Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)
Pediatric Subcommittee Meeting Minutes – December 1, 2025
Attendance:
Morgan Brown, Boston Children’s
Tiffany Malenfant, MPOG
Kate Buehler, MPOG
Viviane Nasr, Boston Children’s
Mei Calabio, MPOG
Katie O'Conor, Johns Hopkins
Joseph Cravero, Boston Children’s
Diana O'Dell, MPOG
Rob Coleman, MPOG
Rebecca Pantis, MPOG
Anjali Dixit, Lucile Packard Children’s*
Rishi Parikh, Johns Hopkins
Lucy Everett, Mass General Brigham
RJ Ramamurthi, Lucile Packard Children’s*
Marla Ferschl, UCSF
Chuck Schrock, St. Louis Children's
Amber Franz, Seattle Children’s
Nirav Shah, MPOG
Jackie Goatley, University of Michigan
Ruchika Sharma, University of Virginia
Kirsten Groody, University of Michigan
Frances Guida Smiatacz, MPOG
Ruchika Gupta, University of Michigan
Brady Still, UChicago Medicine
Bishr Haydar, University of Michigan
T. Wesley Templeton, Wake Forest
Michelle Huntington, Helen Devos Children's
Meridith Wade, MPOG
Rahul Koka, Johns Hopkins
Theodora Wingert, UCLA
Eva Lu-Boettcher, University of Wisconsin
*Denotes participant from non-active MPOG Institution
Start: 1500
Minutes from June 23, 2025 meeting approved -
minutes and recording posted on the MPOG website
for review
Announcements & General Updates
• Pediatric participation in MPOG
o 31 pediatric hospitals now participate in MPOG, with additional sites in the pipeline
(including Arkansas Children’s, CHOP, and Children’s National).
o The MPOG database now contains 3.6 million pediatric anesthetic cases
• Expanded data extract to full hospital admission
o MPOG is piloting collection of full acute-care encounter data (floor/ICU flow sheets,
ADT, meds, microbiology, etc.) beyond the OR.
o Two pathways:
NIH-funded research project (Colquhoun, Sun) building Clarity-based acute-
care extracts.
Michigan operational pilot at Michigan Medicine, U of M Health–West, U of M
Health-Sparrow, and Trinity–Ann Arbor.
o Lessons from these projects will inform how to scale full-encounter data collection to
additional MPOG sites.
MPOG Pediatric Research Update
PCRC 311 - January 12, 2026 @ 10am Eastern
Association of intraoperative hypotension and postoperative acute kidney injury in children undergoing
noncardiac surgery
• Primary Author: Jurgen de Graaff, Weill Cornell
• Anyone from an active MPOG site is invited to attend.
• Credit available for providers who participate
• Email
mpog-research@med.umich.edu if interested in attending
MPOG Pediatric Research in Progress
• PCRC 302 - Practice patterns of inotropic medication use in pediatric cardiac surgery
• PCRC 257 - Neonatal airway management practices: An analysis from the Multicenter
Perioperative Outcomes Group
• PCRC 254 - Pediatric Hemodynamic Management in Anesthesia: A Multicenter Analysis Using
MPOG to Understand Practice Variability and Outcome
• PCRC 192 - Reference values for post-induction hemodynamic measures in pediatric patients
undergoing general anesthesia for non-cardiac procedures
• PCRC 145 - Prophylaxis Practice in Pediatric PONV: A Retrospective Observational Study Using
the MPOG Database
Recent Publications from MPOG Peds
• Congratulations to Dr. Yao and Team on their recent publication in Pediatric Anesthesia!
o Practice variation in intraoperative management of pediatric organ donation after
brain death: A retrospective observational multicenter perioperative outcomes group
study
Leadership & Upcoming Meengs
• Leadership transion
o Dr Vikas O’Reilly-Shah rotates off chair role Dec 2025; Dr. Morgan Brown assumes chair
on January 1, 2026.
o Nominaons are open for a two-year Vice-Chair term (2026-28). Role Descripon
o Email Morgan (Morgan.Brown@childrens.harvard.edu) or Meridith
(meridith@med.umich.edu) if interested in the Vice-Chair role
• Plans for Spring and Fall 2026 pediatric subcommittee meetings.
• MPOG Retreat at ASA (Friday, October 16) will again provide QI/research updates and pediatric
networking; virtual option available
June 2025 Meeng Recap
Peds Commiee voted to:
• Modify NMB-03, inial NMB dosing –
Complete!
o Exclude cases where inial NMB dose → extubaon was > 180 minutes
o Exclude emergency cases
o Did not apply exclusion for cases with pyloromyotomy and short gut. Logic needs
refinement.
• Rere TRAN-04, Overtransfusion –
Complete!
• Modify TRAN-03, Transfusion vigilance – In Progress
o Include cases with any PRBC transfusion to catch all clinically significant events.
(removed 15 mL/kg rule)
o Aer addional case review, decided to also exclude emergent cases
o Allow mulple administraon of PRBC within 60 minutes without requiring addional
lab check
2026 Measures Requiring Formal Review
• Four pediatric measures are scheduled for literature review and update:
1. FLUID-02 – Minimizing Colloid Use
2. PAIN-01 – Multimodal Analgesia
3. SUS-06 – Low Fresh Gas Flow, Induction
4. TEMP-04 – Intraoperative Normothermia
• Main reviewers must practice at an active MPOG site and will use an MPOG review template.
• Contributions will be recognized on the MPOG website and at the annual meeting.
• Volunteers are encouraged, especially where there is strong clinical interest.
SUS-05 – Nitrous Oxide Avoided During Induction
• Background: SUS-05 was previously narrowed to focus on inhalational inductions (rather than
all GA cases).
• New proposal: Question raised (Dr. Bob Brustowicz, Boston Children’s):
o Should cases with ≤2 minutes of nitrous use (e.g., for IV placement) be excluded from
the metric?
• Discussion
o Lucy Everett (MGH): CHOP data showed no change in induction quality/duration after
nitrous elimination. Recommend keeping the metric simple and using SUS-05 as a
“minimization” goal rather than adding time-based exclusions.
o Eva Lu-Boettcher (University of Wisconsin) [via chat]: I’d also leave it as is, not using
nitrous is a metric we are interested in. Not just shortened use of metric
o Bishr Haydar (University of Michigan) [via chat]: I agree. The long term consequences
of that short term nitrous is still significant to the environment
• Decision
o Will not add nitrous time-based exclusion
o SUS-05 will remain focused on avoiding nitrous during inhalational induction without a
“≤2-minute” carve-out.
o Group acknowledged that QI metrics are not meant to be 100% and that some
clinically appropriate exceptions will occur.
