Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)
Quality Committee Meeting Notes – Monday, October 27, 2014
Attendees: P=Present; A=Absent; X=Expected Absence
A
Abdallah, Arbi ‘Ben’ (Wash U)
P
Lagasse, Robert (Yale)
P
Agarwala, Aalok (MGH)
A
LaGorio, John (Mercy Muskegon)
A
Aziz, Michael (OHSU)
P
Levy, Warren (Pennsylvania)
P
Becker, Aimee (Wisconsin)
P
Lirk, Philipp (AMC)
P
Bell, Genevieve (Michigan)
A
Madden, Lawrence (Mercy Muskegon)
A
Berman, Mitch (Columbia)
A
Martin, Matt (Munson)
A
Biggs, Daniel (Oklahoma)
A
Morey, Timothy (Florida)
A
Bonifer, Thomas (Allegiance)
P
Naik, Bhiken (Virginia)
P
Buehler, Katie (A4)
A
Noles, Michael (OHSU)
P
Cuff, Germaine (NYU Langone)
A
O’Donnell, Steve (Vermont)
P
Natalie Cuffman (Holland)
A
Pasma, Weize (Utrecht)
A
Dehring, Mark (Michigan)
P
Pace, Nathan (Utah
A
Domino, Karen (Washington)
P
Pagenelli, William (Vermont)
P
Eastman, Jaime (OHSU)
A
Price, Matthew (Beaumont)
A
Epps, Jerry, (Tennessee)
A
Ramachandran, Satya Krishna (Michigan)
P
Fleisher, Lee (Pennsylania)
A
Robinowicz, David (UCSF)
A
Fleishut, Peter (Weill Cornell)
A
St. Jacques, Paul (Vanderbilt)
A
Haehn, Melissa (UCSF)
P
Segal, Scott (Tufts)
P
Jerri Heiter (St. Joseph)
P
Shah, Nirav (Michigan)
A
Ianchulev, Stefan (Tufts)
P
Sharma, Anshuman (Wash U)
P
Jacobson, Cameron (Utah)
P
Simon, Tom (NYU Langone)
P
Jameson, Leslie (Colorado)
A
Smith, Jeffrey (McLaren)
A
Kappen, Teus (Utrecht)
A
Sommer, Richard (NYU Langone)
P
Samie Kendale (NYU Langone)
A
Soto, Roy (Beaumont)
P
Kheterpal, Sachin (Michigan)
A
Stefanich, Lyle (Oklahoma)
P
King, Lisa (Oklahoma)
A
Tocco-Bradley, Rosalie (St. Joseph)
A
Kooij, Fabian (AMC)
A
Tom, Simon (NYU Langone)
P
Kuck, Kai (Utah)
P
Wedeven, Chris (Holland Hospital)
A
Kuhl, Mackenzie (Marquette)
A
Wilczak, Janet (Oakwood)
P
Lacca, Tory (Michigan)
1. Announcements
2. Review discussion at the MPOG Retreat
a. Future Directions
i. Having a separate QI track in the afternoon
ii. Thoughts on Directions for next year?
1. Do we need to make a distinction between research and QI? It seems we are
creating a hard line between the two and we need to consider the overlap. We
are focused on the measures and we need to be more thoughtful to the
relationship between research and QI.
b. New member – Jaime Osborne, PACU nurse and currently a professor in the School of Nursing,
she will provide clinical expertise for the ASPIRE program.
3. Review QI Measure Survey Results (see Attachment A for slides from meeting)
a. Twenty-nine people responded to the survey.
b. We required all questions to be answered. This is a review the results of the individual
questions and this is a broader snap shot of the results.
i. Category: SCIP measures
1. Most hospitals are showing high compliance with preop administration, where
we are lacking is the type of antibiotics. If we just look at administration and it
might be hard to show improvement.
2. Amsterdam – we feel this is very important to include SCIP, because this is what
our institution interested in and this will be helpful. This will be a good way to
show our hospital how we are using the data.
a. What are the National compliance measures for the Netherlands? In
the 90s/50s or somewhere in between?
i. The quality indicators for Europe are 80 – 90 % and this is
something that we need to work on in Europe.
3. For antibiotic administration most people are good, but the issue that is a
problem is re-dosing. Is it possible to look at re-dosing as a secondary measure?
We have to submit to CMS 9-measures and this may be an easy measure that
people are already working on in their practice.
a. Dr. Lagasse: It is important to keep the measure, because as ASPIRE
develops, you will want to learn how to retire measures. High
compliance and no actual relationship to the outcome to SSI and it
should not be retired until you develop strict criteria.
b. Dr. Fleisher – One of the reasons that SCIP measure was put in reserve
was because if a hospital decides not to monitor it, in the future it can
be picked up again. ASPIRE can provide this data that others cannot.
