MPOG QI - Quality Committee Meeting Notes – Monday, February 24

, 2025

Attendance:

Abess, Alex (Dartmouth)

Lalonde, Heather (Trinity Health)

Addo, Henrietta (MPOG)

Liu, Linda (UCSF)

Adelmann, Dieter (UCSF)

Liwo, Amandiy (UAB)

Anders, Megan (Maryland)

Lauer, Kathryn (Froedtert)

Andrew, Ben (Duke)

Lopacki, Kayla (Mercy Health - Muskegon)

Barrios, Nicole (MPOG)

Lozon, Tim (Henry Ford - Wyandotte)

Bauza, Diego (Weill Cornell)

Lu-Boettcher, Eva (Wisconsin)

Berndt, Brad (Bronson)

Malenfant, Tiffany (MPOG)

Bollini, Mara (WUSTL)

McKinney, Mary (Corewell Dearborn / Taylor)

Bow, Peter (Michigan)

Mentz, Graciela (MPOG)

Bowman-Young, Cathlin (ASA)

Milliken, Christopher (Sparrow)

Brennan, Alison (Maryland)

Mirizzi, Kam (MPOG)

Bryant, Ayesha (UAB)

Musulin, Angela (Henry Ford)

Buehler, Kate (MPOG)

Norman, J. Blake (UAB)

Cain, James (University of Florida)

O’Conor, Katie (Johns Hopkins)

Calabio, Mei (MPOG)

O’Dell, Diana (MPOG)

Cassidy, Ruth (MPOG)

Ohlendorf, Brian (Duke)

Chopra, Ketan (Henry Ford - Detroit)

Owens, Wendy (MyMichigan - Midland)

Clark, David (Stanford)

Pace, Nathan (Utah)

Cohen, Bryan (Henry Ford - West Bloomfield)

Pantis, Rebecca (MPOG)

Coleman, Rob (MPOG)

Pardo, Nichole (Corewell)

Colquhoun, Douglas (MPOG)

Parks, Dale (UAB)

Corpus, Charity (Corewell Royal Oak)

Paul, Jonathan (Columbia)

Cuff, Germaine (NYU)

Penningon, Bethany (WUSTL)

Delhey, Leanna (MPOG)

PIlat, Marianne (Sparrow)

Denchev, Krassimir (St Joseph Oakland)

Poindexter, Amy (Holland)

Dewhirst, Bill (Dartmouth)

Ring, Laurence (Columbia)

Domino, Karen (Washington)

Ruiz, Joseph (MD Anderson)

Doney, Allison (MGH)

Schroeck, Hedi (Dartmouth)

Drennan, Emily (Utah)

Schwerin, Denise (Bronson)

Edelman, Tony (MPOG)

Scranton, Kathy (Trinity Health St. Mary’s)

Elkhateb, Rania (UAMS)

Shah, Nirav (MPOG)

Esmail, Tariq (Toronto)

Shaygan, Lida (UT Southwestern)

Finch, Kim (Henry Ford Detroit)

Shettar, Shashank (OUHSC)

Gibbons, Miranda (Maryland)

Smiatacz, Frances Guida (MPOG)

Glanding, Kimberly (UAB)

Smith, Mason (MyMichigan)

Goatley, Jackie (Michigan)

Stam, Benjamin (UMHS West)

Goldblatt, Josh (Henry Ford Allegiance)

Stanislaus, Mellany (Johns Hopkins)

Hall, Meredith (Bronson Battle Creek)

Steadman, Randolph (Houston Methodist)

Harwood, Tim (Wake Forest)

Stierer, Tracey (Johns Hopkins)

Heiter, Jerri (St. Joseph A2)

Stumpf, Rachel (MPOG)

Henson, Patrick (Vanderbilt)

Tyler, Pam (Corewell Farmington Hills)

Hyman, Jamie (Yale)

Vitale, Katherine (Trinity Health)

Jewell, Elizabeth (MPOG)

Wade, Meredith (MPOG)

Johnson, Rebecca (Spectrum & UMHS West)

Wedeven, Chris (Holland)

Kaper, Jon (Corewell Trenton)

Weinberg, Aaron (Weill Cornell)

Khan, Meraj (Henry Ford)

Wilson, Blake (MyMichigan)

