Obstetric Anesthesia Subcommiee Minutes
February 26th, 2025
1:00-2:00 pm EST - Zoom
Aendees:
Sharon Abramovitz, Weill Cornell
Tiffany Malenfant, MPOG
Henriea Addo, MPOG
Chrisne McKenzie, UNC
Nicole Barrios, MPOG
Mary McKinney, Corewell Health
Kate Buehler, MPOG
Chris Milliken, Sparrow
Meilou Calabio, MPOG
Kam Mirizzi, MPOG
Arthur Calimaran, Cleveland Clinic
Melinda Mitchell, Henry Ford
Johanna Cobb, Dartmouth
Kae O'Conor, Johns Hopkins
Laura Cohen, Massachuses
Diana O'Dell, MPOG
Robert Coleman, MPOG
Rebecca Pans, MPOG
Charity Corpus, Corewell Health
Jack Peace, Temple
Leanna Delhey, MPOG
Nirav Shah, MPOG
Kim Finch, Henry Ford
Shashank Shear, Oklahoma
Jackie Goatley, Michigan
Frances Guida Smiatacz, MPOG
Ronald George, Sinai Health
Rachel Stumpf, MPOG
Josh Goldbla, Henry Ford
Alexander Taylor, Trinity Health
Ashraf Habib, Duke
Brandon Togioka, OHSU
Jerri Heiter, Trinity Health
Pam Tyler, Corewell Health
Wandana Joshi, Dartmouth
Meridith Wade, MPOG
Jeremy Juang, UCSF
Jennifer Woodbury, UCSF
John Kowalczyk, Brigham & Women's
Joshua Younger, Health
• Agenda:
• Announcements
• December meeng recap
• Days Before Delivery Phenotype update
• OB Champion role discussion
• ABX-06 measure released.
• 2025 Goals
• Announcements:
Future Meeng Dates
• May 14th, 2025, at 1pm EST
• September 3, 2025, at 1pm EST
• December 3, 2025, at 1pm EST
• In the News
• Reported incidence of pain during cesarean delivery is approximately 15-23%.
• Adverse outcomes:
PPD
PTSD
Chronic pain
• December Meeng Recap
• OB Paent Blood Management Toolkit
now available! Adapt as needed to share this
educaonal resource with your department.
• OB PCRC update: All OB Subcommiee members from acve MPOG sites will be invited
to Perioperave Clinical Research Commiee
(PCRC) meengs when obstetric
anesthesia research projects are proposed. Aendance is oponal.
• GA-01-OB: General Anesthesia During Cesarean Delivery will remain an informaonal
measure with no threshold to define ‘success.’
• SOAP/OB Subcommiee: Support overall alignment with SOAP Centers of Excellence
(COE)
• TXA measure- Subcommiee voted against building TXA measure – percentage of cases
with TXA administered with EBL > 1000 ml.
• Transfusion ≥ 4 units blood products measure- Subcommiee voted against building
measure to assess percentage of cases with transfusion of ≥ 4 units of any blood
products.
• Pregnancy Phenotype: Days Before Delivery Update
• Descripon- the Days Before Delivery phenotype
will be used to determine the days
before delivery using our Obstetric Anesthesia Type (OBAT) Phenotype to determine if a
paent had a delivery in MPOG within 42 weeks of an OBAT procedure.
• Phase I- Once this is developed, we will develop phase II which will be more sensive for
pregnant paents.
• Enumeraons:
o 0= No delivery found in MPOG
o 1= Delivery found in MPOG within 42 weeks of procedure
o 2= Delivery found in MPOG more than 43 weeks before procedure
o 3= Delivery found in MPOG aer 42 weeks
• Limitaon
o This phenotype relies on the MPOG Obstetric Anesthesia Type Phenotype which
has limitaons due to predicted or actual CPT codes and accurate procedure text
documentaon. Addionally, if a delivery is performed outside an MPOG
instuon, or if that delivery is a vaginal delivery with no labor epidural that
informaon will not be available.
