1. Quality Committee Meeting January 25, 2016

2. Agenda Approval of minutes Matters arising and upcoming events Provider feedback email options New measures Kidney Injury Pulmonary Bundle (Low Tidal Volume, Peep, Recruitment Maneuvers) Handoff Measures Measure details questions NMB 02 - Neostigmine timing Trans 01 – Autologous blood This meeting will be recorded and posted on the ASPIRE website

3. Approval of Minutes

4. ASPIRE 2016 Meeting Schedule For more information see the ASPIRE Website: www.aspirecqi.org/calendar Friday, October 21, 2016 MPOG/ASPIRE Retreat at the ASA 7:30 a.m. - 4:00 p.m. Chicago, Illinois Friday, December 9, 2016 ASPIRE Quarterly Meeting 10:00 a.m. - 2:30 p.m. Location TBD - Ann Arbor, MI Friday, March 18, 2016 ASPIRE Quarterly Meeting 10:00 a.m. - 2:30 p.m. Lansing Community College Friday, June 10, 2016 ASPIRE/MSQC Meeting 8:30 a.m. - 2:00 p.m. Radisson, Kalamazoo, Michigan Friday, September 16, 2016 ASPIRE/MSQC Meeting 8:30 a.m. - 2:00 p.m. Bavarian Inn, Frankenmuth, Michigan

5. March 18 th, 2016, Lansing Community College

7. Year 2 Cohort – Status – On track Holland Hospital – Holland, MI Bronson Health System – Battle Creek and Kalamazoo, MI Beaumont Health – Farmington Hills) St. Mary Mercy – Livonia, MI St. Joseph Mercy – Oakland, MI Sparrow Health System – Lansing, MI

8. Provider email feedback options Monthly option BCBSM sites QCDR sites Quarterly option Other sites that do not submit data on a monthly basis No email option

9. QCDR Status Feedback emails went out by end of year Application for 2016 designation due by 1/31 Will be sending out formal notice for sites interested in 2016 participation Likely will have fee in 2017 to participate

10. Roll Call

11. Measure Review Pulmonary Bundle Kidney Injury Handoff

12. Pulmonary Bundle Current measure (Pul 01) identifies cases where TV is greater than 10 cc/kg Research indicates that low tidal volumes should be accompanied by PEEP and Recruitment maneuvers PEEP comes from anesthesia machine and most centers send to MPOG Recruitment maneuver concept has to be created (both in MPOG and in AIMS)

13. Outcomes measure – Kidney Injury Measure Summary AKI 01 identifies when a patient has an increase in their baseline creatinine observed in the first 7 post–op days. More specifically, it identifies when 1.5x baseline serum creatinine (measured within 60 preoperative days ) observed in first 7 post-op days. Considerations Should we use creatinine 1.5x baseline (KDIGO criteria) or something else (GFR)? Duration of preoperative measurement - 30 days or more? If there are multiple labs available, do we choose the lab drawn closest to the surgery date or the highest lab value?

14. Inclusions: All anesthetic cases requiring an inpatient stay Exclusions: ASA 5 & 6 Outpatient surgery Patients with pre-existing renal dysfunction Patients undergoing urologic surgery or surgery directly affecting kidneys Patients where a creatinine lab is not available within 7 days post-op Patients that do not have a baseline creatinine 60 preoperative days Labor epidural Considerations: Do we need to exclude outpatients when we are only looking at patients that have a creatinine level drawn within 7 days post-op? Need to define pre-existing renal dysfunction: Based on GFR, do we only exclude Kidney disease stage 3-5 or 2-5? Akin model? Exclude based on CPTs

15. Responsible Provider: The provider signed in during the case when the BP 01 measure failed (it is possible to have more than one provider). If there is no failure for the BP 01 measure, then the responsible provider is the provider signed in the longest.

16. Success The creatinine level does not go above 1.5x the baseline creatinine 7 days post-op. Risk Adjustment Yes Considerations For sites that report Non-African GFR and African GFR, we use only the GFR appropriate for the documented race. If race is not documented, can we impute it? If GFR is not available, the standard GFR calculation is used: 186 x (Creat / 88.4) -1.154 x (Age) -0.203 x (0.742 if female) x (1.210 if black)

17. Measure project - Handoff TOC 01TOC 02 This measure states the percentage of intraoperative anesthesia staff changes where completion of a predefined handoff checklist is documented during each instance of permanent intraoperative staff change This measure states the percentage of OR to PACU transitions of care where completion of a predefined handoff checklist is documented TOC 01TOC 02 All permanent transfer of care events between anesthesia providers All cases where patients are transferred from operating room to PACU at end of procedure Measure Summary Inclusions

18. TOC 01TOC 02 Temporary relief for breaksDirect transfers from OR to ICU Cases with no permanent shift relief TOC 01TOC 02 Provider who is assuming care of the patientProviders who are signed in at Anesthesia End Provider who is transferring care to the next providerProvider who documents postoperative vital signs Oncoming and leaving provider TOC 01TOC 02 Cases with documentation of transfer of care Exclusions Responsible Provider Success

19. Measure details questions NMB 02 - Neostigmine timing Trans 01 – Autologous blood – include or exclude

20. Introduction to “QI Module” Feedback needed

21. ASPIRE NMB 01: Personal Performance Improvement Module Goal : Increase the % of your patients that have a documented TOF monitor when receiving a non-depolarizing neuromuscular blocker