Kinney, Tyler (Houston Methodist)

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)

Zittleman, Andrew (MPOG)

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 January 2025 Quality Committee Meeting

4. Upcoming Events – 2025 Meetings

1. Friday, April 11, 2025 – MSQC/ASPIRE Collaborative Meeting – Novi, MI

2. Friday, July 18, 2025 – ASPIRE Collaborative Meeting – Henry Execute Center – Lansing,

3. Friday, September 2025 – ACQR Retreat – Location TBD

4. Friday, October 10, 2025 – MPOG Retreat – San Antonio, Texas

5. Announcements

1. Update: QI for Learners Committee

a. Committee met last Thursday to discuss how MPOG data is currently being used

to support residency programs and identified additional opportunities:

i. Identify MPOG QI measures best suited for resident feedback program

ii. Identify process for assigning measures to residents at different times

throughout residency (separate from overall department measure

selection)

iii. Create additional phenotypes to track resident experience as filters in

QIRT

b. Coordinating Center will meet to determine next steps

c. Plan to schedule follow-up meeting with QI for Learners Committee to finalize

plan within the next couple of months

2. Sustainability Workgroup

a. All MPOG Sustainability measures due for review at the May QC Meeting

b. The Coordinating Center is convening a workgroup to review the measures

c. If interested in participating and not already listed, please contact Nirav Shah

(nirshah@med.umich.edu) or Henrie Addo (addo@med.umich.edu)

d. We will send out a Doodle poll asap and schedule the first meeting in March

2025

Name

Institution

Brady Still, MD

UChicago

Seema Gandhi, MD

UCSF

Ben Stam, MD

Corewell West and UM West

Eva Lu Boettcher, MD

University of Wisconsin

Katie O’Connor, MD, MBA

Johns Hopkins

Nick Dalesio, MD

Johns Hopkins

Lucy Everett, MD

Mass General

Liz Hansen, MD

Seattle Children’s

3. Quality Champion Role

a. Implement local QI initiatives supported by MPOG data

b. Provider feedback and vote on new and reviewed measures

c. Quality Committee Meeting Attendance

d. Participation in performance review (mostly in state of Michigan currently)

e. Provide feedback to Coordinating Center

4. Quality Champion Vs Quality Member Roles

MPOG Anesthesia Quality Champion

MPOG Quality Member

Anesthesiologist at MPOG Site

Anesthesia provider, administrator, or QI leaders

interested in participating in MPOG QI initiatives

Votes on behalf of site at MPOG QI meetings

Serves a backup to champion for MPOG QI votes

Attends MPOG Quality meetings

Conducts measure reviews

6. Measure Review: PONV-05 – Emily Lai, MD – MD Anderson Cancer Center

Transcription of presentation: My name is Emily Lai, and I have been part of the MD Anderson

PONV algorithm committee for the past 6 months. There have been no new consensus

guidelines since the one in 2020 that was published by T.J. Gan. One of the more recent

systematic reviews shows that there was a decrease incidence of post-op nausea and vomiting

with perioperative benzodiazepine administration. The 2020 consensus did mention Midazolam

and showed that there were meta-analyses that show reduction in post-op nausea and vomiting

after Midazolam administration at induction. The consensus also showed that there is no big

difference in PONV between Midazolam and Ondansetron if it was given 30 minutes before the

end of surgery. May not be able to administer Midazolam all the time due to the sedation

related adverse effects and potential for increased delirium in the elderly population.

Midazolam combined with other anti-emetics have increased efficacy over a single agent

therapy. Lower and higher doses showed no difference in PONV of the efficacy of PONV

incidence was significantly reduced after the administration at the end of surgery. They

compared Midazolam 2mg given 30 minutes before end of surgery and it was just as effective as

Ondansetron 4mg. There is very limited data suggesting Midazolam is as effective as Zofran for

treating established PONV. At MD Anderson we have our own nausea vomiting algorithm. The

rationale, inclusion, and exclusion criteria are all appropriate. Our initial recommendation was

to modify the measure to include Midazolam in the recommended pharmacologic antiemetics

due to the inclusion of in the 2020 consensus. After further discussion with Dr. TJ Gan, who is

the first author of the consensus, he recommended not including Midazolam yet due to lack of

data comparing it to more established medications. Perhaps something in the future to

consider. Currently, there is still a paucity of data, and will not recommend adding it.

