MPOG QI - Quality Committee Meeting Notes – Monday, July 28

, 2025

Attendance:

Addo, Henrietta (MPOG)

Lewandowski, Kristyn (Corewell)

Agerson, Ashley (Spectrum)

Lopacki, Kayla (Mercy Health - Muskegon)

Armstrong-Browder, Lavonda (Henry Ford)

Lu-Boettcher, Eva (Wisconsin)

Bauza, Diego (Weill Cornell)

Maerz, David (Trinity Health)

Berndt, Brad (Bronson)

Mathis, Mike (MPOG)

Berris, Josh (Corewell - Farmington Hills)

McKinney, Mary (Corewell Dearborn / Taylor)

Bow, Peter (Michigan)

Milliken, Christopher (Sparrow)

Bowman-Young, Cathlin (ASA)

Mirizzi, Kam (MPOG)

Boyd, Kristina (Michigan)

Musulin, Angela (Henry Ford)

Brown, Morgan (Boston Children’s)

O’Dell, Diana (MPOG)

Brown, Sheree (Trinity Health)

Ohlendorf, Brian (Duke)

Buehler, Kate (MPOG)

Owens, Wendy (MyMichigan - Midland)

Cain, James (University of Florida)

Pace, Nathan (Utah)

Calabio, Mei (MPOG)

Pantis, Rebecca (MPOG)

Cassidy, Ruth (MPOG)

Pardo, Nichole (Corewell)

Coleman, Rob (MPOG)

Paul, Jonathan (Columbia)

Corpus, Charity (Corewell Royal Oak)

Pennington, Bethany (WUSTL)

Cuff, Germaine (NYU)

Phillips, Brad (MD Anderson)

Denchev, Krassimir (St Joseph Oakland)

Pimentel, Marc Phillip (B&W)

Dewhirst, Bill (Dartmouth)

Poindexter, Amy (Holland)

Doney, Allison (MGH)

Rolfzen, Megan, MD (Nebraska)

Drennan, Emily (Utah)

Roselinsky, Howard (Yale)

Ellis, Terry (Henry Ford)

Schwerin, Denise (Bronson)

Esmail, Tariq (Toronto)

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

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)

Gonzalez, Marbella (Dartmouth)

Smith, Mason (MyMichigan)

Gostic, Will (Stanford)

Steadman, Randolph (Houston Methodist)

Greenblatt, Lorile (U Penn)

Stewart, Alvin (UAMS)

Hall, Meredith (Bronson Battle Creek)

Stierer, Tracey (Johns Hopkins)

Heiter, Jerri (St. Joseph A2)

Tom, Simon (NYU Langone)

Henson, Patrick (Vanderbilt)

Tyler, Pam (Corewell Farmington Hills)

Janda, Allison (MPOG)

Vaughn, Shelley (MPOG)

Johnson, Rebecca (Spectrum & UMHS West)

Vitale, Katherine (Trinity Health)

Karamchandani, Kunal (UT Southwestern)

Wade, Meredith (MPOG)

Kinney, Tyler (Houston Methodist)

Wedeven, Chris (Holland)

Kirke, Sarah (Nebraska)

Weinberg, Aaron (Weill Cornell)

Lacca, Tory (MPOG)

Wildes, Troy (Nebraska)

LaGorio, John (Trinity Health)

Woody, Nathan (UNC)

Lalonde, Heather (Trinity Health)

Yuan, Yuan (MPOG)

Liu, Linda (UCSF)

Zhu, Shu (Columbia)

Lauer, Kathryn (Froedtert)

Meeting Start: 1002

Roll Call: Via Zoom or contact Coordinating Center (support@mpog.zendesk.com

) if you were present

but not listed on Zoom.

Minutes from May 2025 Quality Committee Meeting

Featured Members

• July and August 2025: Marie Aouad, MD – American University of Beirut Medical Center

(AUBMC)

MPOG Staff Transitions

• MPOG QI Specialist Henrie Addo has accepted a new position in Canada. August 15

is her last

day with MPOG. Contact Kate Buehler

with questions regarding your site’s QI contact.

Upcoming Events

• Friday, September 2025 – ACQR Retreat – Ann Arbor, MI

• Friday, October 10, 2025 – MPOG Retreat – San Antonio, TX

Measure Review

1. TEMP-01

– Sunny Chiao, MD - University of Virginia

a) No recommended changes to rationale, threshold, inclusion criteria

b) Recommended updates to ≤ 60-minute case duration exclusion:

c) Consider changing start time to be ‘induction end’ instead of ‘Patient in Room’ in this algorithm:

i) Induction End. If not available, then

ii) Patient out of room. If not available, then

iii) Anesthesia Start.

d) Recommend addition of self-warming blankets as ‘active warming’ -

Self-warming blankets

versus active warming by forced-air devices for preventing hypothermia: A systematic review

and meta-analysis - PubMed

2. Discussion:

a) Josh Goldblatt (Henry Ford Health): Confirm please…are hysterectomy with c-section an

exclusion but c-section alone is not?

i) Sunny Chiao (UVA): That’s correct.

ii) Josh Goldblatt (Henry Ford Health): I’m unclear why c-section hysterectomies are excluded

but c-sections included.

