Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)
Quality Committee Meeting Notes – Monday, January 27
th
, 2025
Attendance:
Abess, Alex (Dartmouth)
Lalonde, Heather (Trinity Health)
Abou Nafeh, Nancy (AUB)
Liu, Linda (UCSF)
Addo, Henrietta (MPOG)
Liwo, Amandiy (UAB)
Adelmann, Dieter (UCSF)
Lewandowski, Kristyn (Corewell)
Agerson, Ashley (Spectrum)
Lopacki, Kayla (Mercy Health - Muskegon)
Andreae, Michael (Utah)
Lozon, Tim (Henry Ford - Wyandotte)
Andrew, Ben (Duke)
Lu-Boettcher, Eva (Wisconsin)
Aouad, Marie (AUB)
Mack, Patricia (Weill Cornell)
Aziz, Mike (OHSU)
Madoff, Lauren (Boston Children’s)
Barrios, Nicole (MPOG)
Malenfant, Tiffany (MPOG)
Bauza, Diego (Weill Cornell)
McComb, Joseph (Temple U)
Berndt, Brad (Bronson)
McCullough, Rose (Houston Methodist)
Berris, Josh (Corewell - Farmington Hills)
McKinney, Mary (Corewell Dearborn / Taylor)
Bollini, Mara (WUSTL)
Milliken, Christopher (Sparrow)
Bow, Peter (Michigan)
Mirizzi, Kam (MPOG)
Brennan, Alison (Maryland)
O’Conor, Katie (Johns Hopkins)
Buehler, Kate (MPOG)
O’Dell, Diana (MPOG)
Calabio, Mei (MPOG)
Ohlendorf, Brian (Duke)
Cassidy, Ruth (MPOG)
Ostarello, Claire (ASA)
Charette, Kristin (Dartmouth)
Owens, Wendy (MyMichigan - Midland)
Chopra, Ketan (Henry Ford - Detroit)
Pace, Nathan (Utah)
Clark, David (Stanford)
Pantis, Rebecca (MPOG)
Cohen, Bryan (Henry Ford - West Bloomfield)
Pardo, Nichole (Corewell)
Coleman, Rob (MPOG)
Parks, Dale (UAB)
Delhey, Leanna (MPOG)
Penningon, Bethany (WUSTL)
Denchev, Krassimir (St Joseph Oakland)
Phillips, Latoya (Trinity Health)
Dewhirst, Bill (Dartmouth)
Pimentel, Marc Phillip (B&W)
Drennan, Emily (Utah)
Poindexter, Amy (Holland)
Edelman, Tony (MPOG)
Qazi, Aisha (Corewell)
Elkhateb, Rania (UAMS)
Roselinsky, Howard (Yale)
Esmail, Tariq (Toronto)
Sakkab, Julie (AUB)
Everett, Lucy (MGH)
Schwerin, Denise (Bronson)
Finch, Kim (Henry Ford Detroit)
Shah, Nirav (MPOG)
Gibbons, Miranda (Maryland)
Shaygan, Lida (UT Southwestern)
Goatley, Jackie (Michigan)
Shettar, Shashank (OUHSC)
Goldblatt, Josh (Henry Ford Allegiance)
Smiatacz, Frances Guida (MPOG)
Greenblatt, Lorile (U Penn)
Smith, Mason (MyMichigan)
Grewal, Ashan (Maryland)
Steadman, Randy (Houston Methodist)
Hall, Meredith (Bronson Battle Creek)
Stewart, Alvin (UAMS)
Harwood, Tim (Wake Forest)
Stewart, Margaret (Michigan)
Heiter, Jerri (St. Joseph A2)
Stierer, Tracey (Johns Hopkins)
Horton, Brandy (Anes Associates)
Stumpf, Rachel (MPOG)
Janda, Allison (MPOG)
Tao, Jing (MSKCC)
Jewell, Elizabeth (MPOG)
Tyler, Pam (Corewell Farmington Hills)
Johnson, Rebecca (Spectrum & UMHS West)
Uzarski, Michelle (Corewell)
Joseph, Tom (U Penn)
Vaughn, Shelley (MPOG)
Kaper, Jon (Corewell Trenton)
Vitale, Katherine (Trinity Health)
Karamchandani, Kunal (UT Southwestern)
Wade, Meredith (MPOG)
Khan, Meraj (Henry Ford)
Walters, Andrew (UW)
Kheterpal, Sachin (MPOG)
Wedeven, Chris (Holland)
Kinney, Tyler (Houston Methodist)
Wilson, Blake (MyMichigan)
Krauss, Kristin (Temple)
Woody, Nathan (UNC)
Kumar, Vikram (MGH)
Yuan, Yuan (MPOG)
Lacca, Tory (MPOG)
Zhao, Xinyi (Sarah) (MPOG)
Lai, Emily (MD Anderson)
Zhu, Shu (Columbia)
LaGorio, John (Trinity Health)
Agenda & Notes
Meeting Start: 1001
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 November 2024 Quality Committee Meeting