PONV-04-Peds – Planned Updates
• Measure was reviewed in November 2024. Committee proposed the following modifications:
o Broaden age range to include infants, based on preliminary data from MPOG
coordinating center showing reported PONV in this group.
o Opioid risk factor: change from “long-acting intraop opioid only” to “any
intraoperative opioid.”
o Success criteria to mirror new 2025 consensus guidelines:
0 risk factors: ≥1 prophylactic antiemetic.
1–2 risk factors: ≥2 prophylactic antiemetics.
≥3 risk factors: ≥2 prophylactic antiemetics plus other risk mitigation
strategies.
o Add intraop anticholinesterase administration as a PONV risk factor.
o Count IV hydrocortisone given intraoperatively as an accepted prophylactic agent
• Discussion:
o Lucy Evere (MGH): Do the guidelines consider propofol infusion to be an anemec in
the same way that MPOG does?
Chuck Schrock (WashU) [via chat]: So long as propofol only TIVA for imaging
studies does not require ondansetron...
o Nirav Shah (MPOG QI Director): Currently any propofol infusion dose counts as
prophylaxis. Essenally there's no minimum. At the MPOG retreat, when Dr Gan was
talking, he casually menoned that he thought the benefit was from pure TIVA and
removing the inhalaonal agent was where the primary benefit was but I don't know if
that's borne out in the guidelines. I think we just have to look into that a lile bit more
and also get some feedback from the group about what's praccal.
Joe Cravero (Boston Children’s): I thought what he said was it has to be running
at rates of 100 mics per kilo per minute, based on the literature, to really be of
any effect. So I don't know, I didn't hear him say it had to be pure TIVA, but
there was a dose that was significant in the background. And I think he was
discounng the 25 mics per kilo, or 50 mics per kilo that some people use, or I
think urban legend has been that it's effecve, and I think he was discounng
that. I think this is a appropriate thing to take a close look at for sure.
o Kate Buehler (MPOG): Yeah, they don't specifically specify in the new guidelines. They
just say both propofol TIVA and sub hypnoc dose propofol infusion are effecve in
combinaon with other anemecs. So I think we're going to have to figure out what
that equates to. I don't think it matches our current definion that we have in the
measure.
Morgan Brown (Boston Children’s): I think when he was speaking, obviously he
was specifically targeng the adult populaons. Because, at least by some
hypnoc doses, I would take that to be any dose. We can all look into that, and
that is a good reminder to go find that paper and actually spend some me
reviewing that in detail.
o RJ Ramamurthi (Stanford)[via chat]: If ancholinesterase isn’t a risk factor, why should
we recommend use of sugammadex in this context?
Meridith Wade (MPOG): in the current measure, it's not coded as a as a risk
factor, and I can't remember why we did not include that, but we plan on
adding it moving forward.
o Morgan Brown (Boston Children’s): Yes, and that will probably be another good study
to do at some point is, have we dropped PONV rates? Because we use sugammadex, I
feel like my paents are sll voming, so I don't know, but it will be interesng to see.
I'm always surprised to review that metric myself and find paents who didn't know
had nausea and voming.
• Decision
o Meridith, Kate, Nirav, and colleagues will:
Review the new guidelines and key studies (including Dr. Gan’s work).
Propose a revised, clinically meaningful definition of propofol TIVA/sub
hypnotic infusion for PONV-04.
Aim to implement the core PONV-04 changes by the next meeting (mid-2026).
2026 Measures Requiring Formal Review
• Four pediatric measures are scheduled for literature review and update:
5. FLUID-02 – Minimizing Colloid Use
6. PAIN-01 – Multimodal Analgesia
7. SUS-06 – Low Fresh Gas Flow, Induction
8. TEMP-04 – Intraoperative Normothermia
• Main reviewers must practice at an active MPOG site and will use an MPOG review template.
• Contributions will be recognized on the MPOG website and at the annual meeting.
• Volunteers are encouraged, especially where there is strong clinical interest.
Measure Development – Patient Blood Management (PBM)
• Work has begun on AKI-03-C, the first pediatric cardiac-specific metric (CPB cases) using
KDIGO AKI criteria, including neonates.
• PBM emerged as a priority topic at the June meeting and MPOG Retreat.
• Potential PBM metrics discussed
o Preoperative anemia prevalence
% of patients with pre-op anemia (likely within a high-risk cohort).
Could support development of pre-op optimization pathways.
o Outcome metric: change in Hgb (pre-op to post-op)
Could identify gross over/under transfusion, but requires careful framing and
guardrails.
o Informational process metrics
% of eligible cases receiving TXA.
% of cases transfused intraoperatively, stratified by case type.
• Discussion:
• Joe Cravero (Boston Children’s): The perioperative anemia metric is worth exploring—it's
likely more common than appreciated. Outcome-based measures (like change in
hemoglobin) are harder to define and would require careful framing to avoid mislabeling
appropriate care. Looking at extreme post-op hemoglobin values could highlight over- or
under-transfusion but must be approached cautiously. TXA use is nearly standard in many
high-risk cases, so a metric showing whether appropriate cases received TXA could be
useful. Overall, pre-op anemia and TXA-use metrics seem most straightforward; outcome
metrics would need more work.
o Morgan Brown (Boston Children’s): A key question is whether we should limit PBM
metrics to high-risk non-cardiac cases rather than all children, since many routine
cases won’t have relevant labs or anemia issues. Potential groups include spine,
craniosynostosis, and other major surgeries, similar to how adult PBM metrics
target joint replacement. Developing such a cohort could support multiple related
measures.
• Morgan Brown (Boston Children’s): Asked whether defining a high-risk non-cardiac cohort
would help focus PBM efforts and reduce noise.
o Nirav Shah (MPOG QI Director): Agreed that stratifying by procedure type is
essential; this mirrors adult PBM work, where surgeon engagement depends on
having service-specific data. Without case-type stratification, performance signals
get diluted and workflow change becomes much harder.
o Rahul Koka (Johns Hopkins) [via chat]: Supported high-risk case stratification.
o Morgan Brown (Boston Children’s): Noted that defining “high-risk major non-
cardiac cases” will rely partly on expert opinion.
o Nirav Shah (MPOG QI Director): Proposed starting with a few procedure types—
similar to adults (e.g., major spine, major abdominal surgery). Some phenotypes
already exist, which would speed implementation; others may require new
phenotype development and more time.
o Morgan Brown (Boston Children’s): Recognized the complexity but agreed this
approach makes sense.
o Nirav Shah (MPOG QI Director): Suggested leveraging existing phenotypes and
focusing on larger case groups (e.g., spine, craniofacial, major GI surgeries) rather
than rare edge cases.