• Discussion: Group shared that a new enumeraon would help best idenfy labor
epidural/delivery cases. Workgroup will meet one last me before moving this
phenotype to prod.
o Nicole will schedule follow up meeng with phenotype work group before this
goes to PROD.
• OB Champion Role Descripon
Role Summary
• Each parcipang site that provides obstetric anesthesia care is encouraged to select an
Obstetrics (OB) Champion to parcipate on the MPOG OB Subcommiee.
• The primary role of an OB Champion is to understand and use MPOG tools and data to
improve anesthesia care for laboring mothers.
• The OB Champion can work alongside their MPOG Quality Champion to implement local
QI iniaves supported by MPOG data.
• OB Subcommiee Member vs. Champion
• Sites without a named MPOG OB Champion:
•
American University of Beirut Medical Center
•
Atrium Health (Wake Forest)
•
Columbia University
•
Corewell Health: all except Butterworth
•
Holland Hospital
•
University of Maryland
•
Massachusetts General Hospital
•
Michigan Medicine
•
MyMichigan - all sites
•
Nebraska
•
NYU Langone Medical Center
•
Temple University Hospital
•
University of Alabama
•
University of Arkansas
•
UCLA
•
University of Chicago
•
University of Florida
•
University of Wisconsin
•
University of Tennessee
•
UT Southwestern
•
Vanderbilt University
• Departmental Dashboard Access
• Subspecialty dashboard access (Obstetrics, Pediatrics and Cardiac) was removed in
December 2024.
• Many OB Champions and ACQRs have full departmental dashboard access and may not
have noced a change in access.
• If you have noced a change in access, please reach out to your Quality Champion and
Nicole
and we can help get access re-established.
• OB Champion Key Responsibilies
• Review Performance Data
• MPOG reviews/provides ongoing measure performance data via reports, dashboards,
and collaborative meetings.
• OB Champions can review case data using several different tools:
– QI Reporting Tool
– Measure Case Report
– DataDirect
• If interested, please contact Nicole to learn more.
• ABX-06-OB
-Azithromycin Administraon for Non-Elecve Cesarean Deliveries
• Description: Percentage of standalone cesarean deliveries in which azithromycin was
administered 60 minutes before surgical incision
• Inclusion: Enumerations 1 and 7 using OBAT (Non-elective cesarean cases.)
1- Conversion (Labor epidural and cesarean delivery charted under one case
ID)
7- Conversion (cesarean delivery portion, labor epidural documented on
another case ID)
• Exclusion: Obstetric Anesthesia Type phenotype:
0 - No
2- Cesarean delivery without a preceding labor epidural
3- Labor Epidural
4- Cesarean Hysterectomy
5- Obstetric Case Unable to Determine
6- Conversion (labor epidural portion)
8- Conversion (cesarean hysterectomy portion)
• Cases with Chorioamnionitis ICD codes: O41.12-O41.1299
• MPOG OB Subcommiee 2025 Goals
• GA rate for all cesarean deliveries
o Available as MPOG metric: GA-01-General Anesthesia During Cesarean
Deliveries
• GA rate for unscheduled cesarean deliveries
o Can be estimated from MPOG metric GA-02
o MPOG metric GA-02 (% of CD cases where GA was administered after
neuraxial labor analgesia)
o Would miss unscheduled CD not proceed by NA
• GA rate for scheduled cesarean deliveries
o Can be estimated from MPOG metric GA-01 – OBAT enumeration #2
o OBAT enumeration #2 (CD without preceding NA)
• Epidural replacement rate
o MPOG measure does not exist
o We could review the data, may be possible to create
• Percentage of laboring patients receiving neuraxial labor analgesia
o Unable to estimate due to lack of data on patients that deliver without
neuraxial labor analgesia.
• PDPH rate & Epidural blood patch rate for PDPH
o Difficult to estimate due to lack of data on conservatively treated PDPH.
• Accidental dural puncture rate
o MPOG measure does not exist.
o Measure would always underestimate true rate.