4. Announcements
A. MPOG App Suite Upgrade Released!
a. Upgrade package has been sent to each site’s IT contact (if you do not know
who this is for your site, contact support@mpog.zendesk.com)
b. More than half of all sites have already applied the upgrade!
c. Sites Using Desktop Virtualization (e.g., Citrix): Your site’s IT team will upgrade
the App Suite
d. Users using the App Suite installed on their PC:
1. Your site’s IT team will distribute the installer to all individuals at their
site after the database upgrade has been applied.
e. Release Notes have posted on the MPOG website
B. Michigan Sites: 2025 Pay-for-Performance (P4P Scorecard)
a. Measure #1: Race and Ethnicity variables mapped to updated MPOG concepts
to align with new OMB standards
1. Sites will need to update Race & Ethnicity mapping to new concepts
that the Coordinating Center has built
b. Sexual Orientation, Sex & Gender Identity: All sexual orientation and gender
identity variables in electronic health record extracted and mapped to an
accepted MPOG concept to align with updated OMB standards
1. Sites will need to extract new data into a Patient Attributes file including
all fields related to Sexual orientation, legal sex, sex at birth, and gender
identity. Once extracted, sites will need to map these variables to
standardized MPOG concepts– Patient Attribute File Specification
c. These initiatives align with MSHIELD definitions to begin assessing healthcare
disparities.
C. Update: QI for Learners Committee
a. As discussed at the September 2024 Quality Committee, MPOG is forming a
committee to develop a QI for Learners program
b. Program would allow residency leadership to assess engagement in practice
improvement
c. Could help fulfill the practice-based learning and improvement components of
residency training
d. If interested, could expand to include SRNAs
e. First meeting to be scheduled in March 2025
Colleagues interested in participating
Name
Institution
Tariq Esmail
University Health Network
Kate O’Connor
Johns Hopkins
Krassimir Denchev
Trinity Oakland
Greg Balfanz
University of North Carolina
Eva Lu-Bettcher
University of Wisconsin
Mara Bollini
Washington University
Bethany Pennington
Washington University
Rachel Moquin
Washington University
Alvin Stewart
University of Arkansas for Medical Sciences
Kunal Karamchandani
University of Texas – Southwestern
Fatima Msheik
American University of Beirut
Matt Caldwell
University of Michigan
Lara Zisblatt
University of Michigan
D. Featured Member – January – February 2025
a. Josh Goldblatt – ACQR – Henry Ford Hospital System – Allegiance
5. Upcoming Events
A. 2025 Meetings
a. Friday, April 11, 2025 – MSQC/ASPIRE Collaborative Meeting – Novi, MI
b. Friday, July 18, 2025 – ASPIRE Collaborative Meeting, Henry Executive Center –
Lansing, MI
1. Will focus on regional anesthesia. Chris Wu, an anesthesiologist in New
York, will be our keynote and discuss the plan of care ultrasound.