• Ruchika Gupta (University of Michigan) [via chat]: Suggested considering neonates as a
subgroup.
o Morgan Brown (Boston Children’s): Neonates are easy to define, but many are
transfused pre-op, making anemia assessment less meaningful. Still, it’s worth
exploring as part of the larger strategy. Overall, there is strong interest in PBM
metrics, and this gives the group a starting point.
• Joe Cravero (Boston Children’s): Susan Goobie’s work shows that identifying surgeries with
high transfusion rates is feasible. Across MPOG, it would be valuable to compare
transfusion rates in anemic vs non-anemic children in these high-risk surgeries. If pre-op
anemia leads to more transfusions, it strengthens the case for pre-op anemia
optimization.
o Morgan Brown (Boston Children’s): Agreed; transfusion almost always indicates a
major case, which can help define the target cohort.
• Rishi Parikh (Johns Hopkins): Noted that target hemoglobin varies by case type, adding
complexity.
o Morgan Brown (Boston Children’s): Yes—variation in comorbidities and transfusion
thresholds makes outcome-based over-transfusion metrics complicated, especially
since clinicians often “top off” small volumes to avoid post-op anemia from blood
draws or ongoing losses. More refinement will be needed, but there is clear
enthusiasm for PBM measure development.
• Next steps: Define a manageable high-risk case cohort. Explore:
Pre-op anemia prevalence.
Relationship between pre-op anemia and intraop transfusion.
TXA use patterns within these cohorts.
2026 Measure Development – Postoperative Pain
• Initial concepts
o % of cases receiving opioids in PACU.
o % of cases with first PACU pain score above a threshold (e.g., >4).
o Response-to-treatment metric – e.g., ≥X-point reduction in pain score.
o Focusing on extreme pain events rather than all scores.
• Discussion:
o Chuck Schrock (WashU) [via chat]: Suggested comparing PACU vs OR opioid (OME)
ratios to identify under-dosing patterns.
Morgan Brown (Boston Children’s): Asked whether certain procedure groups
should be the focus initially to avoid confounding issues like emergence
delirium—for example, tonsil/adenoid procedures or other standardized
surgeries.
o Rishi Parikh (Johns Hopkins): Proposed that repeat opioid dosing in PACU could
indicate poor pain control.
o Joe Cravero (Boston Children’s): Emphasized that continuous pain scores are unreliable
across centers. Recommended categorizing pain instead—e.g., defining “low pain”
(max ≤3–4) vs “high pain” (8–10). This avoids overinterpreting minor score differences
and better reflects real variation in outcomes. Also noted that opioid-sparing
approaches make an objective PACU pain measure even more important, but
thresholds must be clearly defined. The metric should allow for expected opioid use
while still identifying cases with significant, persistent pain.
o Bishr Haydar (University of Michigan) [via chat]: Asked whether PACU nurses are
individually identifiable, as this may help detect variation. Noted that regional
anesthesia complicates interpretation but should not prevent metric development.
Morgan Brown (Boston Children’s): Nurse-level attribution is likely impractical
given staffing volume. Regional anesthesia is a confounder but manageable.
Proposed that for the next meeting, the Coordinating Center pull data on the
frequency of severe PACU pain (e.g., ≥7) to help determine whether a high-
pain–focused metric is feasible and which patient groups are most affected.
o Joe Cravero (Boston Children’s): Recommended starting with a single procedure group
that is common, known for postoperative pain variability, and already phenotyped—
such as tonsil/adenoidectomy—or potentially the high-risk non-cardiac cohort being
discussed for PBM. Starting small may allow the committee to pilot and refine a
workable pain metric
• Decision
o Coordinating Center will:
Pull initial data on the proportion of patients with PACU pain scores ≥7.
Stratify by procedure, opioid use, and regional anesthesia where possible.
o Results will guide:
Choice of index procedure group(s).
Final thresholds for “severe pain” and success definitions.
Wrap Up
• Members interested in: Vice Chair role, Serving as main reviewers for 2026 measure reviews,
or Contributing to PBM or pain metric should contact Morgan Brown, Meridith Wade, or the
MPOG Coordinating Center.
• THANK YOU Dr. O’Reilly-Shah for your many contributions over the past few years as
subcommittee Chair and for your continued participation as a member of the MPOG pediatric
subcommittee!
Meeng Concluded @ 1556
Full Transcript
--
Morgan Brown (Boston Children’s):
We’ll start with a few announcements, updates, talk a lile bit about can pediatric plans that we have,
and then we'll go and look at the new measures that we have started discussing. So this is a map of all
the MPOG sites. And you know, we sll don't have as many as the adult group, but we are growing.
There's 31 pediatric hospitals in MPOG. And on the next slide, Meridith nicely outlined all the new sites
that are either in the applicaon or in a legal or regulatory phase or actually onboarding. And so
welcome to anyone from those sites who are here, and we're happy to have you. And I think it's great
you can see we have some smaller places, some independent places, and then it's great to see some of
the bigger, freestanding instuons joining with Arkansas Children's Hospital of Philadelphia and
Children's Naonal all in the process. So great news for both the quality work that we're all doing, but
also for anybody who is interested in doing any sort of research, there'll be lots of opportunies for all
sorts of projects. Next slide, and I love this slide, just showing how many pediatric paents there are.
We're always talking about how MPOG is predominantly an adult database, but there's 3.6 million
pediatric cases in it, which is really the biggest repository of data on children's anesthecs. And so,
again, I'm happy to have everybody here, and hopefully everyone is enthusiasc about trying to use
this data to all improve the care of our pediatric paents. Next slide. Other news from MPOG, which is
super excing, is that they are going to take on sort of the probably massive amount of data that it's
going to require, but is going to expand how much data that we are collecng now, we collect our
intraoperave data medicaons and much of the billing and discharge data, but and we've been
collecng a lot of laboratory administrave data, but they are going to start collecng data up unl
hospital discharge, which is going to enable us to hopefully look at other outcomes for quality
improvement. But again, it's just going to be a rich source of data for projects or things that people are
interested in doing so that is coming and excited about that. Marla going to go help with, Oh, someone
is unmuted, if you just want to check your phones in terms of the research aspect. Just to menon, so
there's projects that are presented through the PCRC, which is a commiee of people who review
projects that are upcoming, and the goal of the projects is really trying to help create beer projects.
