Cardiac Anesthesia Subcommittee Minutes

September 30, 2024

11:00am – 12:00pm EST

Zoom

Abernathy, Jake (Johns Hopkins)

Lou, Sunny (WUSTL)

Addo, Henrietta (MPOG)

Lopacki, Kayla (Trinity Health)

Barrios, Nicole (MPOG)

Malenfent, Tiffany (MPOG)

Bartoszko, Justyna (Toronto)

Mathis, Mike (MPOG)

Brown, Morgan (Boston Children's)

Meuhlshlegel, J. Danny (Johns Hopkins)

Buehler, Kate (MPOG)

Notorianni, Andrew (Yale)

Clark, Melissa (Michigan)

O'Conor, Katie (Johns Hopkins)

Coleman, Robert (MPOG)

Pantis, Rebecca (MPOG)

Dubovoy, Anna (Michigan)

Pennington, Bethany (WUSTL)

Edelman, Tony (MPOG)

Schonberger, Rob (Yale)

Fisher, Clark (Yale)

Shaygan, Linda (UT Southwestern)

Ghaly, Tammer (Yale)

Shah, Nirav (MPOG)

Goatley, Jackie (Michigan)

Smeltz, Alan (North Carolina)

Govindaswamy, Radhika (Yale)

Smiatacz, Frances Guida (MPOG)

Grewal, Ashanpreet (Maryland)

Stumpf, Rachel (MPOG)

Guruswamy, Jayakar (Jay) (Henry Ford)

Sturmer, David (Michigan)

Heiter, Jerri (Trinity)

Vaughn, Shelley (MPOG)

Janda, Allison (MPOG)

Velten, Markus (UT Southwestern)

Jewell, Elizabeth (MPOG)

Wade, Meridith (MPOG)

Johnson, Rebecca (Corewell)

Wilkens, Eric (Temple)

Kertai, Miklos (Vanderbilt)

Yuan, Yuan (MPOG)

Korenke, Mark (Michigan)

Zhao, Sarah (MPOG)

Lacca, Tory (MPOG)

Zittleman, Andrew (MPOG)

1. Agenda

a. Introduction & announcements

b. Transfusion measures cardiac inclusion updates (TRAN-01/TRAN-02)

c. ABX-03-C Update

d. New Measures: AKI-02-C, ABX-04-C, ABX-05-C

e. Contraction-CS Study: Inotrope barriers/facilitators to use in cardiac surgery

f. New Measure Brainstorming

g. 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. 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

4. 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

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

5. Dissemination of Anonymized Performance Data

a. Background

a. At the 9/23 meeting, Quality Committee voted to approve sharing anonymized

data with AQI

b. 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)

c. AQI may submit the following screenshot (view slides) to CMS as part of their

QCDR measure submission (without threshold line included)

d. Demonstrating variation in care would help the AQI measures obtain approval

as QCDR measures

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. Update

vi. Cardiac cases are now included in TRAN-01 and TRAN-02

vii. “Ignore” autologous blood transfusion for cardiac cases – cases with only

autologous units administered are excluded

viii. Scores for most sites increased modestly. A few sites had a decrease in

performance scores for both measures, based on site cardiac transfusion

practices

7. ABX-03-C Update

a. ABX-03-C: Antibiotic Redosing, Open Cardiac Procedures

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

appropriate antibiotic re-dosed for surgical site infection prophylaxis

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

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

IV. Change: The following antibiotics are now excluded from the measure due to varying

half-lives:

1. Ceftriaxone

2. Cefotetan

3. Cefoxitin

V. Score changes were minimal as majority of sites do not routinely use these medications

for cardiac surgery.

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).

ii. Discussion:

1. Anna Vladimirovna Dubovoy (University of Michigan) via chat: are

mediastinal explorations/chest exposures excluded?

a. Allison Janda (MPOG Cardiac Subcommittee Chair): They should be

considered ‘cardiac: other’ cases and should be excluded from this

measure. However, this is dependent on the quality of

documentation so if there are cases unintentionally included, it

could be related to how the case was scheduled or the CPT code

assigned.

b. Kate Buehler (MPOG Coordinating Center) via chat: Cardiac

phenotype specifications – only open cardiac cases (value =1)

should be included for AKI-02-C.