• Discussion-Brandon Togioka (OHSU, Chair): Looking at the GA measures, I have a
question for the group. We could try to create a different measure to assess the rate of
GA for scheduled and unscheduled cesarean deliveries by including a time component.
It is not perfect, but most scheduled extend delivers will occur between 7 A.M 5 PM, we
could potentially do that -is that of interest to the group?
• Ashraf Habib (Duke): Just a question related to scheduled vs unscheduled cesareans. It is
a designation, at least in my institution for the C-section, whether it is scheduled or
unscheduled- I wonder whether this would be available in the Epic chart to indicate the
leveling or the nature of this of this cesarean that we can use for measure.
• Brandon Togioka (OHSU, Chair): That is a great idea. Could just send us a screenshot of
how that is coded in your system, perhaps we can look and see if we can find something
similar to other institutions.
• New Measure Development Discussion
1. Epidural replacement measure: Proportion of patients that require a second neuraxial
procedure prior to delivery.
2. Temp measure: Proportion of patients undergoing cesarean delivery with at least one core
body temperature measured.
3. Pain Measure: Two options for pain measures.
a. Multimodal: PAIN- Proportion of patients administered at least two non-opioid
adjuncts preoperatively or intraoperatively (multimodal)
b. Inadequate pain control: Proportion of patients undergoing cesarean delivery with
inadequate anesthesia (supplemental analgesia)
4. Accidental dural puncture measure: Proportion of patients receiving neuraxial labor
analgesia with an unintentional dural puncture.
• Epidural Replacement Rate
• SOAP COE core metric for neuraxial labor analgesia
• Longstanding interest in this measure on the OB subcommittee
• Methods to capture replacement:
o Two neuraxial procedure notes in a single record or admission
o Two timestamps for "neuraxial procedure start" or "end"
o Medications administered?
o Free text search, challenging
o Other ideas?
• Questions:
o How do you document neuraxial procedures?
o For a CSE or DPE, do you document two procedure notes?
o Should there be a time threshold?
Discussion:
• Brandon Togioka (OHSU, Chair): We thought of a few methods to capture the
replacement rate. We could look for several things like more than one neuraxial
procedure note in a single record, time stamps for numerical procedure, start or
end. We could look for certain medications, such as a test dose. Free text is
challenging, that perhaps could be like a fourth or fifth option. If we cannot find the
other ones, and then perhaps other ideas that we have not thought of. All of you are
very bright, and we will think of things that we did not. question here for the group?
How do you all document neuraxial procedures? How feasible do you all think this
is?
• Wandana Joshi (Dartmouth, Vice Chair): The one comment I wanted to
make is and I welcome feedback from everybody, but most people tend to
write a second note. If you see two notes for labor analgesia within one
encounter that that probably means that that patient had an epidural
replacement rate. As opposed to someone who may have had a repeat like
went to cesarean delivery and had a repeat.
• Ashraf Habib (Duke): We use two neuraxial procedure notes. We have the
neuraxial procedure. Note for every, for every interaction procedure. So,
this is the way we are doing it at Duke we are finding two procedure notes
w/in the same record.
• John Kowalczyk (Brigham and Women’s): Looking at procedure notes would
be a really great way to capture it. Most people are probably doing new
procedure notes for all of the procedures. That is certainly what we do here.
Typically, what I have done at other places as well. I would imagine that
would be in a great way to capture it as a high reliability high fidelity way.
• Brandon (OHSU, Chair): Christine and Laura had great comments in the chat.
Christine is also looking at procedure notes. Laura says, they have, something great
that is built on their institution, which we do not have that asks if it is a replacement
epidural, and perhaps it's and probably easier to identify if there is a second note.
Another question for the group- we built a CSE note and it took years to then build a
DPE note, and we have people putting in dual spinal notes without any medication
administered with an epidural. I am wondering how others document procedure
notes.