c. Friday, September 2025 – Specific Date TBD – ACQR Retreat, Location TBD
d. Friday, October 10, 2025 – MPOG Retreat, San Antonio, Texas
Thanks to all that attended the 2024 Retreat
6. 2025 Measure Review Plan
A. Quality Committee Measure Review Schedule
Reviewer
Date
Measure
Description
Tony Edelman, UMichigan
1/2025
NMB-01
Train of Four Monitoring
Mike Aziz, OHSU
1/2025
NMB-02
Reversal Administered
Kunal Karamchandani, UTSW
1/2025
TOC-01
Intraop Handoff
Joseph Ruiz, MD Anderson
2/20255
PONV-05
Postoperative Nausea
Sustainability Group
5/2025
All SUS
Sustainability Measures (All)
Sunny Chiao, UVA
7/2025
TEMP-01
Active Warming
Jonathan Kaper, Corewell
Trenton
7/2025
TEMP-02
Core Temperature Monitoring
Marc Pimentel, Brigham &
Women’s
9/2025
BP-02
BP Monitoring Gaps
Rob Schonberger, Yale
9/2025
BP-05
Low MAP Avoidance < 55 mm Hg,
Induction
Joe McComb, Temple
11/2025
PUL-01
Median Tital Volume < 10 mL/kg
PBW
Ketan Chopra, HFH
11/2025
PUL-03
Administration of PEEP
B. Cardiac Committee Measure Review Schedule
Date
Measure
Description
2/2025
TEMP-06-C
Hypothermia Avoidance in Cardiac
Surgery
2/2025
TEMP-07-C
Hyperthermia Avoidance in Cardiac
Surgery
C. Pediatric Committee Measure Review Schedule
Reviewer
Date
Measure
Description
Brady Still – University of
Chicago
Spring
SUS-05-Peds
Nitrous Avoidance, Induction
Charles Schrock – St. Louis
Children’s
Spring
NMB-03-Peds
NMB Dosing, Infants
TBD
Fall
FLUID-02-Peds
Minimizing Colloid Use,
Pediatrics
Jeana Havidich - Vanderbilt
Winter
TRAN-03-Peds
TRAN-04-Peds
Transfusion Vigilance
Overtransfusion
7. Measure Reviews:
A. TOC-01: Transfer of Care – Intraoperative – Kunal Karamchandani, UTSW
a. Description: percentage of patients with documentation of intraoperative
handoff for permanent transfers of care between in-room anesthesia providers
b. Threshold: 90%
c. Exclusions:
1. ASA 5 & 6 including Organ Procurement
2. Case with no permanent shift relief (outgoing provider returns within 40
minutes)
3. Labor Epidurals including obstetric non-operative procedures
4. Handovers between supervising anesthesiologists – those not
performing anesthesia care in the operating room
d. Success Criteria: Documentation of intraoperative transfer of care in the
electronic anesthesia record including the key handoff elements used
e. Other Measure Details:
1. For cesarean delivery conversion cases, measure start time is 5 minutes
after cesarean delivery start time to anesthesia end
2. Only permanent intraoperative handoffs between in-room providers
will be considered for this measure
3. If more than one permanent intraoperative handoff occurs during the
case, all events will be considered for determining success
4. A permanent handoff is defined as:
1. Staff relieve for > 40 minutes between staff change and
Anesthesia End, or
2. Staff change in which the original provider is relieved and does
not sign back into the case
5. The accepted time frame for documenting the intraoperative handoff is
15 minutes before to 15 minutes after the staff change.
f. Summary of presentation:
1. Multi-center Handoff Collaboration (MHC) is working with Epic to
finalize a tool with individual handoff elements for O.R to ICU handoff
and looking for a few centers to do a pilot. Anesthesia providers as well
as other perioperative team members (nurses, surgeons) will be
included in the development of this tool. Possibly could partner with
MPOG to track compliance with implementation.
g. Discussion:
• Kunal Karamchandani (UT Southwestern): UT Southwestern discussing with
Epic to see if there is any way the individual component of the handoff can
be tracked and incorporated into the handoff tool.
• Several site representatives mention that they have a single button for
handoff documentation and do not include the individual handoff elements.
• Joshua Berris (Corewell Health Farmington Hills) via chat: Corewell
Farmington Hills’ prior Epic instance had handoff with all the individual
smart data elements that were reportable.
• Joeseph McComb (Temple University): Temple uses Epic and have a button
they can click on to say that handoff occurred. They have the option to add
special elements if any major events occurred during a procedure.
• Tariq Esmail (University Health Network): UHN uses Epic and has a button
that says handoff. The click boxes can remind someone to do a handoff to
address elements that they otherwise would have missed.
• Nirav Shah (MPOG Quality Director): It is difficult to measure the quality of a
handoff. Previous feedback we’ve received for this measure is that it is more
of a ‘check-the-check box’ measure, but at least it captures whether
someone performed a handoff to the postoperative care team.
• Joshua Berris (Corewell Health Farmington Hills) via chat: The handoff
should be built to display all the elements that should be part of the
handover.
• Alexander Abess (Dartmouth Hitchcock) via chat: A thought of caution
regarding mandated elements in handoffs: CMS mandated covering the 7
different elements in post-anesthesia note years ago. This has essentially
limited the amount of meaningful information in postoperative notes for
our team.
• Joeseph McComb (Temple University): Maybe have a button that says
handoff occurred and I have no ongoing concerns or handoff occurred and
had some issues intraoperatively. Fundamental question is, ‘do you have
concerns for the PACU or postoperative period?’