9. Antibiotic Selection Measure

1. ABX-04-C: Antibiotic Selection for Open Cardiac Procedures

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

with the recommended antibiotic agents administered for surgical site

infection prophylaxis

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

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

Time

iv. Inclusions: Adult patients undergoing open cardiac surgical procedures

v. Exclusions:

1. Age < 18 years

2. ASA 6 including Organ Procurement

3. 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

4. Non-cardiac, Transcatheter/Endovascular, EP/Cath groups and Other

Cardiac cases as determined by the Procedure Type: Cardiac phenotype

5. Lung Transplant cases as determined by the Procedure Type: Lung

Transplant phenotype

vi. Acceptable antibiotic combinations for Open Cardiac Procedures:

1. Vancomycin + Cephalosporin

2. Vancomycin + Aminoglycoside

3. Vancomycin Only

4. Cephalosporin Only

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

1. Passed – Vancomycin + Cephalosporin

2. Passed – Vancomycin + Aminoglycoside

3. Passed – Vancomycin Only

4. Passed – Cephalosporin Only

5. Flagged – Non-standard antibiotic selection

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

MAR)

7. Flagged – Antibiotic not ordered/indicated per surgeon

8. Flagged – Not administered for medical reasons

9. Excluded – Scheduled antibiotics/documented infection

viii. Discussion:

i. Danny Muehlschlegel (Johns Hopkins): Allison, what about antibiotic

infusions?

1. Allison Janda (MPOG Cardiac Subcommittee Chair): Infusions and bolus

doses are included for this measure with the start time considered for

the timing of the initial dose and continuation of the infusion should

count for subsequent redosing if currently running at the time the

redose is due.

ii. Rob Schonberger (Yale) via chat: STS: The Society of Thoracic Surgeons (STS)

does not recommend vancomycin alone as the primary prophylactic for

cardiac surgery procedures. This is because of the known risk of gram-

negative risk to cause mediastinitis.

1. Kate Buehler (MPOG Coordinating Center): The STS provides a caveat

statement that specifically mentions that there is not enough literature

to suggest that an additional antibiotic is required with the initial dose

of vancomycin though is strongly recommended for gram negative

coverage. At this point, we’ve opted for the measure to be more lenient

and account for all circumstances. Over time, as more literature is

published, we hope to make the measure more stringent as advised by

this subcommittee.

2. Kate Buehler (MPOG Coordinating Center) via chat: The STS Guidelines

also recommend gentamicin or other aminoglycoside be administered

with vancomycin for gram negative coverage, however, the efficacy of

adding an aminoglycoside is not well established in the literature. ABX-

04-C draft specification

3. Note: After the meeting, additional literature was provided to Dr. Janda

from Bethany Pennington (Washington University) to suggest that

Vancomycin alone is not recommended. The measure has since been

updated to flag cases in which Vancomycin alone was administered.

Measure specification has been updated with this literature as well as

the rationale for this decision. Please contact ajanda@med.umich.edu

with any questions.

4. Jake Abernathy (Johns Hopkins): This may be specific to Johns Hopkins

but how would continuous antibiotic infusions be handled?

5. Allison Janda (MPOG Cardiac Subcommittee Chair): Those should be

passed as long as they are running for the duration or majority of the

case. Re-dose should also pass if running at the time a re-dose would be

due (4 hours after the start of the bolus or infusion).

6. Kate Buehler (MPOG Coordinating Center): We may need to look into

some cases for Johns Hopkins. Thought we had accounted for that but

perhaps we need to adjust the measure code. Also, worth mentioning

for all sites, we are only looking at the IV route. Recommend sites verify

mapping is correct for routes as this will result in a flagged

7. Michael Mathis (MPOG Research Director): Is there a reason or specific

rationale for why Johns Hopkins administers continuous antibiotic

infusions for cardiac cases?

8. Jake Abernathy (Johns Hopkins): Ancef infusion pre-dated me. From

what it sounds like, an increase in sternal wound infections drove this

change although I’m not sure we have any data to support that

infections have decreased since starting infusions.

iii. Next Steps:

1. Modify measure to flag cases with Vancomycin only administered.

2. Validate and publish ABX-04-C – will post to forum once available on

dashboards.

