Author: David P. Martin, MD, PhD
ASA Monitor 11 2015, Vol.79, 14-15.
Physician anesthesiologists have long recognized the importance of measuring and maintaining normal body temperature. Multiple research studies have demonstrated that hypothermia increases cardiac arrhythmias, increases blood loss, raises rates of surgical infections and delays patient awakening. Reflecting that importance, temperature management was one of the first quality measures adopted by the profession. This measure combined two categories of performance, specifically an outcome as well as a process. The outcome was maintenance of normothermia as defined by a core temperature of 36 degrees Celsius at the end of the case. The process measure was as simple as the application of a warming blanket. Practices rapidly learned that applying warming blankets could result in 100 percent achievement of the performance measure.
Over time, national performance has “topped out” at 100 percent. With no more gap to achieve improvement, the old measure has become somewhat irrelevant and will likely be changed in the near future. Nevertheless, patient temperature remains a physiologically vital parameter. Recent scientific evidence has noted deficiencies in the process measure as originally specified.1 This paper observed that 5.8 percent of patients who “passed” the measure were still hypothermic in the postanesthesia care unit and thus at risk for adverse outcomes. Therefore, the loophole of including a process measurement will likely be removed from the measure. As a compromise, the definition of normothermia has been relaxed somewhat to a core temperature of 35.5 degrees Celsius.
Forced-air warming systems provide clinical warming for the patient throughout the perioperative process.
The transition to reporting this outcome measure from the original perioperative temperature management (PQRS #193) measure has taken years to achieve. A short history of this measure further illustrates the measure development and implementation saga. In 2010, the ASA House of Delegates (HOD) approved the measure at the request of the Committee on Performance and Outcomes Measurement (CPOM). Citing the need to revise what has become known as PQRS #193, CPOM noted that the original measure contained both an outcome (a determined temperature at the conclusion of the procedure) and a process (use of active warming) for compliance. In short – the anesthesiologist could receive credit for trying to keep the patient warm. CPOM argued the measure should focus on the outcome only. The HOD agreed and the measure was submitted to the American Medical Association Physician Consortium of Performance Improvement (PCPI) for further review.
Measure development, however, is not just the identification of a numerator and denominator – physicians and staff must review clinical recommendations, conduct literature reviews to support the measure, and test available data for validity and reliability. To assist measure developers in a step-by-step approach, the Centers for Medicare & Medicaid Services (CMS) annually releases a measure development “bluebook” containing more than 400 pages of materials. But in 2011, those resources were few and far between, especially with the National Anesthesia Clinical Outcomes Registry (NACOR) in its infancy and ASA just starting to build its resources for measure development and support. With that in mind, ASA worked with the PCPI Anesthesiology and Critical Care Workgroup and PCPI staff to review and prepare this measure for further refinement in preparation of PQRS submission.
During the physician-led review and then hand-off back to ASA, the PCPI workgroup provided supporting evidence for lowering the temperature threshold to 35.5 degrees centigrade and received endorsement of the measures from the general PCPI membership. Last year, ASA took this measure (as well as the transfer of care to intensive care unit and postoperative nausea and vomiting measures) for consideration in PQRS 2016. In June 2015, CMS proposed the measures for inclusion in PQRS 2016. We will learn this month if it has been finalized for the program. Finally, in January 2016, more than five years after the measure began its path, practices may finally be able to receive PQRS credit for reporting this outcome.
The temperature management measure has also undergone a rigorous NQF endorsement process. In January, ASA staff coordinated with the Anesthesia Quality Institute (AQI), CPOM and other ASA members to compile data on, and submit, the measure for NQF endorsement. Although not required by CMS, NQF endorsement remains a key process that CMS considers when proposing measures for PQRS. In March, James Moore, M.D., as chair of CPOM, participated in the NQF Surgery Standing Committee meeting to explain the measure’s importance to anesthesia. He walked committee members through how the measure is used and how it contributes to patient outcomes. The committee recommended the measure for endorsement in March; by the publication of this article nearly seven months later, we expect the measure to finally be NQF-endorsed.
ASA, the medical community, CMS and other stakeholders have long recognized that the PQRS measure submission and approval process is inefficient and dated. Under the current system, ASA staff estimates it can take upward of three years for a single measure to move from conception to inclusion in PQRS. Within this process, there are multiple levels of review and public comment opportunities, each part aimed at ensuring that the public, stakeholders and interested parties can provide feedback.
Within ASA, CPOM has actively engaged the Board of Directors and, in October the HOD, to improve the internal development of measures. Federally, CMS has encouraged the growth of the Qualified Clinical Data Registry (QCDR) reporting option that uses specialty-specific quality measures and is aimed at driving quality improvement. Even the NQF has acknowledged that its process for measure endorsement can be improved.
But this returns us to the original challenge – as a specialty, what measures do physician anesthesiologists want and need to be scored on that will serve to improve patient care? In one specific instance, and for CPOM and the ASA House of Delegates, that measure was an outcome related to patient temperature at the end of surgery.
To actually achieve the outcome of warm patients, anesthesiologists will need to be more aggressive in protecting their patients from hypothermia. Proven methods include keeping the ambient room temperature at an appropriately warm level, using warming blankets intraoperatively and avoiding unnecessary exposure of skin to the environment, and applying fluid warmers and breathing circuit humidifiers. An additional step that has been proven successful in some practices is to pre-warm patients prior to bringing them to the O.R. By warming the patient to the point that there is minimal vasoconstrictive tone in the arms and legs, it is possible to reduce the heat distribution that is observed after induction of general or regional anesthesia when sympathetic tone decreases.
Measure development does not happen overnight. However, the process incorporates the best of many worlds – it is based on sound clinical recommendations, informed upon by a variety of stakeholders and members, and followed through to its successful implementation at our places of work. Over the years, we have seen substantial progress in the implementation and refinement of performance and outcome measurements. Gradually, these interventions are bringing us closer to the ultimate goal of improving the quality of patient care and minimizing complications.
ASA Director of Quality and Regulatory Affairs Matthew Popovich, Ph.D., contributed regulatory information for inclusion in this article.
Steelman VN, Perkhounkova YS, Lemke JH. The gap between compliance with the quality performance measure “perioperative temperature management” and normothermia