MPOG Coordinating Center Review:

Consider minimum duration for propofol infusion (15 minutes)?

1. Nirav Shah (MPOG Quality Director): Currently, any duration of propofol infusion counts as

an antiemetic. We wanted to bring this to the committee’s attention to know if it makes

sense to consider minimum duration for propofol infusion. There is currently no good data

on this, but theoretically, one could game the measure by adding a propofol infusion for 1

minute and I am not sure if that is effective or not. Does it make sense to consider a

minimum duration for propofol infusion?

2. Megan Anders (University of Maryland) via chat: I would not restrict the propofol infusion

duration if there’s no data to support it

3. Joe Ruiz (MD Anderson) via chat: Re: propofol infusion, is it a matter of not having vapor on

board which reduces PONV risk

4. Xan Abess (Dartmouth): I do think we shouldn’t put a time limit on the propofol in the

absence of an evidence base.

Review updated PONV guidelines this year for additional recommendations

1. Nirav Shah (MPOG Quality Director): There may be updated PONV guidelines coming

out later this year. If and when those come out, we will look at those and if there’s

additional recommendations, I want to leave us that opportunity to incorporate those

recommendations.

Discussion:

1. Ketan Chopra (Henry Ford - Detroit) via chat: Should we also be adding midazolam as a

PONV agent for our measure?

2. Lida Shaygan (UT Southwestern): Attendings are reporting that they are getting flagged for

intubated patients or patients going to the ICU. I looked in the record and couldn’t find any

evidence of it. I'm not sure what the disconnect is if some of our patients are going to the

ICU and on MPOG, it is saying they are not going to the ICU. That is the only feedback I had.

1. Nirav Shah (MPOG Quality Director): That is a good point. The exclusion criteria for

patients going to the ICU is only as good as the data so there may be some cases

that we miss it. If we miss it, we will want to know about those cases.

2. Kate Buehler (MPOG): It is worth mentioning that this was proposed a couple of

years ago when we reviewed the PONV-03 measure and there was recommendation

to build a remained intubated phenotype. We are working on building a ‘Remained

Intubated’ phenotype. We had to take a step back and make an extubation times

phenotype first, then well make a remained intubated phenotype. By large, this

transfer to ICU documentation is weak across most MPOG sites to use it as a true

surrogate for remaining intubated. We will work on it and hope to release it in the

next couple of months. When we have the remained intubated phenotype; we will

change the exclusion to use that instead of transfer to ICU. Anyone who remains

intubated will be excluded from the PONV measures. That is our intent. It is taking a

bit longer than expected since documentation of extubation is not the same at most

sites. So, we will clean it up first and then move on to that phenotype.

3. Xan Abess (Dartmouth) via chat: We had a similar incidence regarding ICU – it came

down to mapping issue for our CVCC

4. Tariq Esmail (University Health Network) via chat: That sounds awesome – as it

would apply to many other measures where transfer to ICU is an exclusion

3. Katie O’Connor (Johns Hopkins): This is more food for thought or would love to hear from

the rest of the group. One thing we’ve been navigating locally is that a lot of our providers

are doing poorly and need to do better. Some of our providers are wondering about the

disconnect because the outcomes measures, we are all doing relatively better on those,

which arguably is the thing that actually matters. It could also be that it is under reported

since it’s harder to capture those compared to whether a medication was administered. We

worry a lot about polypharmacy and over medication and the unexpected or intended

consequences every time you give additional medication. Wanted to see if there are any

thoughts on the 90% threshold as the right number? Are there other nuances of which cases

are included? I agree with the ICU cases needing to be excluded. Other than technical issues,

are there other ways we can refine how it is quantified to make sure we are aiming for the

right things. Another piece is that I think a lot of us get disenchanted if it’s 40 then we feel

hopeless and wonder if maybe this is an irrelevant metric. So just make sure we’ve

calibrated this target properly. I don’t have any specific recommendation, I just wanted to

hear if anyone else is contemplating this.