3. Investigate ABX-03 re-dosing antibiotic infusion cases for Johns Hopkins

since they should not be flagged.

2. ABX-05-C: 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

1. Case level attribution, viewable on the dashboard at the case level, not

provided to individual clinicians

iv. Success: Case must pass all 3 antibiotic prophylaxis for open cardiac

procedure measures

1. ABX-02-C / ABX-03-C / ABX-04-C

v. Inclusions: Adult patients undergoing open cardiac surgical procedures

vi. Exclusions:

1. Age < 18 years

2. ASA 6 including Organ Procurement

3. Patients already on scheduled antibiotic or had a documented infection

prior to surgery, as determined by “Patient on Scheduled

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

phenotype

4. Non-cardiac, Transcatheter/Endovascular, EP/Cath groups and Other

Cardiac cases as determined by the Procedure Type: Cardiac phenotype

5. Lung Transplant cases as determined by the Procedure Type: Lung

Transplant phenotype

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

1. Passed – Antibiotic Prophylaxis Standards Met

2. Flagged – Timing, Re-dosing, & Selection Not Met (ABX-02-C, ABX-03-C,

& ABX-04-C flagged)

3. Flagged – Timing & Selection Not Met (ABX-02-C & ABX-04-C flagged)

4. Flagged – Re-dosing & Selection Not Met (ABX-03-C & ABX-04-C flagged)

5. Flagged – Timing & Re-dosing Not Met (ABX-02-C & ABX-03-C flagged)

6. Flagged – Antibiotic not administered on time (ABX-02-C flagged)

7. Flagged – Antibiotic not appropriately re-dosed (ABX-03-C flagged)

8. Flagged – Non-standard antibiotics selection (ABX-04-C flagged)

9. Excluded – Scheduled antibiotics/documented infection

viii. Discussion:

i. Nirav Shah (MPOG Quality Director): This the first example of a measure that

has pass/flag from other measures. There are some areas like temperature or

sustainability that could benefit from a composite measure if sites find this

helpful. Will be interested to know how the composite measure for antibiotics

is used across sites to improve quality and guide antibiotic administration for

cardiac surgery.

10. COmparing iNoTRope prACtice variaTION in Cardiac Surgery (CONTRACTION-CS)

ix. The Problem:

1. Cardiac inotropes have tradeoffs impacting complications after cardiac

surgery, yet current evidence fails to capture the nuanced clinical

contexts in which they are harmful versus helpful

ii. The Big Questions:

1. What factors currently drive inotrope decision-making?

2. What barriers and facilitators to inotrope practice change?

3. Can we use integrated health data to better estimate context-specific

casual effects of inotropes on outcomes?

iii. Specific Aims

iv. Discussion:

1. Mike Mathis (MPOG Research Director): Would like to solicit some initial

feedback on what are some of the factors that drive site inotrope

decision making?

2. Danny Muehlschlegel (Johns Hopkins): I adapt to what the Hopkins

practice is - it is very much institutional. Unless there is evidence in a

certain direction, seems best to go with the common practice at the

institution to make sure everyone is comfortable.

3. Jake Abernathy (Johns Hopkins): I love this! I’ve long thought that

inotrope decision is cultural, not clinical. If there is no data to drive

decisions, how do decisions get made?

a. Mike Mathis (MPOG Research Director): Everyone goes into this

wanting to ensure good care for patients and…variation does

exist across hospitals. Will be a fun study to explain why that

might be.

4. Ashanpreet Grewal (University of Maryland) via chat: @UMaryland Epi

is the primary inotrope used post CPB. Its use depends on the patients

preCPB Cardiac function

5. Morgan Brown (Boston Children’s Hospital) via chat: I think institutional

preference and surgeon preferences matter. But I think myocardial

protection is a big confounder that is difficult to adjust for and is

definitely an art. Our surgeons' practices vary a lot.

a. Mike Mathis (MPOG Research Director): Can only go so far with

an observational study but we do have STS data that might

assist with this analysis. May need to be pragmatic trial in the

future.