(1) Nirav Shah (MPOG Quality Director): I think the OB Subcommittee voted on this decision

originally, with a compromise to exclude c-section hysterectomies given the emergency

nature of these (often times). Can bring back to the OB Subcommittee to revisit this

decision as well.

(2) Mason Smith (MyMichigan Sault): I would like c-sections to be excluded. Our space in

OB is very limited. The room is small and cramped even without the Bair machine being

used. having a Bair blanket over the chest with an awake patient is an issue. My

institution will fail this measure just on c-sections

(3) Joshua Berris (Corewell - Farmington Hills): I am not understanding why a C-section with

a hysterectomy is an exclusion, but a regular C-section isn't.

(4) Josh Goldblatt (Henry Ford Health):

(a) Self-warming blankets versus active warming by forced-air devices for preventing

hypothermia: A systematic review and meta-analysis - PubMed

iii) Marbelia Gonzalez (Dartmouth): What is the indication of those self-warming blankets?

Likely short duration cases? Outpatient cases?

(1) Sunny Chiao (UVA): Yes, I think so.

b) Will Gostic (Stanford): Risk of infection with forced air warming?

c) Tariq Esmail (UHN): Maybe more used for non-anesthetized patients? It would be hard to

monitor for burns with the self-warming blankets.

d) Marc Pimentel (BWH): I wonder about safety/effectiveness vs. potential for burns under GA?

e) Tracey Stierer (Johns Hopkins): Some orthos defer forced air warming due to infection. Should

we consider pre-warming as a measure of compliance?

f) Kunal Karamchandani (UT Southwestern): But doesn’t hypothermia predispose to infections?

i) Marc Pimentel (BWH): Hypothermia and infections is a mixed bag

ii) Kunal Karamchandani (UT Southwestern): Bu N, Zhao E, Gao Y, Zhao S, Bo W, Kong Z, Wang

Q, Gao W. Association between perioperative hypothermia and surgical site infection: A

meta-analysis. Medicine (Baltimore). 2019 Feb;98(6):e14392.

iii) Mike Mathis (MPOG Research Director):

Surgical Site Infections and the Use of Forced-Air

Warming Devices During Surgical Procedures: A Systematic Review and Meta-Analysis

iv) Marc Pimentel (BWH): classically supported for colectomy. "The meta-analysis suggests that

perioperative hypothermia is not associated with SSI in surgical patients. However, the 8

eligible studies were mostly cohort studies. Thus, further randomized controlled trials are

required to confirm this finding."

g) Tracey Stierer (Johns Hopkins): Should we consider pre-warming as a measure of compliance?

h) Will Gostic (Stanford): Yeah, at Stanford, we considered a project on SSI and warming and

eventually decided against it due to lack of evidence

i) Emily Drennan (University of Utah): We are fairly successful with application but our patients are

still often cold. Struggling with this.

 Vote:

 Next Steps:

1. Coordinating Center to update spec to reflect ‘patient out of room’ in end time

algorithm for 60-minute case duration exclusion

2. Update Measure start time to Induction Start

3. Add references shared to measure specification

4. Decided not to update measure to consider self-warming blankets as active warming

due to a lack of use across MPOG sites and lack of evidence in the literature to date.

SUS-07 – Nirav Shah, MD – University of Michigan/MPOG Quality Director

1. Recommendation to modify exclusions:

a. Exclude sedation cases.

2. Recommendation to update threshold to 95%

3. Track elimination of piped nitrous

4. Discussion:

a. Patrick Henson (Vanderbilt): I agree excluding sedation cases wouldn’t impact our

scores

b. Germaine Cuff (NYU Langone): We have eliminated piped nitrous. Took awhile but

within 8 months we completely removed it

c. Marc Pimental (BWH): We’ve struggled with who is going to supply the nitrous

tanks. We are working through that. I’ve come across a number of cases where we

did not use nitrous during the case but the anesthesia machine still documents 0.1%

which is causing some false flags

i. Nirav Shah (MPOG Quality Director): There is an artifact reduction algorithm

but we may be missing something. If you can send us some example cases

we can take a look.

d. Emily Drennan (Utah): We also removed our piped nitrous without a phased

approach. One issue we had was also having the anesthesia machine document

values for nitrous when none was used on the case. We did a lead up explaining why

and showing what we used and gave a date when we would shut it off. Also

provided tanks early on

e. Marbelia Gonzalez (Dartmouth): I believe most institutions, when building new

sites, rooms, or suites, are advised by us. We do not advocate piping nitrous. It is a

good idea to encourage people to advocate for NO nitrous in new areas. Asked for

profit sharing w/hospital. Trying with scanning drugs to capture more charges.