Reserve status is from the National Quality Forum that says a measure
has topped out but it is not being unendorsed. Concerned that once
SCIP 1 was no longer a national performance measure, people would
give what they want and that has unintended negative consequences. It
can be reinstated because all it did was go into reserve status and was
not retired it was unendorsed for being an inaccurate measure.
4. Where should the efforts be put for SCIP measures, since it cannot be on all five
of the measures by January? Should it be re-dosing or is it on SCIP 1? Re-dosing
will be for surgeries greater than 3 – 4 hours long. Dosing intervals vary across
hospitals and national guidelines may be inconsistent with hospital pharmacies.
Dosing and re-dosing will be coming down the line. We will stick with measures
as listed and work on re-dosing in future. All in agreement.
c. Neuromuscular blockade: TOF/neostigmine: This was indicated as an important category. We
are looking to include in Year 1 and group one and we will send out the inclusion and exclusion
criteria to make sure we are on the right track. Comments?
i. When we do the neostigmine portion of the neuromuscular blockade measures, will we
have criteria (agreed upon by ASPIRE group] on the timing of neostigmine administered
based on the last time the neuromuscular blocker was given?
1. If patient does not need neostigmine, we do not want the measure to
determine care delivery. Neostigmine dosage reporting may not be intiated in
the first year, because there are a lot of different opinions on this. Do the TOF
measure first and follow up with the neostigmine measure next.
2. Dr. Jameson, University of Colorado implemented neuromuscular blockade
reporting as a package and she will send the measures/criteria/associated
literature.
a. Another way to look at this measure is the same one you use for
overdosing, you can look at neostigmine as administered after
extubation or administered twice as a measure of residual blockade.
d. Monitoring vigilance: Gaps in the record specifically in regards to systolic and diastolic BP.
i. Comments? Depends on when you will be defining the time frames of the monitoring
and if it is in the beginning of the case, you might expect larger gaps.
1. We are going to look at post induction and in general anesthetics. Getting a
baseline prior to induction will be important.
ii. The feedback indicates that we need to split this into two separate measures.
e. Transfusion management: Documenting HCT and checking post-operative HCT were high on the
list.
i. In terms of where we stand in Year 1 we believe we should focus on some of the other
measures that are more important.
ii. Some sites do not get lab values and this might not be feasible.
iii. Any strong feelings against this thought? Colorado volunteers to play with this measure
to determine if this is feasible.
1. If we have sites that are interested in some of the measures, we can work with
them to have them write the script and get them involved with the
development process. We will open that up to the sites to use. Do other sites
have a developer available to help with these scripts?
a. Yes, other sites do have people available and would be interested.
Amsterdam would be interested in assisting.
f. Glucose management: insulin/recheck is the highest score on the survey. We plan to include
this into the first group of measures?
i. Were there any exclusion?
1. Pancreatic transplant will be excluded.
ii. We need to make sure all centers are contributing CPT codes to allow more effective
comparison between procedures. Nirav and Sachin will follow up on the CPT codes.
g. Ventilator management:
i. We are going to hold off on this measure for Year 1. This will be hard to get people to
document recruitment maneuvers.
h. Colloid Management: Anyone wants to speak to why this was low rated? No response. Is this
low because are not using colloids very often.
i. We do not think that we will find anything in this to make a difference and nobody had
any interest on this measure.
ii. Dr. Becker: At Wisconsin we use albumin frequently and this will be meaningful to our
institution. This should not be one of the first measures or put a lot of effort in
developing it. The interest scientifically is low, but it may be more of a way to
discourage use and find the abusers.
i. PONV: We will not do this for Year 1 due to the fact that this is dependent on PACU data and
currently, we do not have good PACU data from institutions.
j. Overdose: Lower end of the survey scores, planning to leave it out for Year 1.
k. End Organ Failure: Rated high amongst all of them, but we will leave this out in Year 1 due to
feasibility. We will try to add this in as soon as possible when we know we have the data.
l. Pain Management: Relates to PACU scoring and this will be held off for Year 1.
m. When we send out the measures we will be clear with the wording.
4. We have created a forum on the ASPIRE website under the Performance Measures tab. We can
continue these debates on the forum.
a. Once people reply to it, it pushes it to your e-mail and we will roll this out and add everyone in
the committee to the forum in the next.
5. Final Decisions: Measures we are going to be moving forward with for initially:
a. SCIP
i. Antibiotic
b. NMB
i. TOF
ii. Neostigmine
c. Glucose Management
i. Insulin
d. End Organ Failure (when PACU data becomes available)
6. Roll call
Attachment A: ASPIRE Survey Results Presentation