1. Ketan Chopra (Henry Ford - Detroit): I look at the numbers at the graph and it shows

all the hospitals across MPOG, and when you have any measure where only has 4

hospitals achieving the measure threshold, we need to reconsider what exactly we

are looking for with this measure. I am at 88% and trying hard. I am on everyone

about this on a weekly basis asking what I can do to help, what are we missing? Our

outcome scores do appear to be better. I wanted to echo that when the whole

system is missing a measure, we just need to evaluate what are goals are for that

measure specifically.

2. Brian Ohlendorf (Duke) via chat: I agree with Katie and Ketan...does anyone have

thoughts about why the vast majority of sites are failing to meet the benchmark, is

many cases, significantly?

3. Nirav Shah (MPOG Quality Director): When there is a skewed performance at the

bottom, sometimes you would think there is a systemic issue that is preventing

people from performing well. Or if performance is skewed at the very top, maybe ,

its topped out like the old skip measures like antibiotic timing?? In this case, we are

seeing significant variation across sites, and it’s now skewed one way or the other.

We should discuss if the threshold is not appropriate. Especially if we are missing a

lot of ECTs or bronchoscopies, or other exclusions are not being excluded, and are

they leaking into the flagged cases. That is one reason for modifying the threshold.

Another potential thing to consider is in the elderly population. That if someone is in

the high-risk category, the guidelines don’t make a comment on age and at least

modify the number of agents or maybe modify the types of agents that you give.

Another component is whether from a practical perspective, smoking as a risk

factor. If there is no documentation, the patient is considered a non-smoker, and

that adds an additional risk factor. In those cases where we are not capturing

smoking documentation, but the patient is actually a smoker and therefore would

not have 1 more risk factor, in those cases that patients will be receiving 2 instead of

3 classes of antiemetics. The distribution of performance lends itself to show there

is actually variation in practice. Typically, those are the most ripe for quality

improvement initiatives. In most cases the threshold we have at MPOG is not a

data-driven threshold. We typically set it at 90% for most quality measures, and that

is something we can modify.

4. Ben Andrew (Duke) via chat: Performance, at least our center, falls off precipitously

at the 3-risk factor point, where the addition is a third agent required

i. Nirav Shah (MPOG Quality Director): Do you think it is an intentional

practice issue, or do you think it’s just not part of the workflow of

providers? Getting the answer behind the question is an important

component of the overall discussion about whether there’s an issue with

the measure or is it a workflow thing.

5. Xan Abess (Dartmouth): One thought on the measure performance at 90%, I

understand that some people are saying maybe it’s too high. On the other hand, at

Dartmouth in our main OR, our performance is at about 70%, and for the same

people who go the OSC, our performance is at 90%. I think the measure is attainable

and reasonable. I think whether or not you choose to focus on or whether you are

meeting the 90% mark is up to shop or not.

6. Joe Ruiz (MD Anderson): Maybe the 90% is too much, but it is certainly not

something that should go away, because we can improve on this. It’s those metrics

that are 95% or 100% with no room for improvement. That’s not a quality metric.

7. Katie O’Connor (Johns Hopkins): I agree. If we are not doing well, just lowering the

90% threshold just so we do better isn’t what I was angling for. More so to see if

there are ways, we can do analyses, because even though there is a distribution

across MPOG, are there opportunities to do analyses of where our gaps are and

maybe investigate just some of the nuances of the criteria. Are there other ways we

can look at these “failures” intentional practice decisions and is there more to

investigate or maybe even adjustments to what the measure is applied to with ICU,

we know that this is coded, but are there other things that are not coded? That

should be, or just a more thoughtful analysis of these trends at a macro level, even

though we can all individually do it at the micro level.

i. Tariq Esmail (University Health Network) via chat: With respect to more

analysis… The only risk factor which is not automatically captured and relies

on a human to input it into the system is the risk factor of PONV or motion

sickness and it would be interesting to understand if some of the sites have

that WELL mapped and are not meeting the criteria as it is documented in

some pre-admission process and not visible to the clinician at the time of

the OR or vice versa, it isn’t mapped in sites doing well and so they often

miss out on one relatively common risk factor… ? I don’t know how

impactful this would be, just a thought I am having while discussing this.

