2 1 2024 MIPS Quality Measures List: Perioperative Temperature Management Darius R.

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2024 MIPS Quality Measures List: Perioperative Temperature Management

Darius R. Bolling

University Of Cincinnati-College of Nursing

NDNP 9015 Quality Improvement & Patient Safety

Dr. Lynne Garvey DNP, CRNP, RN

June 13, 2024

2024 MIPS Quality Measures List: Perioperative Temperature Management

Perioperative temperature management is a key quality indicator in the 2024 Merit-Based Incentive Payment System (MIPS) as outlined by the Centers for Medicare and Medicaid Services (CMS, 2023). The importance of temperature monitoring is underscored in perioperative monitoring guidelines (Koh et al., 2021). Bindu et al. (2018) emphasized the necessity of continuous monitoring of vital parameters, including temperature, during the administration of general anesthesia. This is in line with the American Society of Anesthesiologists’ (ASA, 2020) requirements for constant monitoring of patient circulation, oxygenation, ventilation, and temperature.

Bindu et al. (2018) further recommended thermoregulation, given its basis on numerous signals from various tissue types. It’s important to note that general or neuraxial anesthesia can disrupt both central and peripheral thermoregulation. Factors such as exposed body cavities and low ambient operating room temperatures also affect perioperative thermoregulation (Koh et al., 2021). These factors can lead to unintentional perioperative hypothermia in surgical patients who are not warmed (Koh et al., 2021).

Research has shown that perioperative hypothermia can have significant effects on perioperative morbidity and mortality (Koh et al., 2021). Epstein et al. (2018) found a correlation between perioperative hypothermia and surgical wound infections, coagulopathy, blood loss, transfusion, and cardiac mortality. Thus, effective temperature management is crucial in perioperative care.

Research has indicated a lack of adherence to existing perioperative thermoregulation guidelines among clinicians. Epstein et al. (2018) analyzed intraoperative temperature and interval data from the anesthesia information management systems of four U.S. hospitals. Their focus was on clinician compliance with ensuring that at least one body temperature is above 35.5°C within 30 minutes before or 15 minutes after anesthesia for all patients under general anesthesia for at least 60 minutes. The study found that intraoperative temperature monitoring was discontinued less than 30 minutes before the end of anesthesia in 34% to 60% of patients. Additionally, 9% to 21% of all cases reported end-of-case intraoperative temperatures below the recommended 35.5°C (Epstein et al., 2018).

Furthermore, adherence to perioperative temperature management standards among clinicians is generally poor, as established by scholars. Koh et al. (2021) conducted a cross-sectional survey involving anesthesiologists from various jurisdictions. The study reported that less than half of the respondents performed active intraoperative warming for most of their patients, and less than 25% of the clinicians reported prewarming most of their patients. Notably, these clinicians did not adhere to the best practices outlined in international temperature management guidelines (Koh et al., 2021). Bindu et al. (2018) also discussed a survey that found that clinicians in Europe only performed temperature monitoring in 19% of patients, and only 39% of patients were routinely warmed. These findings underscore the need for improved adherence to perioperative temperature management guidelines.

The poor compliance of clinicians to intraoperative temperature guidelines has partly been attributed to inconsistencies in the standards. The United States National Quality Programs for perioperative thermoregulation recommend ensuring that at least one body temperature is above or at least 35.5°C within 30 minutes prior to or 15 minutes following anesthesia end time (Epstein et al., 2018). Koh et al. (2021) and Rauch et al. (2021), on the other hand, defined unintentional perioperative hypothermia as a core temperature under 36°C in the perioperative duration. It is also worth noting that ASA does not provide succinct guidelines, only recommending that patients receiving anesthesia should have temperature monitoring when clinicians expect, intend, anticipate, or suspect significant body temperature changes (ASA, 2020; Koh et al., 2021). The lack of specificity is also evident in the 2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines, which only recommend maintaining body temperature in the normothermic range for most procedures to reduce perioperative cardiac events unless mild hypothermia is needed to protect organs (Bindu et al, 2018). Within this discourse, it is also worth noting that temperature is affected by multiple factors. The thresholds for shivering and vasoconstriction are 36.0°C and 36.5°C, respectively (Bindu et al., 2018). General anesthesia reduces these thresholds by 2°C to 3°C. The thresholds also differ daily because of the circadian rhythm and monthly period in women by up to 0.5°C (Bindu et al., 2018). Equally important is the impact of exercise, food intake, infections, temperature site assessed, and hypothyroid or hyperthyroid states (Bindu et al., 2018).