And many people go review this as a main reviewer, but then everyone is allowed to contribute
informaon and ideas and thoughts about how to make any sort of research more fruiul for the
authors, and they have a really nice process that if you parcipate, you can become forget exactly the
terminology, but there's a way to get some credit for the effort that you put into this. And so in January,
it's excing that Jurgen at well Cornell was going to be presenng on his project on intraoperave
hypotension and postoperave AKI and children undergoing non cardiac surgery. This is great. There's,
you know, it's a low frequency event, but we have so many paents that it's hopefully possible project.
And so if you are interested, please email mpog-research@med.umich.edu, if you would like to aend.
And it's great discussion, usually, about projects, and it's just excing to have more pediatric
presentaons at that meeng.
Also wanted to highlight recent publicaon using MPOG data, there is a it's published in pediatric
anesthesia, and it's looking at Intraoperave management of pediatric organ donaon aer brain
death, which is very interesng. Obviously, it's not something that people are thinking of oen, but it is
an important part of our care, as how we take care of our donors is going to be how those organs
perform in the recipients. So that's a great paper. Congratulaons to those authors and take a look at it
if you haven't seen it.
Also, just to menon some of the other things that are ongoing, there's a project from some authors at
Brigham and Women's I'm involved with. This one, looking at inotropic medicaon use in pediatric
cardiac surgery. This one the data they are pulling for us now. Dr Stein here at Boston Children's, who's
done a lot of work on airways, is specifically looking at neonatal airway management pracces, and she
has been busy reviewing this data, and hopefully, then the next six months or year, we're going to see a
very nice publicaon out of that data from her, a group of people based out of Seale Children's, Dr.
O’Reilly-Shah also Dr. Templeton, are looking at some of the hemodynamics in paents who are
undergoing anesthesia, and they, I guess, have their study data. And so that will be also excing to see
what comes from that, also from Weill Cornell, they are looking at reference values for post
hemodynamic, post inducon, hemodynamic measures in pediatric paents for non cardiac surgery.
And that is also going to be excing. I'm sure that will be a follow up on some of on that prior paper
looking at blood pressure, normal values in children under anesthesia. And then lastly, for Mass
General Hospital, Dr. Evere is looking at PONV which is also really interesng. I will be very excited to
read that manuscript, just because we really have so lile current data on what is going on with
pediatric pond, and it's definitely a daily queson that runs through my mind. So it'll be interesng to
see those results.
The next thing we wanted to talk about was just reviewing what we discussed at our last meeng,
which is now back in June, we voted to modify our NMB-03 measure and so we've excluded cases
where the duraon between first NMB dose and extubaon is over 180 minutes, because people felt
like the it didn't make clinical sense. You may have just given one for inducon, and then you may not
reverse a paent for a very if you give any for a very long period of me. And then we also excluded
emergency cases. And there was some discussion about trying to exclude cases, some specific cases.
But as everyone knows, everything is always more complicated than you first want it to be, and so
trying to exclude certain cases sll needs a lile bit of work. We also reviewed our transfusion 04 our
over transfusion metric, and we decided that we would rere that it didn't really make clinical sense to
people. And we decided to also modify TRAN-03 the vigilance. And so we've where we've at with that is
we've been reviewing some specific cases, trying to see why paents may have might why they might
actually fail the metric. And so we've decided to include cases with any PRBC transfusion to collect all
the clinically significant events and not just have the 15 mils per kilo rule. And then we've also decided
we're going to try to remove emergent cases and allow mulple administraons of Packed cells within
60 minutes without requiring an addional lab check. Since it's prey common for people to, for
example, start an infusion and give a small bolus at this at a similar me frame that kind of thing. So
because people were somemes failing this, when really people probably would not be checking
another lab value yet. So that will be hopefully updated and ready to go at our next commiee
meeng. Okay? That any quesons anyone had about any of those where I'm happy to answer to just,
you know, either put your hand up or answer in the put something in the chat.
Nirav Shah (MPOG QI Director) Actually, it's not a queson, but I do have a comment and thank you so
much for sharing some of our programs or plans to expand the extract to essenally include the enre
acute care encounter. It's super excing for us. We think it'll unlock just a lot of potenal projects on
the quality and research side and developing outcome measures and understanding what happens
aer the paent leaves the pacu. So super excited about that. I The one thing I wanted to add Morgan
is that in 2026 it's hap it's happening in essenally two specific pathways. One is via an NIH funded
project. That's what Douglas Calhoun and Eric sun where they're essenally developing clarity extracts
to include acute care data like floor and ICU data, admit, discharge, transfer, medicaons, microbiology,
things like that. And so that's one pathway, is this research focused pathway for a specific research
project, and the other is via a pilot grant that we're doing in the state of Michigan, where via four
hospitals. So Michigan medicine, U of M health-West, Sparrow and Trinity-Ann Arbor were collecng
this, this data, so this floor in ICU data, including things like flow sheet data, medicaons, orders via like
this more operaonal pathway. And so the thought is that we would learn from those two projects
started this past year and connuing next year, and based on what we learn in those projects, we
would have a pathway to expand that across the rest of the the rest of empire. And so sll, like early
days, we're super, super excited about it, but we'll probably know more at this me next year about
how other sites across MPOG, you know, would be able to parcipate in it.
Morgan Brown (Boston Children’s) 12:32
Yeah, no, that's great. Thanks, Nirav for all that extra clarity and yeah, it's as we can all imagine, the
process of trying to collect large amounts of data from mulple instuons has to be done slowly. Yeah,
for sure. For sure. Yeah, no, that's great. Great. Thank you. And then we got a request, and so I wanted
to bring it to the group for discussion. We recently reviewed our SUS-05 measure minimizing nitrous
during inducon, and we voted to modify the inclusion criteria to avoid nitrous during cases with
inhalaonal inducon, instead of including all general anesthesia cases. And so an addional proposal
from Dr Brustowitz here at Boston Children's, he had contacted us and asked, you know if you used
nitrous for two minutes or less. Should we consider adding that as a further exclusion criteria? Because
some paents you may be, you know, just doing it to place an IV, I think some of the me, because
we're trying to clarify only inhalaonal inducons, those paents would not make it into the cohort.
