Quality Committee Meeting

March 16th, 2015

Agenda

•Review dashboards

•Measure updates

•Year 2 measures

Review Dashboards –aspirecqi.org

Measure Updates

•INF 01 –shelved until we are able to exclude with CPT codes and

better documentation of exceptions

•GLU 01b –shelved until more sites have preop and PACU data

•GLU 02b –shelved until more sites have preop and PACU data

•NMB 02 –discuss reducing duration of time after non-depolarizing

neuromuscular blockade not needed from 4 hours to 3 hours.

•PUL 01 –Using median tidal volume

Active warming for all patients at risk of intraoperative hypothermia

Core temperature measurement for all general anesthetics

-risk adults undergoing general anesthesia given 2 or more classes of anti-emetics

-risk pediatric patients undergoing general anesthesia given 2 or more classes of

anti

-emetics

Colloid use limited in cases with no indication

Hemoglobin or hematocrit measurement for patients receiving discretionary

intraoperative red blood cell transfusions

Transfusion goal of hematocrit less than 30

Measures

Appropriate intraoperative handoff

Appropriate postoperative transition of care handoff performed

Avoiding intraoperative hypotension

Avoiding gaps in systolic or mean arterial pressure measurement

Avoiding myocardial Injury

Avoiding kidney

injury

Preventing uncontrolled post

-operative pain

Mortality

Avoiding medication overdose

Measures

Discussion points for each measure

•Should be included

•Should not be included

•Appropriate inclusion/ exclusion criteria

•Definition of success

•Responsible providers

Measure

Perioperative normothermia

Description

Active warming for all patients at risk of intraoperative hypothermia

Inclusion

Patients undergoing general

and neuraxial anesthetics

Exclusion

Cases less than 60 minutes

- Anesthesia Start to End

Success

Documentation

of active warming device for patients (convective warmer)

Rational

Core temperatures outside the normal range pose a risk in all patients

undergoing surgery. Published research has correlated impaired wound healing,

adverse cardiac events, altered drug metabolism, and coagulopathies with

unplanned perioperative hypothermia. These adverse outcomes resulted in

prolonged hospital stays and increased healthcare expenditures.

Measure

Perioperative normothermia

Description

Core temperature measurement for all general anesthetics

Inclusion

Patients undergoing general anesthetics

Exclusion

Cases less than 30 minutes

Success

Documentation

of patient temperature –esophageal, nasal, bladder

Rational

Core temperatures outside the normal range pose a risk in all patients

undergoing surgery. Published research has correlated impaired wound healing,

adverse cardiac events, altered drug metabolism, and coagulopathies with

unplanned perioperative hypothermia. These adverse outcomes resulted in

prolonged hospital stays and increased healthcare expenditures.

Measure

PONV (adult)

Description

-risk adults undergoing general anesthesia given 2 or more classes of anti-

emetics

Inclusion

Patients undergoing general anesthetics

Exclusion

Non

-general anesthetics

General anesthetic without use of inhalational anesthetic

Fewer than 3 risk factors for PONV (female gender, non smoker, PONV/motion

sickness history, opiate administration

)

Success

Documentation of 2 or more classes

of antiemetics in the intraoperative record

Rational

Postoperative nausea and vomiting (PONV) is an important patient

-centered

outcome of anesthesia care. PONV is highly dis

-satisfying to patients, although

rarely life

threatening. A large body of scientific literature has defined risk factors

for PONV, demonstrated effective prophylactic regimes based on these risk

factors, and demonstrated high variability in this outcome across individual

centers and providers.

Measure

PONV (peds)

Description

Patients administered 2 or more classes antiemetics

Inclusion

Patients undergoing general anesthetics

Exclusion

Non

-general anesthetics

General anesthetic without use of inhalational anesthetic

Fewer than 2 risk factors for PONV

• Surgery ≥ 30 minutes

• Age ≥ 3 years

• Strabismus surgery

• History of POV or PONV in parent or

sibling

Success

Documentation of 2 or more classes

of antiemetics in the intraoperative record

Rational

Postoperative nausea and vomiting (PONV) is an important patient

-centered

outcome of anesthesia care. PONV is highly dis

-satisfying to patients, although

rarely life

threatening. A large body of scientific literature has defined risk factors

for PONV, demonstrated effective prophylactic regimes based on these risk

factors, and demonstrated high variability in this outcome across individual

centers and providers.

Measure

Colloid use limited in cases with no indication

Description

Colloid use limited

for patients that likely do not need colloid (Patients with

mild

to moderate blood loss

, outpatient surgery, short to medium length prone

surgery,

all but the longest surgeries in other positions)

Inclusion

All patients

undergoing procedures

Exclusion

Patients with >=4 units of intraoperative PRBC transfused

EBL >= 2000 ML

Prone

surgery > 4 hours anesthesia time

Any

surgery > 8 hours anesthesia time

Success

Patients

not receiving 5% albumin, 25% Albumin, Hextend or other starches

Rational

Avoiding colloid and using crystalloid instead when

appropriate avoids

unnecessary cost, and

is part of ASA's Choosing Wisely program

Measure

Transfusion management vigilance

Description

Hemoglobin or hematocrit measurement always performed for patients receiving

discretionary intraoperative red blood cell transfusions

Inclusion

All patients

undergoing surgery receiving transfusions

Exclusion

Cases

with 4 or more units of blood transfused, to account for the situation of

treating acute exsanguination

EBL >= 2000 ML

Patients

under 6 years old, due to the possible need for transfusions in patients

with congenital heart disease

Success

Patients with documented hematocrit or hemoglobin before or concurrent with

intraoperative transfusion

Rational

Providing a transfusion to a patient without checking the hematocrit first, to

confirm the patient needs the blood, can lead to unnecessary risk and costs.