Currently, there are no standardized guidelines outlining the most effective strategies for warming patients during the perioperative period (Koh et al., 2021). Koh et al. (2021) noted that a single layer of passive insulation only mitigates a third of the heat loss related to skin during anesthesia, and adding more passive layers has proven to be ineffective. However, numerous systematic reviews and randomized controlled studies have confirmed the effectiveness of active warming methods in maintaining perioperative normothermia (Koh et al., 2021). Balki et al. (2020), for instance, observed that active body surface warming is more effective than non-active warming strategies in reducing the risks of shivering, wound infections, and blood transfusion needs in non-cardiac surgical patients. Active warming approaches are also better than passive controls in supporting normothermia during surgery, at the end of surgery, and four hours postoperatively (Balki et al., 2020). It is also prudent to note that no guidelines on the best temperature monitoring site exist (Bindu et al, 2018). The core, however, is about 2°C warmer than peripheral tissues (Rauch et al., 2021).

The literature review highlights inconsistencies and gaps in current practices, and the detrimental effects of perioperative hypothermia. These findings underscore the necessity for the proposed quality improvement initiative. This initiative aims to develop and implement standardized protocols for managing temperature during the perioperative period, thereby addressing these issues and improving patient outcomes.

References

American Society of Anesthesiologists (ASA). (2020). Standards for basic anesthetic monitoring. https://www.asahq.org/standards-and-practice-parameters/standards-for-basic-anesthetic-monitoring.

Balki, I., Khan, J., Staibano, P., Duceppe, E., Bessissow, A., Sloan, E., Morley, E., Thompson, A., Devereaux, B., Rojas, C., Rojas, C., Siddiqui, N., Sessler, D., & Devereaux, P. (2020). Effect of perioperative active body surface warming systems on analgesic and clinical outcomes: A systematic review and meta-analysis of randomized controlled trials. Anesthesia & Analgesia, 131(5), 1430-1443. https://doi.org/10.1213/ANE.0000000000005145

Bindu, B., Bindra, A., & Rath, G. (2017). Temperature management under general anesthesia: Compulsion or option. Journal of Anesthesiology Clinical Pharmacology, 33, 306-326.

Centers for Medicare and Medicaid Services (CMS). (2023). Quality ID #424: Perioperative temperature management. https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_424_MIPSCQM.pdf.

Epstein, R., Dexter, F., Hofer, I., Rodriguez, L., Schwenk, E., Maga, J., & Hindman, B. (2018). Perioperative temperature measurement considerations relevant to reporting requirements for national quality programs using data from anesthesia information management systems. Anesthesia & Analgesia, 126(2), 478-486. https://doi.org/10.1213/ANE.0000000000002098

Koh, W., Chakravarthy, M., Simon, E., Rasiah, R., Charuluxananan, S., Kim, T., Chew, S., Bräuer, A., & Ti, L. (2021).Perioperative temperature management: A survey of 6 Asia–Pacific countries. BMC Anesthesiology, 21, 1-10. https://doi.org/10.1186/s12871-021-01414-6

Rauch, S., Miller, C., Bräuer, A., Wallner, B., Bock, M., & Paal, P. (2021).Perioperative hypothermia: A narrative review. International Journal of Environmental Research and Public Health, 18, 1-15. https://doi.org/10. 3390/ijerph18168749