• Ashraf Habib (Duke): We have two types of procedure notes- an epidural note and a
CSE/DPE note. Within the CSE/DPE note we have a mandatory field to indicate
whether this was a CSE or a DPE. We can tease out which technique was used
between the two.
• John Kowalczyk (Brigham and Women’s): We have a similar thing. We have an
epidural note that splits epidural and DPE, and then a separate CSE note, slight
variaon on the same theme.
• Ron George (Mt. Sinai, Toronto via Chat): Will we capture replacements in the OR?
• Brandon (OHSU, Chair): We could possibly capture any replacements, what
about 20 minutes aer the first placement?
• John Kowalczyk (Brigham and Women’s): I think that is very reasonable me
frame.
• Chrisne McKenzie (UNC): Just a quick point if we were looking at the enre
hospitalizaon, could we set the delivery me as the end me so that you are only
looking for procedures before that. Just in case, you know, people are doing another
neuraxial for, DNC, or a tubal?
• Brandon Togioka (OHSU, Chair): Excellent point. Thank you. Okay, any other
thoughts? We will go on to the next slide then.
• Core Body Temperature
• Proportion of patients undergoing cesarean delivery with at least one core body
temperature measured.
o SOAP COE measure
o TEMP-02: Percentage of patients receiving GA that have at least one
core body temperature documented.
Measure time period: "anesthesia start" to "out of
room"
Excludes cases < 30 minutes
Threshold for success, > 90%
• Questions:
o Modify to include all CD patients (NA+GA)?
o Does this impact patient outcomes?
o How do you measure temperature?
• Discussion:
• Brandon Togioka (OHSU, Chair): Core Body Temperature- percentage of paents that
have at least one core body temperature documented. We know that hypothermia is
associated with mulple issues, including impaired wound healing, adverse cardiac
events impaired drug metabolism and at the extremes it can prolong length of stay and
increased cost of hospitalizaon. The queson here is -is this something of interest to
the group? Should we create a specific measure for interoperave temperature?
o Wandana Joshi (Dartmouth, Vice-Chair): I am not overly enthusiasc about this
measure, but I think it is worth looking into. Temperature is not rounely
measured during neuraxial anesthesia due lack of equipment or cost.
• Brandon Togioka (OHSU, Chair): Great comment. I will say, the skin and temporal artery
measurements do not count in Temp-02, which is the current Core monitoring MPOG
measure. We do not measure this either on admission to PACU and we would do poorly
on this measure. Does anyone feel strongly that this is important?
o Josh Younger (Northwell): Do we know how impacul this is, in this populaon?
Not knowing the literature off hand here, but I know that we're presuming that
infecon rates are increased with this, but do we know how much we expect the
temperature to decrease in a surgery that takes anywhere from, you know, one
to two hours on average in this this populaon
o Ashraf Habib (Duke): It is potenally very important, there was a study from
South African group a few years ago and they measured the temperature over
eight hours, and the results were striking. Many of the paents’ temperatures
remained low for quite some me aer surgery. Acve warming was not
incorporated rounely in this study it suggesng it is important and probably
impacul.
o Brandon Togioka (OHSU, Chair): Thank you for that comment. Did anyone else
have other thoughts on this were nearing the end. We have a few more
measures to go through, and we will start within our next meeng. To get good
feedback. The most important part of this meeng is to have these collaborave
discussions because there's so much shared knowledge. Nicole, just briefly skip
to the very end where we have the measure, build reliability, effort, graph just to
give a preview of what we will vote on next me.
• Brandon Togioka (OHSU, Chair): We will go through these last comments before we end.
I want to be considerate of everyone's me. In terms of when we think about building
these measures, there is obviously measures that people are excited about because it
makes a big difference, but some of these are difficult to build. Some are easy to build
with high reliability, but maybe not as interesng. So, we tried to chart them based on
effort.
• Brandon Togioka (OHSU, Chair): Thank you all very much for being here. I really
appreciate you all. It is very excing to see so much interest in OB quality.
Meeng concluded: 2:01pm
