal (UMaryland): For TRAN-01 is blood transfusion only referring to

PRBCs?

1. Allison Janda (MPOG Cardiac Subcommittee Chair): Yes

xvi. Mike Mathis (Michigan Medicine): I think we will inevitably be able to improve

this measure with cardiac-specific details eventually, but to do that we have to

at least get the TRAN measures on the runway for cardiac cases.

h. TRAN-01 – Vote: 1 vote per site

i. Continue measure as is

ii. Modify to include cardiac cases (some or all)

iii. Create new cardiac specific PBM measure

iv. Coordinating center will review all votes after meeting to ensure no duplication

i. TRAN-02 – Vote: 1 vote per site

i. Continue measure as is

ii. Modify to include cardiac cases (some or all)

iii. Create new cardiac specific PBM measure for overtransfusion

iv. Coordinating center will review all votes after meeting to ensure no duplication

j. Next steps: Modify TRAN-01 and TRAN-02 to include cardiac cases (we will present

performance at our next meeting to reassess).

7. Antibiotic Selection Measure

a. ABX-04: Antibiotic Selection for Open Cardiac Procedures

i. Description: Percentage of adult patients undergoing open cardiac surgery with an

appropriate antibiotic administered for surgical site infection prophylaxis

i. Timing: 120 minutes prior to Anesthesia Start through Anesthesia End

ii. Attribution: All anesthesia providers signed in at the time of Anesthesia Start Time

iii. Inclusions: Adult patients undergoing open cardiac surgical procedures

iv. Acceptable Antibiotics:

1. Vancomycin + Cephalosporin

2. Vancomycin + Aminoglycoside

3. Cephalosporin Only

v. Exclusions:

1. ASA 5 & 6 or Organ Procurement (CPT:01990)

2. Non-cardiac cases as defined as those cases not meeting criteria for the

cardiac case type phenotype

3. Within the general cardiac case type phenotype, exclude:

Transcatheter/Endovascular, EP/Cath groups and Other Cardiac

4. Cases with age < 18

5. Patients already on scheduled antibiotics or had a documented infection

prior to surgery, as specified by “Patient on Scheduled

Antibiotics/Documented Infection” (value:2) of the

ABX Notes

Phenotype

vi. Cases will be assigned one of the following result reasons:

1. Passed – Appropriate antibiotics administered

2. Flagged – Non-standard antibiotic selection

3. Flagged – Prophylactic antibiotic not administered (Not documented in

MAR)

4. Flagged – Antibiotic not ordered/indicated per surgeon

5. Flagged – Incision/procedure start time not documented: No

6. Flagged – Not administered for medical reasons

7. Excluded – Scheduled antibiotics/documented infection

vii. Is this list of acceptable antibiotics complete?

1. Vancomycin + Cephalosporin

2. Vancomycin + Aminoglycoside

3. Cephalosporin only

viii. Add additional PCN allergy considerations?

1. Vancomycin + Clindamycin

2. Vancomycin + Fluoroquinolone

3. Vancomycin + Aztreonam

ix. Reference: Bardia publication: https://pubmed.ncbi.nlm.nih.gov/37075942/

x. Prelim performance is very high 95-100% across all participating MPOG sites

ii. Discussion:

1. Jake Abernathy (Johns Hopkins): is there usefulness in not grouping

these antibiotics together? Instead of you get a ‘pass’ if you give any

one of these combinations, would it be better to outline the specific

combinations?