4. Jaime Hyman (Yale): This was a good discussion, and we grapple with that at Yale as well. I

wanted to propose considering another pharmacologic antiemetic addition. I do not know if

there’s an adequate body of evidence, but I added it to the Google document. The

medication is Olanzapine, and it has been used for chemotherapy induced nausea vomiting

for about a decade now. There’s been 5 RCT trials published since the 2020 guidelines. Small

trials, so still relatively small evidence based, but there were 2 meta-analyses of these small

trials. It is something to consider. Maybe we wait until the next iteration of The American

Society of Enhanced Recovery guidelines, which I know are going to be imminently

published. It is being used clinically at Yale, and the evidence base that does exist for it, at

least 3 of the 5 trials, as a third additional antiemetic for the highest risk group. I wanted to

put that up for discussion.

1. Nirav Shah (MPOG Quality Director): We are definitely open to adding new

medications. One thing we can quickly do is see if Olanzapine is a mapped concept

for us and see if sites are using it right now – we do have a concept for it – MPOG

Concept ID: Olanzapine (10848). I am curious to know if Olanzapine is on any PONV

algorithm or guidelines for any of our institutions.

5. Tariq Esmail (University Health Network) via chat: What's the default with motion sickness

or history of PONV...if not available does it assume no risk – I guess it would be a look at the

local mapping to know where that information is being incorporated from?

1. Kate Buehler (MPOG) via chat: Correct, if not documented, assume no risk

6. Xan Abess (Dartmouth): I am perplexed on whether or not to consider adding

benzodiazepines to the mix or not. A lot of the medications that we use have side effects

and risks of side effects. On one hand, I am hesitant to say let's use benzodiazepines as

another agent. One one hand, it has been used for a long time, especially in the oncology

settings as a therapeutic agent, and there’s probably less evidence on the other one. I am

mixed on the benzo one. I can see how it can be beneficial, but I can also see how people

wouldn’t want to encourage people to give it.

1. Nirav Shah (MPOG Quality Director): Question for Emily and Joe. Any thoughts on

the timing of Midazolam? If we people decide we should include it, at what point

during the case will it be appropriate to administer?

2. Emily Lai (MD Anderson): The meta-analyses had a wide range from preoperative, to

intraoperative, to postoperative. The majority of them were intraoperative. The

actual consensus did mention that Midazolam at induction was associated with

reduced PONV.

3. Joe Ruiz (MD Anderson): In my career I have had maybe 2 or 3 patients who had

anticipatory nausea and vomiting and when we arrived at the recovery room and

administered a benzo, after everything else failed, it subsided her nausea. At MD

Anderson, this was our original quality measure before AQI and before joining

MPOG, our surgery center decided to administer 3 antiemetics for everyone. The

argument from those doctors was that the drugs were benign. There is a risk

associated with everything you administer, and they said the risk is low and we will

administer it. I was shocked by our 40% metric performance. I thought we nailed

this, as 10-15 years ago, we were at 90% because everyone was aware of it. I think

our institution has had such an influx of new people and we’ve had such little

emphasis on PONV education in terms of how important it is to patients.

4. Megan Anders (University of Maryland) via chat: although I am not a big benzo fan,

being true to the nature of this measure to me would mean including it (we can

monitor brain separately - especially if we could get provider level!

5. Josh Goldblatt (Henry Ford Allegiance): Given that Midazolam is a potent sedative,

and our typical practice is focused on giving agents near the end of the case. Given

that there is no differentiation with the elderly and low GFR patients, we do have

some side effect risks by adding this on. Any agent that we add to our success

criteria we’re kind of endorsing its use in whatever patient population it applies to.

The question comes down to just because an agent has antiemetic properties, does

it warrant inclusion on this list and de facto encouraging its use?

i. Nirav Shah (MPOG Quality Director): So, Josh your thought is that the

potential for harm with Midazolam may be more than the benefit. Now, if

you look at the list, we are also including antiemetics like metoclopramide

and other things we don’t use commonly but we know that may have side

effects but also have antiemetic properties. We have also used antiemetics

more frequently in the past than they are now and those kinds of legacy

drugs that are used as 3

and 4

level agents are added to the list. They are

given equal weighting as Ondansetron or Dexamethasone and Aprepitant

and Propofol infusions. It is tough to navigate because we have medications

of varying side effects and efficacy already on the list.

