Project Kickoff Session January 2021 2021 Hysterectomy QI Project Overview All elective hysterectomy patients Follows recommendations of the MSQC Hysterectomy Care Pathway Preoperative intraoperative and postoperative measures ID: 907828
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Slide1
2021 Hysterectomy Care QI
Project Kickoff Session
January 2021
Slide22021 Hysterectomy QI Project Overview
All elective hysterectomy patientsFollows recommendations of the MSQC Hysterectomy Care PathwayPreoperative, intraoperative, and postoperative measuresMultidisciplinary meeting to be held by 3/31/2021
Implement process to ensure documentation of cases is complete
Describe
your hospital’s process for reviewing and monitoring uterine surgical specimens without pathology findings
Designate
OB/GYN
surgeon
as
project champion
Promote project with peers and department/hospital leadership
Does not replace your hospital’s assigned Surgeon
Champion
Slide32021 QI Timeline
1/1/2021 OR cases – begins measurement period for:M-OPEN prescribing recommendations (hysterectomy cases)Collaborative Wide Measure (CWM) of Intraoperative Multimodal Pain Management (all MSQC-eligible procedures)3/31/2021 – must hold multidisciplinary meeting by this date4/1/2021 – measurement period for all other measures in hysterectomy project1/17/2022 – Completed Hysterectomy Project Tracking Sheet and Narrative Summary Report due to MSQC
Slide4Collaborative Wide Measure (CWM)
Measure: Use
of
Intraoperative Multimodal Pain Management across all MSQC procedures*
Measurement
Period:
1/1/2021
– 12/31/2021
Goal: Increase use greater than 2020 baseline of 44%
CWM ScorePoints Awarded> 60%20 points 55-59%15 points50-54%10 points45-49%5 points< 44%0 points
*Intraoperative
Multimodal Pain Management administered?
Yes selected
All surgical priorities
Slide5Hysterectomy Preoperative Measures
Goal: 80% compliance with preoperative measures (10 points)Measurement Period: 4/1/2021 – 12/31/2021Measures:Preadmission teaching includes multimodal pain managementSame measure as in the 2020 QI projectsPreadmission counseling/ teaching (ERP Tab) Pain Management selectedGlycemic control: HgbA1C if diabetic*; fasting blood sugar (or HgbA1C) if
not
diabetic
Document preoperative values in Lab Values Tab
*Diabetes Mellitus = Non-insulin or Insulin
Slide6Hysterectomy Preoperative Measures, continued
Alternative treatments tried / offered / declined, or contraindications documented, for specific diagnosesEligible diagnoses:Adenomyosis
, chronic pelvic pain, endometriosis
Abnormal
uterine bleeding, uterine fibroids
Prolapse
Alternative Treatments to Hysterectomy (Preop Tab)
Yes, or Methods discussed, but not specifically documented selected
Slide7Hysterectomy Preoperative Measures, continued
Appropriate Antibiotics AdministeredMSQC Recommendation1:Cefazolin 2g IV for patients < 120kg; 3g IV for patients ≥ 120kg
AND
Metronidazole
500mg IV
Administer 15 to 60 minutes before incision
Acceptable antibiotic alternatives:
ASHP Guidelines
21Till SR, Morgan DM, Bazzi AA, et al. Reducing surgical site infections after hysterectomy:metronidazole plus cefazolin compared with cephalosporin alone. Am J Obstet Gynecol 2017;217:187.e1-11.2Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195–283.
Slide8Hysterectomy Preoperative Measures, continued
Antibiotic measure exclusions:cases with current antibiotic measure
Exception
order for scheduled IV
abx
present at Surgery Start
Time
therapeutic IV abx administered/ordered for existing or suspected infection within 24 hours of Surgery Start Timecertain Hysterectomy Care Pathway QI exception rationales:not an elective Hysterectomy, or not a Hysterectomy Care Pathway QI Case
AllergyShortageOther MSQC-approved reason
Slide9Hysterectomy Intraoperative Measures
Goal: 80% compliance with intraoperative measures (10 points)Measurement Period: 4/1/2021 – 12/31/2021Measures:Intraoperative use of multimodal pain managementSame measure as in the 2020 QI projects2 or more non-opioid pain medications or pharmacologic strategies administeredIntraoperative Multimodal Pain Management administered?
(
ERP Tab
)
Yes selected
Slide10Hysterectomy Intraoperative Measures, continued
Intraoperative nausea and vomiting prophylaxis for PONV for all hysterectomy casesAdministration of 2 or more anti-emetic medications from two different medication categories (refer to 2021 Program Manual for guidance)
Intraop
Nausea and Vomiting Prophylaxis for PONV
(ERP
Tab
)
Yes selected
Slide11Hysterectomy Intraoperative Measures, continued
Anti-emetic Medication Categories
Slide12Hysterectomy Intraoperative Measures, continued
Helpful Abstraction HintsToradol administered at the end of the surgery in the operating room is not included for intraoperative or postoperative multimodal pain management. Duration of action is only 4-6 hours. EXPAREL wound infiltration has a duration of action of up to 72 hours. EXPAREL placed in the beginning of the surgery is included as one type of intraoperative and postoperative multimodal pain management. EXPAREL placed at the end of surgery will only count as postoperative multimodal pain management.