But it may be, at mes, a lile bit difficult to tell. But I just wanted to see if anyone had any thoughts or
opinions on whether they would be interested in adding in this addion, an addional exclusion criteria
of a me requirement, essenally, of nitrous, or did we want to sck with an idea of having no nitrous
at all?
Lucy Evere (MGH): I was just going to say Morgan, you know, CHOP did do a big QA study on the
eliminaon of nitrous during inhalaon inducons, and said that they found no. Difference in the
quality or duraon of the inducon in children. And I don't know that that means, like, I guess I would
leave it simple and just say, you know, it is what it is. You probably are going to use it, you know, you're
not going to be 100% without nitrous. And it's just sort of a goal to minimize the use of it and so, you
know, I wouldn't like build that extra me in.
Morgan Brown (Boston Children’s):
Yep, no, I think that that's quite fair.
Eva Lu-Boecher (UWisconsin) [via chat]: I’d also leave it as is, not using nitrous is a metric we
are interested in; not just shortened use of metric.
Bishr Haydar (University of Michigan) [via chat]: I agree. The long term consequences of that
short term nitrous is sll significant to the environment
Morgan Brown (Boston Children’s)
Okay, unless I hear any other opinions, I think we will just sck with our current exclusion criteria. And
as Lucy menoned, you know the it's very difficult to not want to get 100% on everything in our lives,
but QI metrics are not something that we should be geng 100% on otherwise, I think we're probably
not really actually doing things right. And so it is. It is hard though, to somemes look at these and
realize that you could have done beer and but some of them are clinically not indicated, too. So, all
right, that sounds great. Thank you for everybody for giving me your opinions on that.
MPOG Pediatric 2026 Plans
And then let's start to talk a lile bit about our pediatric plans. So as I menoned earlier, I will be
starng the chair role in January. If you are at an acve MPOG site and you would like to join as the vice
chair, please email Meridith or me, or both. We'd be happy to have you. It's not, you know, an
incredible everything takes some me, but it's not an incredible amount of me. And obviously, I think
there's just huge potenal here at MPOG, and I hope that we can have someone be interested in
connuing all the good work that's been done before me on this, and you need to build all the pediatric
metrics. So if you are interested, just please let us know.
Our next meengs We are going to have a spring and a fall meeng. And I also want to highlight there
is an MPOG Retreat at ASA, if you haven't heard about it or been to it, it is a very nice day that is spent
talking about all sorts of things, both quality and research. MPOG people, the leadership is there and
also can provide a lot of the updates about what's going on. It does, unfortunately for us, conflict with
SPA, but it, you know, potenally, you may decide at some point that this would be an interesng
meeng, and it is going to be, I guess, on Friday, October 16. And if you can come, or, you know, for
some reason you can't come, they have, at least in the past, been able to offer some remote viewing
too. So it is a nice me, though, to actually connect with some of these other MPOG sites. And we were
informally geng together at that meeng just to have some discussions in person with everyone,
rather than just having everything on Zoom Next slide. So there are four. So if you don't recall, and park
has a process by which you know these metrics are not just stac. The idea is that we need to provide
connual review of these metrics to make sure that they're sll pernent and best pracces based on
any new data that's out there. So we have four measures that are up for review this year. In order to be
the main reviewer, you need to pracce at an acve MPOG site. And if you would be interested, and I
would encourage you to really consider it if it's an either an area that is maybe close to your own
personal interests, or something that you actually just would like to, you know, read up on and make
sure that you're actually current. It's a great opportunity to just sit and review what has actually been
wrien in the last few years. So the first one is minimizing colloid use and pediatrics. Yes, and I don't
know what data is out there about that one. So that's interesng. There's our mulmodal analgesia.
PAIN-01, the sustainability, low fresh gas flow at pediatric inducon is also up for review, SUS-06. And
then the normothermia intraoperavely, TEMP-04 as well. But yeah, these are a great chance to review
things. The there is a template that is provided to help you be able to do this, and MPOG is trying its
best to recognize the work that people put into this. You can see that there they do list people on
websites. And I know it's always menoned at the annual meeng all the people who've actually
contributed their me to doing these. And, yeah, it's a great, a great chance to be able to, I just think,
spend some me actually looking at, you know, oen, what we consider to be prey basic pracces.
But you know is it really actually was, what if what you're doing and what your biases were for when
you train for example are actually sll supported by the literature?
Meridith Wade (MPOG): So back in November, we reviewed PONV-04 and we were waing to make
any changes unl the new consensus guidelines came out this year, and I believe those are published or
in press or about to be so these are the changes that were kind of voted on by this commiee, and kind
of how they align with what the guidelines say. So we had said that we wanted to kind of open up the
measure to include infants as well.
We did a preliminary analysis of the data here at the Coordinang Center, and there was some report
of PONV in that age group. So the commiee agreed to kind of broaden that. We're also going to
update the opioid risk factor definion. Right now, we only consider it a risk factor if it's a long acng
opioid given intra op. So now it'll be any any opioid. And then the success criteria, I think, is the biggest
update, which is instead of a one to one rao, risk factor to prophylacc anemec, the new guidelines
state that if you have zero risk factors, paents should get at least one. If they have one to two risk
factors, they should get two, and then if they have three, they should sll get two plus other risk
migaon. Or do you know other things that they can other than just medicaon. We currently don't
consider ancholinesterases as a risk factor, so we voted to add that. And then there was some
discussion at the last meeng in November about adding hydrocorsone IV intra op. I didn't see that in
in the guidelines, but the commiee kind of had discussed there was consensus to add it. So I think we
were going to go ahead and do that, unless there's any objecons. And this is kind of the, I know they
have a graphic in the previous guidelines. I just kind of took this from the new guidelines to show what
the changes are. So hopefully by I want to say the next meeng, this will be done, at least by June, is
my goal.
Lucy Evere (MGH): One of the quesons that came up, actually, in the reviewer quesons to our
work, was the matching of the propofol T or counng propofol TIVA as an anemec. And I don't, I
didn't, haven't looked back at the guidelines yet, but, but does that match? Does do? Does how MPOG
is addressing it or considering it match how the guidelines? Does the guidelines consider it to be an
anemec in the same way that MPOG does? Do? You know?
Chuck Schrock (WashU) [via chat]: So long as propofol only TIVA for imaging studies does not
require ondansetron...
Meridith Wade (MPOG): I believe so. But I think I remember at the mpog retreat, when Dr Gann was
presenng, thinking that we need to revisit how we define that. I think it's any correct me if I'm wrong,
Kate or Nirav.