Dropped nitrous to 0, saving the hospital money and not us and asking them to feed

back into our department

f. Tariq Esmail (University Health Network): Thats the case here as well, we will not be

building any piping to NEW ORs being built, but the decommissioning of the existing

ones are taking longer (as other have described here). I think rather than a survey,

perhaps the QI specialist for each site could reach out to US (the QI champions) to

clarify the use of Nitrous by pipe or tank.

g. Josh Goldblatt (Henry Ford Health): What are the group’s thoughts on excluding

cesarean delivery cases?

i. Nirav Shah (MPOG Quality Director): – reasonable suggestion but we should

punt this to the obstetrics committee

ii. James Cain (University of Florida, Jacksonville): Similarly nitrous is

sometimes used by the patients in their rooms

iii. Kunal Karamchandani (UT Southwestern): I wonder if we should hold off on

creating a measure of whether sites use piped nitrous since it is difficult

1. Nirav Shah (MPOG Quality Director: wouldn’t be a pass/fail measure

but would be informational for sites to show to their institution

leadership to make a case for removing the piped nitrous.

2. Kunal Karamchandani (UT Southwestern): you would have to track

this with a survey and not directly from the EHR data which we

should consider. Would it make sense for MPOG/ASPIRE to publish

recommendations for institutions looking to remove piped nitrous?

This would make it more accessible to institutions and would give

more visibility to MPOG in general.

3. Nirav Shah (MPOG Quality Director): definitely. If anyone is

interested in this project we would be happy to support.

4. Kunal Karamchandani (UT Southwestern): Happy to work with a

group on a publication. Can put in recommendations, use MPOG

data, and make recommendations to provide a guideline. Having a

journal publication, provides a better place to share.

 Vote:

 Next Steps:

• Exclude MAC/Sedation cases

Measure Revisions

1. TOC-01: Intraop Transfer of Care

a. Description: Percentage of patients with documentation of intraoperative handoff for

permanent transfer of care between in-room providers

i. This measure does not consider transfer of care events between supervising

anesthesiologists

ii. Only in-room providers are attributed

b. Should a new measure be developed to assess handoff documentation for supervising

anesthesiologists as well? TOC-01b?

c. Intraoperative handovers are significantly associated with adverse outcomes even after

controlling multiple confounding variables. Use of a structured handover tool during

anesthesia care may attenuate the adverse effect (Saha & Scott, 2024).

d. Discussion:

i. Howard Roselinsky (Yale): Thanks for presenting this. When looking at just

attendings only vs. only in-room providers, vs. both, there were worst outcomes

when there were more transitions of care regardless of in-room vs. supervising

provider.

1. Nirav Shah (MPOG Quality Director): When we initially created this

measure, we wondered if it was just a check-the-box measure and were

concerned about adoption. Interested to know if sites are using this

measure to track handoff quality.

2. Howard Roselinsky (Yale): Depends on where you are in your practice,

probably, but the existence of a tool has been proven to be successful in

improving outcomes.

3. Kunal Karamchandani (UT Southwestern): We do have this handoff tool at

our institution. There is utility in tracking the faculty-handoff specifically.

Think we need a dedicated faculty button for this though. Not a bad idea to

include faculty handoffs either as a separate measure or as part of this

existing measure.

4. Germaine Cuff (NYU): At NYU we implemented IPASS and that is part of the

record: RN/Surg/Anes/PACU NPs

5. Tariq Esmail (University Health Network): need to incorporate it culturally.

They have an intraoperative tool. It has not been targeted yet. No one is

using the button. Quality of conversations may be improved by clicking on

the button and using the structure

6. Marbelia Gonzalez (Dartmouth): doesn't mean that handoff doesn't happen.

Sometimes you need the mechanical thing to create the culture. But the

institutions may still be having the conversation. I believe that the NO team

changing might be a better tool to measure quality. Is that sustainable?

Who can practice this way? How are we doing it in systems where CRNAs

and shift systems are the standard of practice?

a. Nirav Shah (MPOG Quality Director): you bring up a great point

here. We could assess the number of handoffs instead, but that has

some operational and political ramifications currently beyond the

scope of this domain. MPOG has published some data about this as

part of a research study on staffing.

 Vote:

 Next Steps:

• Coordinating Center will review vote to determine if majority was reached. Will follow-

up at the next Quality Committee meeting.

• Apologies to the VUMC team for not getting to the glycemic management discussion.

We will make sure we present at the next QC meeting

Meeting Adjourned: 1101

Next meeting: Monday, September 22, 2025