22. What is being measured? Included are all of your patients that have received non-depolarizing neuromuscular blocker (NMB) and were extubated post-operatively. Excluded are ASA 5 and 6 cases, patients that were not extubated in the immediate postoperative period, patients not given NMBs, and cardiac cases. Definition of success: Documentation of either a Train of Four (TOF) count or TOF ratio by acceleromyography AFTER the last dose of NMB. NMB 01 Full Measure Summary

23. Why is this measure important? This ASPIRE quality measure aims to reduce the number of patients who have residual neuromuscular blockade after extubation and in doing so:  Decrease postoperative anesthesia morbidity and mortality  Reduce the risk of reintubation and unplanned ICU admission  Improve postoperative pulmonary function and patient comfort

24. Our current state: ASPIRE-wide performance (as of 12/2/2015)

25. System-based performance improvement efforts: TOF monitors at each anesthetizing location Replacement batteries on anesthesia carts Ensure TOF / acceleromyography values are easy to document on EHRs Create an alert in EHR if possible Optional: Collect individual provider improvement plans to formulate an organizational best practice

26. What can I do to improve my practice? Follow these simple steps: 1.Identify the problem – check your recent performance on NMB-01 metric 2.Review failed cases 3.Study the relevant literature 4.Construct a plan that is specific to your practice (link to sample PDCA) 5.Implement your plan over the next 3 months 6.Review your practice performance and document improvement

27. Targeting an Improvement Effort: Developing your clinical improvement plan The following worksheet is an example of a document you can use to track your performance improvement efforts. The document is available on the IHI Website. IHI Website

29. Literature Summary Intermediate acting neuromuscular blockers (widely used in general anesthesia) may increase the incidence of postoperative respiratory complications. In this prospective, propensity score matched cohort study, ~18.5K surgical patients who received intermediate active neuromuscular blockers were matched with patients who did not receive these agents. Those that did receive these agents were at increased risk of postoperative oxygen desaturation (odds ratio 1.36) and reintubation requiring unplanned admission to ICU (odds ratio 1.40). Of note, in this trial neuromuscular monitoring and reversal of neuromuscular blocking drugs did not decrease this risk. Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, Uribe JV, Nguyen NT, et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. Bmj. 2012;345:e6329. PMCID: 3473088 PMCID: 23077290.

30. Literature Summary This study examined if the use of a specific type of monitoring for neuromuscular blockade (acceleromyography) would reduce the symptoms of residual paralysis during recovery from anesthesia. The subjective experience of muscle weakness may be associated with residual neuromuscular blockage in the PACU (post anesthesia care unit) and adverse respiratory complications. 155 patients were randomized to receive either acceleromyography or conventional monitoring (Train of Four Monitoring). The incidence of residual blockade in the acceleromyography group was reduced compared to the Train of Four group (14.5% vs 50.0%). The acceleromyography group had less subjective muscle weakness. Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Marymont JH, Vender JS, et al. Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesthesiology. 2011;115(5):946-54 PMCID: 21946094.

31. Literature Summary (cont’d) A 10-year survey on anesthesia related mortality ( n=240,483) revealed that mortality related to anesthesia has decreased. While the frequency of anesthesia contributed mortality decreased from 0.33 per 1000 in the previous 10 years to 0.22 per 1000 anaesthetics there is still room for improvement. These deaths were responsible for 2.2% of the total mortality from surgery. Two-thirds of the "anaesthetic" deaths were attributable to (in order of frequency): (a) hypovolemia; (b) respiratory inadequacy following myoneural blockade; (c) complications of tracheal intubation; (d) inadequate postoperative care and supervision. Harrison GG. Death attributable to anaesthesia. A 10-year survey (1967-1976). Br J Anaesth 1978; 50:1041-6.

32. Literature Summary (cont’d) A categorization of contributable cause of mortality by surgeons and anesthetists revealed that 16% of the deaths were attributed to anesthetic management. Postoperative respiratory failure was listed as a cause in 55 instances of all contributable causes (n=231).This was often ascribed to bronchopneumonia (24): other causes were neuromuscular (five), pneumothorax (two), failure to use artificial ventilation (seven), inappropriate narcotics (seven), pulmonary embolism (five) and miscellaneous (five). Lunn JN, Hunter AR, Scott DB. Anaesthesia-related surgical mortality. Anaesthesia 1983; 38:1090-6.

33. Resources to achieve your goals Become actively involved in ASPIRE quality improvement initiatives. Visit the ASPIRE website to access all the latest information that is important to you and your clinical practice.website Additional learning opportunities to expand your QI knowledge-base: The Institute for Healthcare Improvement Institute (IHI) Open School offers online courses in patient safety and quality improvement.Institute for Healthcare Improvement Institute Coursera offers a selection of courses related to quality improvement process improvementCoursera

34. Additional learning opportunities to expand your QI knowledge-base CourseraCoursera offers a selection of courses related to quality improvement & process improvement The Institute for Healthcare Improvement (IHI) Open School offers online courses in patient safety/quality improvement.Institute for Healthcare Improvement

35. Actively particpate in ASPIRE Become actively involved in ASPIRE quality improvement initiatives. Visit the ASPIRE website to access all the latest information that is important to you and your clinical practice.website On the website you can view the upcoming meeting schedule for on-site meetings and teleconferences as well as previous meeting minutes. Click here to be taken directly to the schedule.here Keep up with current and future measures by clicking here.here

36. What else would be helpful? Share documentation practices across sites Audio/Video format? Handouts? Other tools to help with implementation?

37. Thank you