6. Josh Goldblatt (Henry Ford Allegiance): I wanted to ask too, I understand there’s

some research into our PONV metrics and the correlation between the outcome

PONV-03, and our process of PONV-05, does it make sense to wait until that

research is in publication or until the guidelines are released?

i. Nirav Shah (MPOG Quality Director): For the guidelines, it’s up to this group.

For the research, I can say that those proposals were just made a couple of

weeks ago, and for those who have attempted to do multicenter research

analysis have figured out that it could take a long time by the time an idea is

proposed to PCRC to the time it’s published. I think it is fair to see what

direction this group wants to go into. I don’t necessarily think we have to

wait because it can be a long time from now.

1. Blake Wilson (MyMichigan) via chat: Agree with Nirav, current

pharmacologic agents that are currently on the list have significant

risk of side effects (especially in elderly). I believe midazolam should

be included and allow our providers to decide what is most

appropriate for individual patients.

7. Nirav Shah (MPOG Quality Director): Comments in the chats are discussing

correlating PONV-03, which is the outcome measure, to PONV-05, which is the

process measure. I think that’s what some of these research projects are aiming at.

To see is there a relationship between PONV-05, which is essentially a

representation of the 2020 guidelines, with PONV outcomes, as best as MPOG can

define it. I am interested in seeing the results of that. I do think, Josh, that the

results of that study may significantly affect PONV-05, but that could be a ways off.

i. Vikram Kumar (MGH) via chat: There is a disconnect between outcome and

process but drawing from experience from our site we did notice

improvement in outcome measures as our compliance with process

measures improved. Improvement in PONV05 led to a better PONV 03.

ii. Tony Edelman (MPOG) via chat: we need to pair PONV-5 (process measure)

with PONV-3 (outcome measure). while overall PONV-3 is having better

success than PONV-5 there is still significant room for improvement and

both should still be reasonable

iii. Kate Buehler (MPOG): I know everyone is focused on PONV-05 in this

conversation but would argue that we should spend the same amount of

rigor that we are spending on PONV-05 and making sure that this measure

is valid, apply that same effort to PONV-03 and PONV-03b. We should

spend as much time reviewing PONV-03 and PONV-03b. When we did our

initial look and building those measures, especially at U of M data, which

was our pilot instance, we found that it was very hard to track down, and I

think Dr. O’Conor mentioned this earlier. It is hard to track down all the

fields where PONV is documented in the health record and trying to make

sure you have all of that in your MPOG extract and mapped appropriately

does take a fair amount of work and some conversation with postop nurses.

I would say that rigor is worth it before we spend too much time measuring

process versus outcome. We should validate that outcome measure just as

much as we are validating the process measure. It does take some extra

work, and you can’t take it at face value. Just like any of the MPOG

measures, make sure you validate them and track them back to whatever

your EHR is.

1. Nirav Shah (MPOG Quality Director): Dr. Esmail also mentioned that

for motion sickness for PONV-05 as well. Is that there may be a ton

of variability in how it’s documented and whether or not we capture

it.

2. Vikram Kumar (MGH) via chat: I agree with Kate. We did notice a lot

of inaccuracies with our PONV-03. There were a lot of questions

raised on how the nurses are documenting and the PONV-03b is

definitely far more inaccurate when you find evidence of vomiting in

the chart that’s much lower. When you talk to individual colleagues,

they mentioned they improved their process measure, but their

outcomes haven't improved. The question remains about the utility

of the measure. From an institutional perspective, and we worked

on it 3-4 years ago, our compliance rates improved on PONV-05

from about 60% to about 80% range. We noticed a 2% drop in the

PONV-03. We didn’t go and check what the nurses were charting or

the way they were charting. Nurses might administer Haldol or

Zofran to someone without any real evidence of nausea and

vomiting. Those are the questions raised in the meetings. If the

nurse feels like giving it, I get dinged for it. I am sure you have heard

that from other institutions as well. That is a sign that things work,

and both are statistically significant on the control chart. Clear

improvement in the process measure leads to improvement in the

outcome measures. that

7. Ben Andrew (Duke): In both kids and adults there is good compliance where just 1 or 2

agents are required, then as soon as you hit the threshold for requiring a third agent, the

compliance drops off and then starts to climb back up as you accumulate more risk factors. I

think initially, crossing that threshold, it is not obvious to the clinician that there’s one more

risk factor that now requires the effort of going beyond typical 5-HT3 Decadron. As you get

into the people with 5, 6, 7 risk factors, those are becoming more obvious to clinicians. The

pattern in that plot is the same with kids. The addition of a third risk is not recognized soon

enough. Then it takes an accumulation of more risk to get them to get back to the third

administration.