2. Kate Buehler (MPOG Clinical Program Manager): Can’t support this with

our standard measure build on the QI Reporting Tool (dashboard)

currently but can bring this information back at an upcoming (Sept)

unblinded review session. Each bar would be labeled with the site as

well as the most common antibiotic combination as a stacked bar chart.

b. ABX-05: Composite Antibiotic Compliance for Open Cardiac’

i. Description: Percentage of adult patients undergoing open cardiac surgery

with appropriate antibiotic selection, timing, and re-dosing administered for

surgical site infection prophylaxis

ii. Timing: 120 minutes prior to Anesthesia Start Time through Anesthesia End

Time

iii. Attribution: Departmental Only – Case level attribution, viewable on

dashboard at the case level, not provided to individual clinicians

iv. Success: Case is passed for all open cardiac antibiotic measures (timing, re-

dosing, selection)

v. Inclusions: Adult patients undergoing open cardiac surgical procedures

vi. Exclusions:

1. ASA 5 & 6 or Organ Procurement (CPT:01990)

2. Non-cardiac cases as defined as those cases not meeting criteria for the

cardiac case type phenotype

3. Within the general cardiac case type phenotype, exclude:

Transcatheter/Endovascular, EP/Cath groups and Other Cardiac

4. Cases with age < 18

5. Patients already on scheduled antibiotics or had a documented infection

prior to surgery, as specified by “Patient on Scheduled

Antibiotics/Documented Infection” (value:2) of the

ABX Notes

Phenotype

vii. Preliminary Results: Variation in performance across MPOG sites

viii. Discussion:

1. Allison Janda (MPOG Cardiac Subcommittee Chair): In the same way we

could show the antibiotic combinations as part of the unblinded review

session in September, could also show bar chart with flagged measures

as the breakdown for ABX-05-C.

ix. Next Steps:

1. Move forward with ABX-05-C composite measure.

2. Share unblinded data for antibiotic measures at next cardiac

subcommittee meeting in September.

8. Acute Kidney Injury – Open Cardiac Surgery Measure Proposal

a. AKI-02-C: Acute Kidney Injury in patients undergoing Open Cardiac Surgery

i. 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 baseline creatinine level increases by > 0.3 mg/dL

within 48 hours postoperatively

ii. Inclusion: Adult patients undergoing open cardiac surgical procedures

(determined by Procedure Type: Cardiac value code:1)

iii. Success:

1. The creatinine level does not go above 1.5x the baseline level within 7

days post-op

2. The creatinine level does not increase > 0.3 mg/dL obtained within 48

hours after Anesthesia End

iv. Exclusions:

1. ASA 6 (including CPT:01990)

2. Cases where a baseline creatinine is not available within 60 days

preoperatively

3. Cases where a creatinine lab is not available within 7 postoperative days.

4. 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

5. 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.

6. Open cardiac procedures performed in conjunction with procedures

affecting the kidney, bladder, or ureter (specific anesthesia and surgical CPT

codes).

v. Provider Attribution:

1. Does the group want to move forward with provider attribution for this

measure or publish initially as ‘departmental only’ measure with no

attribution assigned?

a. Jake Abernathy (Johns Hopkins): Yes, assign provider attribution.

b. Allison Janda (MPOG Cardiac Subcommittee Chair): Any other

thoughts? (None – moving forward with provider attribution)

2. Kate Buehler (MPOG Clinical Program Manager): Does provider signed

in for the longest duration make sense for provider attribution? This is

the logic applied for AKI-01.

c. Subcommittee agrees to this logic.

vi. Discussion:

1. Jake Abernathy (Johns Hopkins): How does this differ from filtering AKI-

01 on the cardiac dashboard?

2. Allison Janda (MPOG Cardiac Subcommittee Chair): That will simply filter

to all cardiac cases, not specifically open cardiac cases.

3. Jake Abernathy (Johns Hopkins): And how does this measure differ from

the STS AKI measure?

4. Allison Janda (MPOG Cardiac Subcommittee Chair): The STS measure

examines renal failure, not AKI specifically.

vii. Next Steps:

1. Move forward with building AKI-02-C measure including provider

attribution.

2. Allow measure to be available for provider feedback emails.

9. Cardiac Anesthesia Subcommittee Membership

a. Open to all anesthesiologists or those interested in improving cardiothoracic measures

o Do not have to practice at an active MPOG institution

b. Proposed 2024 Meeting Schedule

o September 2024

o December 2024

c. Thank you for using the forum for discussion between meetings

Meeting adjourned: 1505