Nirav Shah (MPOG QI Director): well, yeah, yeah, you know you're correct. Yeah. Any propofol infusion
dose. Essenally there's no minimum where, and that's how you know that aligned with the previous
guidelines. I and I have to read these new guidelines to see what they say. But you're absolutely right,
Meridith. At the MPOG retreat, when Dr Gan was talking, he was like, well, from he was kind of casually
menoned that he thought the benefit was from pure TV and removing the inhalaonal agent. That's
where the primary benefit of an anemec perspecve, but I don't know if that's borne out in the
guidelines, and so I think we just have to look into that a lile bit more, in a lile more detail, and also
get some feedback from the group about what's praccal, yeah,
Joe Cravero (Boston Children’s): no, I just, I think, obviously you're correct. I thought what he said was
it has to be running at rates of 102 50 mics per kilo per minute, based on the literature, to really be of
any effect. So I don't know, I didn't hear him say it had to be pure Teva, but there was a dose that was
significant in the background. And I think he was discounng the 25 mics per kilo, or 50 mics per kilo
that some people use, or I think urban legend has been that it's effecve, and I think he was
discounng that. So I agree that. I think this is a appropriate thing to take a close look at for sure.
Kate Buehler (MPOG): Yeah, they don't specifically specify in the new guidelines. They just say both
propofol TIVA and subhypnoc dose propofol infusion are effecve in combinaon with other an
medics. So I think we're going to have to figure out what that equates to. I don't think it matches our
current definion that we have in the measure, which is any confusion at all for any duraon of me.
But you're right. He did specify something more specific, based on a study in at the actual imposter
trait. So we might have to get to the boom of that.
Morgan Brown (Boston Children’s):
Yeah, although I think when he was speaking, obviously he was specifically targeng the adult
populaons. Because, at least by some hypnoc doses, I would take that to be any dose. Per se, I'm
slightly biased, because I, once upon a me, did a small study on this, and to my surprise, thought it
actually worked. When I had come here, I thought this was kind of crazy, but I don't know. Anyhow, yes,
well, with that we can all look into that, and that is a good reminder to go find that paper and actually
spend some me reviewing that in detail.
RJ Rammamurthi (Stanford)[via chat]: Is ancholine -esterase isn’t a risk factor, why should we
recommend use of suggammadex in this context
Meridith Wade (MPOG): in the current measure, it's not coded as a as a risk factor, and I can't
remember why we did not include that, but we plan on adding it moving forward.
Morgan Brown (Boston Children’s):
Yes, and that will probably be another good study to do at some point is, have we dropped po and B
rates? Because we use the gamma x, I feel like my paents are sll voming, so I don't know, but it will
be interesng to see. Anyhow, I'm always surprised to review that metric myself and find paents who
didn't know actually had nausea and voming.
2026 Measure Plans: Paent Blood Management
Morgan Brown (Boston Children’s):
All right, so let's get to talking a lile bit about some of these measures, Meridith and so we have been
working on the our first cardiac specific metric. So we our first task was trying to idenfy these paents
beer amongst all the other cardiac paents, because we really wanted to target our paents who are
on cardiac bypass. And then we used prey standard kid go criteria to this. We did do some various
invesgaons about, you know, can you really apply this in neonatal populaons, etc. And it does seem
like, although there are varying opinions, one can use kid go in neonates, there have also been
discussions about implemenng a metric on paent blood management, which I think we've had. Some
we started the discussion back in June, and then we had some at our retreat, at the mpog retreat, and
hopefully that will be coming. And then also, the consensus, at least at the last meeng, was that
people would be most interested in a metric looking at postoperave pain, trying to get a lile bit of a
outcome based metric. So when we talked, and I'm I'd like input from this group too. I know some of
you were at some of these meengs, but some people were not when we started talking about paent
blood management. We had a nice, interesng discussion. Dr Goobey from who's also here in Boston,
who's been involved a lot in paent blood management, came and was adding her thoughts about
different metrics as well. But we talked a lile bit about having a measure where we looked at the
percentage of cases that had pre operave anemia, the, you know, the there were sort of advantages
to that in that, you know, it's a quite a bit of interest to those people who are In the blood management
area, how many paents are actually anemic? There was some discussion about concerns about how
many paents actually have preoperave lab work done in the pediatric paents, and what we would
do with that. But that is one possible direcon we could go. The second one is looking a lile bit more
at an outcome. So looking at cases where there was a change between the pre op hemoglobin and the
post op hemoglobin, and we'd have to decide what kind of change was meaningful. And then also we
talked about looking just at informaonal metrics, so things just trying to inform us a lile bit beer
about either our own pracces, but also at what is happening across the country, looking at percentage
of cases who are receiving TXA, for example, because that's considered part of the package that most
people for high risk surgical cases that are high risk of bleeding are now giving some dose of TXA, or
looking at the percentage of cases that receive a back red cell administraon intraoperavely. And
again, we would have to focus those two metrics more on certain case types. And it's clearly there's
going to be a lot of cases that we would never want to give TXA or never give PAC cells to. But right
now, I don't even think we brought we don't even know too much about who is receiving these things,
at least in pediatric centers. What does everyone sort of think about these different measures? Specific
interest in any of these? Definitely not interested in any of them. I
Joe Cravero (Boston Children’s): Morgan, I would just say oand that the perioperave anemia
queson is kind of interesng. There's probably a decent amount of interest in this and that. I think it's
probably not appreciated as much as it actually occurs. And there may be something to get from that.
The outcome part, I find a lile difficult, and that, boy, there'd have to be a lot of work done as to, what
are you talking about and what, what exactly is this aiming for. I do think, I mean, the one thing that
obviously Susan and the rest of us have been looking at here is where kids are transfused, and the first
post op hemoglobin is extremely high or extremely low, if that's what she's talking about. That would
maybe be kind of a lile bit interesng to give people an idea of, maybe where they're grossly over
transfusing or grossly under transfusing, but I think it would need to be very much couched with what a
lot of cauon about whether what is right and wrong or indicated not indicated. And I think the TxA
stuff is almost at the point of being standard and indicated. Therefore there might be cases where
different instuons would want to know that TxA was actually given because it is part of our at least at
our place, as part of our protocols, etc. And if people were not giving TxA in cases where we normally
think it's appropriate, least at our instuon, I it would be helpful to know that. So I think one in three
are kind of easy and could be helpful. I think number two, the outcome measure, could be really
interesng. I think just a lot of work need to be done to communicate about it and to set parameters
where people generally agree that there is
an importance to the outcome that was found.