Measure

Transfusion goal of hematocrit less than 30

Description

Intraoperative transfusions

management such that post transfusion HCT is less

than 30.

Inclusion

All patients

undergoing surgery receiving transfusions

Exclusion

Patients with >=4 units of intraoperative PRBC transfused

EBL >= 2000 ML

Patient with documented exclusion/physiologic

need

Success

Patient

with HCT less than 30 after transfusion

Rational

Studies on transfusion and outcomes have demonstrated that most situations

transfusing over

HCT 28 adds risk and expense, with worse patient outcomes.

Measure

Appropriate intraoperative handoff

Description

Handoff documented when more than one provider associated with case

(attending to attending, CRNA/resident to CRNA/ resident)

Inclusion

All intraoperative transitions of care between anesthesia providers

Exclusion

Cases

where there are not any handoffs between anesthesia providers

Success

Documented

handoff with appropriate elements between providers

Rational

Hand

offs of care are a vulnerable moment for patient safety, but required in any

24/7 healthcare system. Anesthesia providers routinely transfer care of a patient

during a case, and are responsible for transmitting knowledge about patient

history, a summary of intraoperative events, and future plans for hemodynamic

and pain management to the new care team. Evidence demonstrates that this

process can be facilitated by use of a checklist that motivates completion of all

key components of the transfer, and this is an emerging best practice in

anesthesia care.

Measure

Appropriate transition of care

Description

Handoff between provider and PACU nurse

documented

Inclusion

All

age patients under the care of an anesthesia practitioner AND

Patients

transferred directly to the PACU at the completion of the anesthetic.

Exclusion

Patients transferred to

the ICU.

Success

Documentation of handoff

with required handoff elements between

anesthesia

provider and PACU clinician

Rational

Hand

offs of care are a vulnerable moment for patient safety, but required in any

24/7 healthcare system. Anesthesia providers routinely transfer care of a patient

during a case, and are responsible for transmitting knowledge about patient

history, a summary of intraoperative events, and future plans for hemodynamic

and pain management to the new care team. Evidence demonstrates that this

process can be facilitated by use of a checklist that motivates completion of all

key components of the transfer, and this is an emerging best practice in

anesthesia care.

Measure

Avoiding intraoperative hypotension

Description

Percentage of patients with mean arterial pressure less than

55 for 10 minutes

Inclusion

All adult patients

undergoing anesthetics

Exclusion

Patients less than 18 years old

Patients with baseline MAP less than 55 mmHg

Success

Cases

where the MAP does not fall below 55 for more than 10 minutes

Rational

A drop in MAP below 55

mHg during surgery puts the patient at higher risk for

postoperative cardiac adverse events (CAEs) and acute renal injury

Measure

Avoiding gaps in systolic or mean arterial pressure measurement

Description

Percentage of patients with gaps in systolic or mean arterial pressure during case

–

greater than 10 minutes

Inclusion

All patients

undergoing anesthetics

Exclusion

None

Success

Cases with no 10 minute gap in systolic

blood pressure measurement

Rational

Standard ASA monitoring includes taking blood pressure at regular intervals to

prevent hypotension and hypertension

Measure

Avoiding myocardial

Injury

Description

Avoiding increases in Troponin

I > 1.00 within 4 postoperative days

Inclusion

All cases

Exclusion

Patient

with recent Troponin I elevation

Patients

with significant preexisting cardiac disease

Success

Patients

without increase in troponin I > 1.00 within 4 postoperative days

Rational

Post

-operative myocardial injury can lead to permanent adverse sequalae for

patients (including death).

Needs risk adjustment

Measure

Avoiding kidney

Injury

Description

Avoiding increases serum

creatinine post-operatively

Inclusion

All cases requiring inpatient

stays

Exclusion

Outpatient surgery

Patients with preexisting renal dysfunction

Patient undergoing urologic surgery or surgery directly affecting kidneys

Patients where creatinine not available within 7 days postoperatively

Success

Patients

without a creatinine increase of .3 mg/dl within 48 hours of surgery

end

Patients with increases in creatinine

1.5x baseline (as measured within first 7

postoperative days)

Rational

Post

-operative kidney injury can lead to permanent adverse sequalae

for patients

(including dialysis).

Needs risk adjustment

Measure

Preventing uncontrolled post

-operative pain

Description

Patients

with peak pain score < 8 in the PACU

Inclusion

All cases where patient was admitted to PACU postoperatively

Exclusion

Patients with

preop pain score of 2 or greater

Success

Patients pain score less than 8 (on scale of 0

-10)

Rational

Comparison

of Preop to Postop pain scores is an indicator of quality of patient

management, and is a fundamental

goal of anesthetic management

Measure

Mortality

Description

All cause 30 day mortality

Inclusion

All cases

Exclusion

ASA 5 and 6

Success

Patients who died less than or equal 30 days before surgical procedure

Rational

All cause mortality can be reasonable method to assess overall quality of care.

Needs

risk adjustment

Measure

Medication Overdose

Description

Measurement of medication overdose by calculating percentage of patients that

receive naloxone or flumazenil

Inclusion

All patients receiving a narcotic or benzdiazepine during their intraoperative

course

Exclusion

???

Success

Patients who received bolus dose or infusion of naloxone or flumazenil

Rational

Flumazenil is given for benzodiazepine (midazolam) overdose

Naloxone is given for narcotic overdose