6. Tammer Ghaly (Yale) via chat: I have definitely started things per

surgeon preference. A transplant surgeon in fellowship liked low dose

dopamine and dobutamine for everybody, but we ran epi as our

primary inotrope.

7. Radhika Govindaswamy (Yale) via chat: It should largely be based on

post op Echo

v. Next Steps:

1. Mike Mathis to continue with this study and provide updates to Cardiac

Subcommittee as needed.

11. Next Measure Discussion:

i. Previous suggested topics include:

2. Antibiotic selection and timing Complete! (ABX-04-C and ABX-02-C)

3. Neuromuscular blockade reversal

4. Pulmonary complication avoidance

5. Hypotension avoidance

6. Acute kidney injury avoidance Complete! (AKI-02-C)

7. Handoffs

8. Transfusion Update – added cardiac cases to TRAN-01/TRAN-02

9. Other ideas?

ii. Discussion:

1. Radhika Govindaswamy (Yale) via chat: Antifibrinolytics in OPCABG –

lots of institutional variation

2. Rob Schonberger (Yale): With patients that receive large volumes of

PRBCs but no plasma, wondering what the group thinks about a new

transfusion measure to assess the ratio of PRBCs transfused to units of

FFP?

a. Anna Dubovoy (University of Michigan): What are you thinking

for this? 1:1:1 for massive transfusion?

b. Rob Schonberger (Yale): I think evidence would support at least

1:1:1. There are examples of an extreme number of PRBC

transfusions without any FFP given.

c. Anna Dubovoy (University of Michigan): Should it instead be

POC viscoelastic testing measure to guide transfusion?

d. Andrew Notarianni (Yale): Interesting area to explore –

especially if we transition to fibrinolytic products over

transfusions

e. Mike Mathis (MPOG Research Director): Would recommend an

informational measure as the first version of this measure.

Viscoelastic data in MPOG would need to be improved before

we could develop a true pass/flag measure in this area.

f. Alan Smeltz (UNC): We refer to this as a ‘yellow MTP’ where

several units of cryo or FFP are administered without any PRBCs

– would recommend capturing cases where only FFP and cryo

are given without any PRBCs.

g. Nirav Shah (MPOG Quality Director): Currently MTP is a blind

spot for us in MPOG as we exclude these cases from our

transfusion measures and focus only on cases with 1-3 PRBC

units transfused.

h. Ashanpreet Grewal (UMaryland) via chat: If POC testing is used

then it will be tough to also assess if a pre-determined formula

was followed such as 1:1:1

i. Tammer Ghaly (Yale) via chat: 4 or more units without

something like viscoelastic testing or another product might be

reasonable. How would we factor cell saver transfusion into

that?

j. Mike Mathis (MPOG Research Director) via chat: FYI - the OB

subcommittee has a research project on transfusion ratio (PCRC

250 on “current projects tab of MPOG website). Cardiac

subcommittee might do a similar project.

k. Tammer Ghaly (Yale) via chat: Also, should the metric consider

units given in ICU after leaving the OR? For example, if we

decide after closing, we want to give FFP or platelets, but didn’t

have them in the room before leaving. Should those units be

factored into the metric if given within 30 or 60 minutes of ICU

arrival?

l. Clark Fisher (Yale): Could also consider hypotension between

anesthesia start and when the case starts (when lines are

placed) as a measure

m. Allison Janda (MPOG Cardiac Subcommittee Chair): Could

consider a transfusion measure based on this discussion or

perhaps another hypotension measure specific to cardiac cases.

Does that seem like the best places to start for 2025 measures?

vi. Next Steps:

1. Plan to build either a transfusion-related measure or a hypotension

measure for cardiac surgery in 2025. We plan to present some

preliminary data for these topics during our February 2025 meeting.

12. Cardiac Anesthesia Subcommittee Membership

i. Open to all anesthesiologists or those interested in improving cardiothoracic

measures

ii. Do not have to practice at an active MPOG institution

iii. Upcoming meetings:

a. December 2024 (unblinded data review *pre-registration will be required*)

b. February 2025

c. June 2025

d. November 2025

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

v. Summary/Next Steps

Meeting adjourned: 1202