Morgan Brown (Boston Children’s):
Yeah, that's good feedback. I think one of the quesons is, say, if we were to look at preoperave
anemia, do we, you know, do we or the TxA, do we, rather than trying to include all children, knowing
that kids who come for all the enormous amount of imaging that we do, and other non leading type of
cases, or cases where anemia is probably not really going to come up as much. Do we focus our original
group to sort of more of a high-risk group? Like, do we look at spine cases? Do we look at
craniosynostosis cases, some other major non cardiac do people feel like that would be like a subtype
of some basically, essenally major non cardiac cases that then would take effort to build something
like that that then we could use that for developing mulple metrics.It would obviously be a lile
challenging. I mean, there'd be other cases we'd have to think about liver cases, But even if we came
up with sort of what we thought were high risk, you know, the adults, right, they can look at hip
replacements, knee replacements.
Morgan Brown (Boston Children’s):
Would it be beneficial to come up with a cohort that then we view our sort of higher risk, non cardiac
cases, to look at this and maybe other things?
Nirav Shah (MPOG QI Director):
Yeah. Morgan, I would agree. I think strafying it by high risk case types, you would almost have to
build that into the measure spec and make it because, you know, what we found on the adult side is
that most of the discussions like. If you were to have a workflow change would involve the surgeons, at
least, would need to include the surgeons. And in order to do that, you need to be able to strafy by
parcular service or parcular case type, whether it's, yeah, right, like hip orthopedic or spine surgery
or, you know, compability area, whatever. And so I wonder if that would apply on the pediatric side as
well, that if you don't, if you can't strafy by case type, then there ends up being a lot of noise in the
measure performance that makes it difficult to then do the kind of collaboraon or discussions needed
to actually change pracce or change workflow.
Rahul Koka (Johns Hopkins) [via chat]: Agree. High risk straficaon would be useful.
Unknown Speaker 10:50
Okay, that's great. I think we could work on trying to develop this. It's going to, obviously have to rely
someone on expert opinion of what a high risk major non cardiac cases,
Nirav Shah (MPOg QI Director): yeah, I mean, you could start with a few, like, specific case types, like,
in the adult populaon, like, maybe, yeah, you're right. It would be hip replacement, major spine
surgery, you know, some, maybe some have really area, you know, some. And you can start with that,
because the flip side of that, of that is that they're just gonna have to be work on the impact
coordinang center side to make sure that we can build a feed the phenotypes for those procedure
types. So that will necessarily, kind of slow the process down a lile bit, because, you know, if we have
an exisng phenotype, great, we can just plop it in. But if we don't have that procedure type
phenotype, then all that we would have to build that and that may, you know, take a lile bit of me.
Morgan Brown (Boston Children’s):
Oh, yeah, every everything, everything is harder than it looks. Yeah, no, that, that, that sounds great.
Nirav Shah (MPOG QI Director): I mean, yeah, I think we should definitely build on, hopefully, some
preexisng phenotypes that are there, rather than trying to totally reinvent the wheel and trying, you
know, we, we may not want to be focusing on trying to find sort of, you know, so called edge cases in
pediatrics, and rather focus on where the big buckets of cases, so, You know, maybe crannies of some
maybe not, spine surgeries, definitely, as you said, some sort of major GI procedures.
Ruchika Gupta (University of Michigan) [via chat]: would it also be worth looking at neonates?
Morgan Brown (Boston Children’s):That's at least a lile bit easier to do, since we can prey easily
define the neonate, I think the only trick with neonates and anemia is, at least for us, they oen
transfused them preop. So I don't know it'd be interesng to see how meaningful or what numbers
they are, because I know at least for cardiac caths, for example, they're rarely going to look anemic,
even though it actually just meant they just got a blood transfusion. So things to think about, but I think
it seems like from what everyone has contributed here and what we've been hearing from members,
this is definitely an area of interest for people. So I think more to come, but at least this gives us a lile
bit of something to work from.
Joe Cravero (Boston Children’s): Can I just say, I think what you know, Susan certainly has done her
work here looking at cases where there's a significant percentage of transfusions applied. So, I mean,
it's easy enough to be fairly objecve about this. If you say we're going to choose cases where there's,
you know, this percentage that actually receive transfusions. I think the other thing that actually could
be interesng to look at from an empire perspecve is what she's shown is that kids that come in
anemic tend to get more transfusions. And that would that is certainly something that's been true here
for the pracce we have. It might be interesng to look across MPOG at high risk surgeries and kids
who come in anemic and the kids who don't, and what the rate of transfusions are for those kids. It
would be a compelling argument to try to see kids preop and manage anemia, if you did find that
transfusion rates could be modified by treatment of anemia pre op. Anyways, it's just, I think the stuff
that she's shown and would be the add on effect of something like this,
Morgan Brown (Boston Children’s): yeah, no, that might be a great place to at least look for Sort of
what we are thinking for are these major non-cardiac cases are, because I think probably most of the
me, if we're transfusing, it's a prey major case, because, you know, no one's shaking that too lightly.
Rishi Parikh: There may also be variaon in target Hgb depending on case type
Morgan Brown (Boston Children’s): Yes, that's where all of this gets so complicated so quick, you know,
underlying comorbidies we're always concerned about using, you know, especially in kids trying to use
the same unit. So that's why these over transfusion metrics, get really complicated, as many of us will
give a lile top off, because we know that otherwise, there's a chance that they made to get an
addional transfusion early in the post operave period due to, you know, blood sampling and
everything else that these kids and their during their hospital stay. So, yeah, so more to come. I'm sure
we're gonna have a lot of refining, but it is excing, because I think at least there's a lot of interest in
this.
2026 Measure Plans: Postoperave Pain
Morgan Brown (Boston Children’s): Yes And then we have just sort of preliminarily started talking
about looking at pain management and kids again. It's a lile tricky to say the least. You know, Dr Rivera
has done much work on this topic over me, and is more than aware of many of these limitaons. But
we talked about looking at either the percentage of cases where paents received opioids in the pacu,
percentage of cases where the first pain score was greater than some amount Joe had found previously
when he tried to look at least pacu data here that you know, it is tricky, and I suspect we are no
different than most PACUs and that how people rate pain is a lile bit challenging to somemes
interpret when you're looking back retrospecvely.
