Quality Outcome Indicators

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“Good job today.” These words were said by the anesthesia attending I was working with. I was a third-year anesthesia resident and felt good about being acknowledged for my hard work, but there were many unanswered questions. What impact did my anesthesia care have on the overall health of my patient? How was my patient doing after surgery? What about a week or a month after surgery? No news was good news – and not hearing about any adverse outcomes was the only feedback I had about my anesthesia care. And sometimes, even the adverse events did not get reported back to me. In a similar manner, friends or family would ask, “Who is a good surgeon?” My knowledge was only limited to the interactions I had with the surgeons in the OR. The better surgeons are the ones who were quicker and finished faster, right? Or were they the ones who had less bleeding and fewer transfusions for the same procedure? Or were they the ones who prepared their patients for the ORs better? Perhaps the best surgeons were the ones who were more collegial with the OR staff. I did not really know which surgeons had better long-term patient outcomes. For a specialty that has been recognized as a leader in patient safety, there are only a few quality outcome measure databases within the field. The best examples are the Multicenter Perioperative Outcomes Group (MPOG) and the Anesthesia Quality Institute (AQI). MPOG collects both patient demographic data and patient outcome data to track performance on a number of different quality measures. However, investments of resources are required to collect and standardize the data from each participating site. MPOG currently is limited mostly to academic medical centers and requires the use of an electronic medical record. The AQI has information on a larger number of patients; however, this is mostly administrative data. The AQI database lacks the granularity of patient data that is required for quality improvement. AQI is currently partnering with Epic to potentially create a more robust dataset of patient demographics and outcomes.1 By comparison, our surgical colleagues have developed quality outcome databases over the past few decades. Three of these databases are the National Surgical Quality Improvement Program (NSQIP) and the National Trauma Databank (from the American College of Surgeons) or the STS National Database on cardiac surgery (from the Society of Thoracic Surgeons). By creating these databases with millions of patients and procedures, both organizations are able to provide benchmarking and quality improvement tools. Having seen presentations from our surgical colleagues showing our hospital's local performance, I have been puzzled that we do not have a similar database system for anesthesia.2-4 ASA has prioritized the reduction of 30-day postoperative mortality as a critical priority in advancing patient safety and quality of care in perioperative medicine. A workgroup of the Committee on Performance and Outcomes Measurement (CPOM) has developed a list of patient outcomes measures for anesthesiologists to consider tracking (Table). The CPOM workgroup has divided the quality measures by organ system: neurological, cardiovascular, pulmonary, renal, hematological, and infection. We believe that decreasing events associated with worse patient outcomes should lead to a decrease in postoperative mortality. We also chose measures in two subspecialty categories (pediatrics/obstetrics) that are intended to track measures of better anesthesia care. Table - Proposed 30-Day Quality Outcome Indicators Neurologic Infection Acute delirium Surgical site infections (SSI) Stroke Central line associated blood stream infections (CLABSI) Quantitative neuromuscular blockade monitoring Cather associate urinary tractinfections (CAUTI) Pneumonia (non-mechanically ventilated patients) Methadone/buprenorphine continued perioperatively Ventilator associated pneumonia (VAP) (mechanically ventilated patients) Sepsis/severe sepsis/septic shock Cardiovascular Pediatric Low blood pressure Cardiac arrest Myocardial ischemia Unplanned admission after ambulatory surgery Cardiac arrest Pulmonary embolism Unplanned intubation/reintubation Deep vein thrombosis Death Pulmonary Obstetric Counseling for smoking cessation Postdural puncture headache rate after neuraxial anesthesia Unplanned intubation/reintubation Frequent blood pressure monitoring for neuraxial anesthesia for cesarean delivery Ventilator dependence > 48 hours Prevention of neuraxial hypotension during cesarean delivery Management of postpartum hemorrhage Rate of general anesthesia administered for cesarean delivery Renal Hematological Acute kidney injury Transfusion to an acceptable hemoglobin level Acute renal failure These measures are intended to be collected for individuals undergoing inpatient surgery who have a higher mortality and morbidity compared to ambulatory surgery patients. Creating a standard set of patient outcomes that are measured by all anesthesiologists would allow for benchmarking and quality improvement activities. While some of these outcomes may not appear to be directly related to poor anesthesia care, as perioperative physicians, we should be investigating what role we can play in decreasing these postoperative adverse events. Some of these measures will require new assessments or changes in the hospital's workflow. Postoperative delirium has been associated with increased health care costs and length of stay. Additionally, postoperative delirium can be a very negative experience for patients and their families. But how do hospitals capture delirium? Capturing it with ICD-10 billing codes would certainly undercount the number. More robust screening with the routine use of the Confusion Assessment Method tool from nursing staff may be required to properly diagnose postoperative delirium. Or perhaps progress notes can be queried to extract any references to delirium. How do we capture that information from electronic medical records? And then what is to be done with that information? Several quality measures from this list are already being captured by hospitals for different reporting. This may decrease the burden required by anesthesia groups to collect and report on these measures. The following measures are being tracked by NSQIP: myocardial infarction, cardiac arrest, pulmonary embolism, unplanned intubation/reintubation, ventilatory dependence >48 hours, sepsis/septic shock, and postoperative pneumonia. The following measures are being tracked within MPOG: acute kidney injury, acute kidney failure, and appropriate transfusion. A few of the infection measures are being reported by hospitals to the National Healthcare Safety Network and Leapfrog, including surgical site infection, central line-associated bloodstream infection, and catheter-associated urinary tract infection. As anesthesia groups collect and review these quality measures, the focus of their efforts will be more in line with the hospital's patient safety and quality goals. For our obstetric category, the committee had chosen quality measures that align with recommendations from the ASA Committee on Obstetric Anesthesia.5 While these events are less associated with maternal mortality, they represent key anesthesia quality measures in this subspeciality. These are patient outcomes that should be tracked and trended by all obstetric anesthesiologists. Having this information would provide the basis for any quality improvement efforts in this area.4 One of the challenges of this work is the ability to provide risk adjustment for individual patients. This list of quality measures represents patient outcomes and particularly adverse outcomes that all anesthesiologists should aim to decrease. For two different hospitals with different rates of comorbidities, the patient outcomes and mortality performances will be different. Risk adjustment based on patient demographics will allow for better comparison between

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