1. Joe Ruiz (MD Anderson) via chat: Ben, what risk factors did you use for the 7?

2. Ben Andrew (Duke) via chat: Age < 50, female, history of PONV / motion sickness,

non-smoker, opioids, high risk procedure, inhaled anesthetic duration >60 minutes.

As listed for PONV-05 on the measure spec

8. Brian Ohlendorf (Duke) via chat: Would it be helpful to have representatives from one of the

top 4 performing sites to share “success” stories of what has worked for them?

9. Jerri Hieter (Trinity St. Joseph Ann Arbor) via chat: I think additional dose of previous med is

given as a third

10. Vikram Kumar (MGH) via chat: Agree with Ben. We noticed the exact same issue.

11. James Cain (University of Florida) via chat: Apologies, came in a bit late. See that there is

conversation about benzos for PONV, another medication with antiemetic properties, albeit

not likely as a sole agent, is dexmedetomidine. Thoughts on this being included as

antiemetic therapy in compliance as pertains to these measures?

1. Benjamin Stam (Corewell) via chat: As far as I understand it, the effective dose for

dexmedetomidine as an antiemetic is pretty large.

2. Nirav Shah (MPOG Quality Director): Dexmedetomidine not as a sole agent, but

maybe as another medication with antiemetic properties. I haven’t seen the same

amount of evidence for Dexmedetomidine as we have for Midazolam or some of the

other agents.

3. Emily Lai (MD Anderson): There were 2 meta-analyses that mentioned it and did

show some decreased incidence of PONV. One of the studies was on laparoscopic

and bariatric surgery. The other study was on patients undergoing thoracic surgery.

12. Xan Abess (Dartmouth) via chat: Scopolamine clearly has antiemetic benefits, but most of us

don’t use it on elderly patients or neurosurgery patients; I think it’s up to the clinicians to

decide - regardless of the measures . . .

13. Kimber Finch (HFHS) via chat: Do the institutions with high midazolam use have better

outcome results for PONV?

14. Tariq Esmail (University Health Network) via chat: Is there a “report” that can be run or

generated for a specific site to show us if we are missing concepts that are related to a

specific measure? (Like a scorecard) or is manual review the only way?

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

5. Nirav Shah (MPOG Quality Director): I think it makes sense to vote

on the measure the way it was originally proposed: to keep as is,

modify it to include Midazolam, or retire. There were some great

points regarding some other things behind the measure itself that’s

affecting performance. Those deep dives will take a lot more time

and thought and may be reliant on future research that comes out. I

don’t know if we have enough information currently within MPOG

to understand if we should be making other significant changes.

With the exception that within your institution, doing a deeper dive

to see, are there things that you are missing, for example, are there

exclusions that are being missed for some reason? Is there

documentation of things like motion sickness that are being missed?

Are there issues with PONV-03 that we are not capturing? This is a

great opportunity or great measure to do the deep dive in, not just

PONV-05 but PONV-03 and PONV-03b. To see if there is something

that can be done locally or at the coordinating center to improve

the accuracy of the measure. To Dr. Andrew’s point, maybe there is

an inflection point where patient’s risk factors go from 2 to 3, we

miss that, but as they from 3 to 7, we start to understand. I think

there’s an opportunity there for education and reinforcement of

these guidelines.

ii. Next steps: Coordinating center will work on updating PONV-05 to

include Midazolam.

1. Nirav Shah (MPOG Quality Director): I think there is a lot more to

this and we’ll be excited to see the new PONV guidelines or as

research projects are being published. Dr. TJ Gan from MD

Anderson has agreed to speak at this year’s MPOG retreat on PONV

process and outcomes. He was the lead author of the previous

guideline. I am looking forward to seeing him share his knowledge

and wisdom.

7. We have released 2 new measures, CARD-04 and ABX-06-OB. We will post that in the basecamp

chat.

Meeting Adjourned: 1102

Next meeting: Monday, May 19, 2025