However, usually if you sort of look for what you consider to be severe pain or a significant pain event,
it seemed to be a lile more meaningful. So, you know, rather than looking for all pain all the me, do
We just focus on paents who were extremely uncomfortable, and it was suggested maybe a pain score
of greater than four in the pacu,or we could even try to look at the success of what we did. So did how
many paents actually reduced their pain score, since some paents, as you know, are reported as a
seven consistently throughout most of their hospital stay. Measuring, You know, did we actually make
some difference and take them from a seven to a five or a five to a three or something like that?
Anyone have thoughts on this area, or ideas for us to consider.
Chuck Schrock (WashU) [via chat]: rao of morphine equivalents in PACU relave to morphine
equivalents in the OR. Can idenfy providers, or paent groups, who rounely under dose?
Morgan Brown (Boston Children’s Looking at this is interesng, You’d have to think a lile bit about
that. Do people think that in this pain group that, again, is there some sort of, are there some surgeries
or procedures that we'd be more interested in to try to weed out, obviously, the problem of pain versus
emergence delirium, type of issues, like, would we be more interested in nothing so procedures, for
example, or something like That?
Rishi Parikh : the need for repeat opioid doses might be a nice signal for a bad pain experience
Joe Cravero (Boston Children’s):
These are obviously, really complex sort of quesons, as we've talked I guess, my only my interest in
what other people think, is that I personally feel like trying to use pain scores as a connuous variable is
just so fraught, and that the way these pain scores are recorded in clinical work, etc, and the way kids
act is it's difficult to know for sure whether across many different centers, you're geng super
consistent data. So I just feel like grouping paents into groups with relavely low pain and then
perhaps high pain, so that you there'd be less ambiguity about whether or not we can agree that the
outcomes were actually different would be important. So for me, that means, you know, like pung
kids who had low pain in the pacu, and kids who never recorded more than a three or four in a pacu as
kids who had an excellent pacu experience, and kids who had pain scores in the 8-10 range as kids who
had a significant pain experience I feel like on FACES, that's sort of a valid comparison to make. I think
when people start dividing it up by point five or one point on a 10 Point pain scale across different
centers, etc, I think you start geng to some real difficult issues. I do think that with the move towards
less and less opioid use in pediatric anesthesia, or at least a strong recommendaon by certain groups
that we should be going to opioid free. I think some idea about how kids are doing the pacu in an
objecve way is really helpful. I just think it needs to be done in a way that people can agree that
across, again, a diverse group of instuons, we are looking at something that actually is a is a real
indicaon of difference. And so I would set the I would set the indicators for good and bad at
significantly different numbers, so that it was possible to sort of see that. I do think, yeah, it's hard for
me to say that someone did a bad job if the kid comes out and needs pain med, but certainly by the
me they leave, you'd like to see them doing well, and I think there is a reason to look at when people
are not giving any opioids, if a significant percentage of those paents are having severe pain in the
back yet, I think that's sort of an important or interesng thing to understand. So anyways, I don't know
if that makes any sense, but I do think these are interesng outcomes to look at. I just think, as you're
saying about other things, this has to be thoughully put together so that we can agree that the
differences or agreement that we're seeing is real. I think that's tough with the outcome measure being
pain scores,
Bishr Haydar (University of Michigan) [via chat]: Do we have PACU nurses individually
idenfied? May be helpful to idenfy outlier pracces, as we previously did in the OME
measure for tonsils. Regional anesthesia also complicates this measure, but it shouldn't be a
hard stop on doing this IMO.
Morgan Brown (Boston Children’s)
True, although if you start to think about how many PACU nurses there probably are, it would be very
difficult to try to just for individuals, I think. And then regional anesthesia also complicates it, but it
shouldn't be a hard stop. Yes. I mean, maybe the thing we could think about, and maybe for the next
meeng, Meridith, we could try to look at, just for example, how many paents are having pain scores
of seven and up in the PACU at all, and sort of see what that data might look like if we were to try to
look at extreme pain, because maybe the right metric is trying to look at how much pain you know,
you'd have extreme pain by the me you're leaving you have less. I don't know. I guess we'll see once,
we sort of see what that data is, but it may give us a clue as to which paents are actually having these
events, because I don't know if I know off the top of my head who that might be.
But all right, we will connue to work on that if you know. Part of the point of all this, obviously, is to
get everyone thinking about it, and try to get these ideas going. When you see your paents in the
pacu, or you're transfusing your paent, trying to think about, How would we demonstrate something
useful and good pracce for our paents, and also trying to figure out, some of the pracce that may
have variaon, which is not so useful to all of us, and what we can do about that?
Joe Cravero (Boston Children’s): I would just suggest that we think about looking at a surgery grouping
or type. It might be nice to start off with a small bite of this, like look at either a constrained group of
procedures where they're common, they're known to have pain issues and that there is some variance
in the way people are managing them. If we could agree on that and then agree on some measures, I
think it could be really kind of interesng. Thanks for bringing this up. Yeah, we have, that's great, yeah.
And I mean, at least, you know, they already have built a tonsil adenoid. I'd have to look into exactly
what is all defined sort of group that might be an interesng paent populaon. Or maybe, you know,
this non cardiac surgery group, this high risk group, might also be interesng to see what they're doing.
Obviously, a component of them are going to be going to ICUs, but those that are go to pack use could
be looked at too, but yeah, we'll have to take a look and see what we find. Or more work for Meridith.
Morgan Brown (Boston Children’s):
yes, and again, just want to express my thank you to Dr O’Reilly-Shah for all that he has done, and I'm
sure he is going to connue to be acve in this group and on this commiee, so we will see him again.
And thank you for everybody else for parcipang as well and all your contribuons. It really does take
an enre village to do all of this.
If anyone has any other thoughts or things, you can always reply to the base camp. I know it always
kind of makes you nervous, because it replies to everybody, but it's just like, reply all. It's okay.Or you
can email Meridith or me directly. We're happy to always talk about these things, and otherwise, we'll
see you in 2026
Nirav Shah (MPOG QI Director): Awesome. Thank you, Morgan. I'll just repeat the plug you made
earlier about a vice chair, you know you, I mean the enre subcommiee leadership there. You guys do
such an incredible job. It's just so impacul. It's amazing. I can't even imagine MPOG without its
subcommiees, and subcommiee leadership is right front and center to make them as valuable as
they are, and it's just a really important posion. I hope it's interesng, but it's certainly impacul, and
for anyone is, if you're even thinking about, you know, maybe being interested in it, you know please
reach out. Morgan, Meridith, myself, someone at the according center, and happy to share more about
it. So did want to end with that plug?
Morgan Brown (Boston Children’s): Sounds great. All right. Well, happy holidays. Everybody. See you
soon. Thanks everyone.