• Dr. Karamchandani will update the group if any relevant recommendations
are made by the MHC group.
h. Vote:
1. 1 vote/site
2. Continue as is/modify/retire
3. Need > 50% to retire measure
4. Coordinating center will review all votes after meeting to ensure no
duplication
i. Next steps:
1. The Coordinating center will add results of the Saha/Segal study to the
rationale, as well as the HandiCAP trial
1. A Qualitative Improvement Initiative to Reduce Adverse Effects
of Transitions of Anesthesia Care on Postoperative Outcomes: A
Retrospective Cohort Study
2. Effect of Intraoperative Handovers of Anesthesia Care on
Mortality, Readmission, or Postoperative Complications Among
Adults: The HandiCAP Randomized Clinical Trial
2. Measure will continue as is – no revisions needed.
B. NMB-01: Train of Four Measured – Tony Edelman, University of Michigan
a. Description: Percentage of patients with a documented Train of Four (TOF) after
last dose of non-depolarizing neuromuscular blocker
b. Threshold: 90%
c. Exclusions:
1. ASA 5 & 6 including Organ Procurement
2. Patients not receiving neuromuscular blockade
3. Patients that were not intubated in the immediate postoperative period
4. Procedure Type: Lung Transplant
d. Success criteria: Documentation of a Train of Four count (1, 2, 3, 4) or sustained
tetany, or TOF ratio provided by acceleromyography AFTER last dose or stopping
of infusion of neuromuscular blocker before earliest extubation. Note: A Train
of Four value of ‘0’ is accepted for cases in which sugammadex is administered
for reversal
e. Other Measure Details:
1. TOF values must be documented before extubation for the case to pass.
If TOF values are only documented after extubation, the case will flag.
2. If the only TOF value is 0 and sugammadex is administered, the
sugammadex must be documented before extubation time for the case
to pass.
3. If tetanic fade is documented prior to extubation, case passes.
f. Summary of presentation:
1. New literature – ASA Guidelines for monitoring and antagonism of
neuromuscular blockade
1. Strong recommendation with moderate evidence that when
neuromuscular block drugs are administered, clinical
assessment alone is not enough to determine level of residual
neuromuscular blockade.
2. Lung transplant exclusion is related to the coordinating center’s ability
to pass or fail based on tube exchanges at the end of cases, so the
exclusion is related to the complications related to the tube exchange.
g. Coordinating center review:
1. Updated measure result reasons and flowcharts
2. Cleaned up measure code so that TOF values must be documented
before extubation for the case to pass. If TOF values are only
documented after extubation, the case will flag
3. If the only TOF value is 0 and sugammadex is administered, the
sugammadex must be documented before extubation time for the case
to pass.
4. If tetanic fade is documented prior to extubation, case passes.
5. Excluded lung transplants as there were false failures when tube
exchanges were being documented as extubation
h. Vote:
1. 1 vote/site
2. Continue as is/modify/retire
3. Need > 50% to retire measure
4. Coordinating center will review all votes after meeting to ensure no
duplication
i. Next steps: Measure to continue as is
C. NMB-02: Reversal Administered – Mike Aziz, OHSU
a. Description: Percentage of patients administered neostigmine, sugammadex,
and/or edrophonium before extubation and after the last dose of non-
depolarizing neuromuscular blocker
b. Threshold: 90%
c. Exclusions:
1. ASA 5 & 6 including Organ Procurement
2. Patients not receiving neuromuscular blockade
3. Patients that were not intubated in the immediate postoperative period
4. Procedure Type: Lung Transplant
d. Success Criteria: Documentation of neostigmine, sugammadex, and/or
edrophonium before earliest extubation OR an acceleromyography ratio > 0.9
documented after last dose of NMB and before earliest extubation before
anesthesia end
e. Other Measure Details:
1. Cases that receive defasciculating doses of NMBs are included in this
measure and require documentation of neostigmine, sugammadex, or
edrophonium before earliest extubation before anesthesia end to pass.
f. Summary of presentation:
1. There has been an updated ASA practice guideline on neuromuscular
blockade monitoring and reversal. One is encouraging the use of
quantitative monitoring, and another is outlining where sugammadex
can and should be used versus neostigmine. Use of quantitative
monitoring is going to be a dichotomous thing where an institution
either uses or it doesn’t. One of the recommendations in reading the
guidelines is to wait 10 minutes from administration of neostigmine to
extubation. Considering that the pharmacology and the neostigmine
peak effect. is 3 minutes, I have some reservations around it, and it
merits a discussion because this will be a modification of this measure if
we were to track the timing for pass to be when neostigmine is
administered 10 minutes to extubation. The measure does give you an
opportunity to demonstrate a TOF ratio of 0.9 and not give a reversal.