Slide13Hysterectomy Intraoperative Measures, continued
Helpful Abstraction Hints, continuedMultimodal Interventions – Administration Timing Comparisons
Slide14Hysterectomy Postoperative Measures
Goal: 80% compliance with postoperative measures (10 points)Measurement Period: 4/1/2021 – 12/31/2021Measures:Order for multimodal pain managementSame measure as in the 2020 QI projectsMultimodal Pain Management ordered within the first 24 hours following surgery? (ERP Tab) Yes selected
Slide15Hysterectomy Postoperative Measures, continued
Discharge education includes pain management teachingSame measure as in the 2020 QI projects
Postop Teaching/Counseling (ERP Tab)
Pain Management
selected
Only cases with Discharge Destination equal to Home, or Home with Home Health Care
Slide16Goal
: 90 % of elective hysterectomy cases (5 points)Measurement Period: 1/1/2021 – 12/31/2021Measure:Opioid type (Opioid Tab) “No opioid prescribed at discharge” selected, OR amount prescribed was at or below Michigan OPEN prescribing recommendations*
Abdominal hysterectomy: 0 – 20 pills
Laparoscopic/robotic/vaginal: 0 – 15 pills
Measure includes pts
DC to home or home with home
care
Data found on Opioid
Dashboard report in WorkstationMeet M-OPEN opioid prescribing recommendations*based on oxycodone 5 mg tablets
Slide17Conduct and document at least one multidisciplinary meeting by
3/31/2021 (5 points)Meeting can be in-person, virtual, or hybrid formatAttendees to include surgeons, nurses, quality, pharmacy and other relevant staffDiscuss and establish the following:hysterectomy care pathway plan to ensure complete documentation of hysterectomy cases
distribute/discuss
the hysterectomy surgical approach
algorithm (included in
hysterectomy care pathway
.
Submit meeting documentation to MSQC with 2021
QI project report (due 1/17/2022)
Slide18Create a plan for ensuring completeness of documentation in the medical record
Develop and implement a documentation template that includes:Indications for hysterectomyAlternatives offered / tried / declined before having surgery (if appropriate, in non-cancerous diagnoses)Contraindications to any alternative treatmentsPreoperative ultrasound/imaging findings (except for prolapse)
Planned
surgical approach and
rationale
Completeness of Documentation
Slide19Submit template to MSQC with 2021 QI project due 1/17/2022
Include summary of template development/implementation process, successes, barriers, challenges to implementation in QI reportPossible approaches to creating template:Synoptic operative note in EMRPreoperative H&P template, operative report
template
Create prompts, headers, and standardized field value options for required
elements
Other options that will work at your
site?
Completeness of Documentation, continued
Slide20Benign
Surgical Specimen Monitoring ProcessDescribe your hospital’s process for reviewing and monitoring uterine surgical specimens without pathology findings supporting the need for hysterectomy. Guidance note: These cases are those with pathology findings (e.g. normal, unremarkable, physiologic, reactive, or of minor importance) amenable to medical or surgical treatment less invasive than hysterectomy. In general, these changes would rarely require hysterectomy to relieve a patient of symptoms.
Slide21Benign Surgical Specimen Monitoring Process, continued
Survey of whether facilities have an established process for monitoring benign surgical specimen pathology, and how those processes are designedDoes your hospital currently
have such a process?
If not, indicate this on the 2021 QI Project Report
If yes, describe your hospital’s process on the 2021 QI Project Report
Not a requirement that you have a process; rather, that you share any process you may have
Slide22QI Tracking
Sheet and Narrative Summary ReportDue to MSQC by 1/17/2022 (10 points)Take credit for QI work on project measures, standardized documentation development and implementationDocument throughout year to track progress on measure performance, capture QI implementation effortsMeetings, communications, process changes, key dates
Describe improvement
efforts, successes, barriers, challenges
Report due earlier than in prior
years
Conform to BCBSM Collaborative time
frames
Slide23Resources
CWM & Hysterectomy Care Pathway Measures Reference Sheet (“one-pager”)QI measure reports available in MSQC Workstation and via Box account. Virtual QI site visits during 2021MSQC Hysterectomy Care Pathway
MSQC May 2019 Hysterectomy Quality Improvement Workshop
sessions and resources
Reducing
surgical site infections after hysterectomy: metronidazole plus cefazolin compared with cephalosporin alone. (2017).
https://
www.ncbi.nlm.nih.gov/pubmed/28363438
ASHP Guidelines: Antimicrobial Prophylaxis in Surgery
Slide24Resources, continued
April 23 MSQC/ASPIRE Collaborative Meeting (virtual) – session on multimodal anesthesia, other content pertinent to your QI workJune 2020 SCQR Training Day recorded session available on MSQC websiteSurgical Pain Management: Procedure Specific EvidenceQualitative analysis of 2019 pain management pathways submitted by sites for 2019 QI project; loaded into your Box account in November
Slide25Q & A