My inclination is to change the measure to look for time of
administration of neostigmine to extubation to determine that it was at
least 10 minutes but do not want to sabotage the measure for anyone. I
am open to keeping the measure as is as an alternative.
g. Coordinating Center review:
1. Analysis of all cases for a month across MPOG last year (October 2024)
showed that across ~8,299 cases where neostigmine was administered
and extubation time documented, the average time between
documentation of neostigmine and extubation was 17 minutes. The
range was between 0 minutes and 22 hours. 23 cases where
documentation (neostigmine and extubation) was at the same time. 16
cases where extubation time was before administration of neostigmine.
This supports that enough variation in data exists to incorporate this
information into a measure. Need discussion about adding this to NMB
02 vs creating a new measure.
2. NMB-02 Measure updates over past year:
1. Updated code to ensure cases would appropriately flag if
reversal was administered after extubation
2. Updated code to ensure cases would appropriately pass if the
acceleromyography ratio of ≥ 0.9 was documented after the last
dose of NMB and before earliest extubation. (Some cases were
being inadvertently excluded).
3. Flowchart and measure result reasons updated
4. Still need to review / validate that new quantitative monitoring concept
values are being included in this measure
h. Discussion:
1. Nirav Shah (MPOG Quality Director): I looked at October 2024 for all
cases across MPOG where neostigmine was administered and had
extubation time documented. There were about 8,000 cases
2. Lucy Everett (MGH) via chat: That is a reason for flagging in our data.
One of the other measures is that it is flagged for reversal after
extubation. It would be helpful to determine the time between
documentation of neostigmine and extubation and determine if reversal
was documented after extubation.
3. Josh Goldblatt (Henry Ford Health System - Allegiance) via chat: Can you
add a column in case report for NMB-02 showing time between
neostigmine and extubation?
1. Nicole Barrios (MPOG) via chat: Yes, we can add that
information to the measure case report
4. Tony Edelman (MPOG): In doing the review for NMB-01, I saw the 10-
minute time frame come up in different articles. We all know that
qualitatively we should be administering neostigmine at the time of or
very near extubation. Will there be any education required around that
10 minute prior to review? Prior to the review, I don’t know if I could
have said 10 minutes is the right time or not the right time. From an
education standpoint, is it the right thing to do to bury it in the existing
measure, or perhaps create a new measure?
1. Mike Aziz (OHSU): I think 10 minutes clinically makes sense. A
lot happens in one minute in the EMR and I worry about the
integrity of it and that will bypass any validation that we have.
I'm not too thrilled about a new measure but concerned about
the data integrity.
1. Nirav Shah (MPOG Quality Director): That is what I was worried
about as well. A lot of documentation would essentially be
happening at the same time. I was surprised to find that out of
8,000 cases, neostigmine documentation and extubation were
on the same time a few dozen times. Sugammadex is coming off
patent within the next year? Will anyone continue to give
neostigmine after?
i. Vote:
1. 1 vote/site
2. Continue as is/modify/retire
3. Need > 50% to retire measure
4. Coordinating center will review all votes after meeting to ensure no
duplication
j. Next steps:
1. Measure to continue as is
2. Add column to measure case report for time between last dose of
neostigmine and earliest extubation
8. Measure Updates
A. QI Reporting Tool Measure Result Reasons
a. Over the past year, we have updated the pass/flag/excluded verbiage for each
of our measures
b. As part of this review, we have updated the measure code to ensure alignment
with the description
c. All measure result reasons should now have a clear description for pass, flag, or
excluded criteria
d. Please reach out to us if you have any questions: support@mpog.zendesk.com
B. NMB-05: Provider Attribution
a. Since the release of NMB-05 in March 2024, sites have been updating variable
mapping to train-of-four count and ratio to MPOG concepts
b. More sites have expressed interest in measuring quantitative monitoring use
across their operating rooms
c. Currently, NMB-05 is informational only and available for departmental view
only. No provider attribution assigned
d. Should attribution rules be developed? Make available for provider feedback
emails?
C. SUS-03: Updated Threshold
a. Description: Total carbon dioxide equivalents per induction for cases where
halogenated agents and/or nitrous oxide were administered during the
induction period of anesthesia
b. Updated threshold: A carbon dioxide limit of 250 kg CO2 will be applied for this
informational measure as a threshold has not yet been established in the
literature for the induction phase of anesthesia
c. Most cases will now pass, however, cases with a total CO2 equivalent > 250 kg
for induction will still flag. Sites may wish to review these cases to assess
potential data quality issues.
Meeting Adjourned: 1102
Next meeting: February 24
th
, 2025