This informational measure (there is no threshold or target) is calculated based on data extracted from the electronic medical record combined with administrative data sources such as professional fee and discharge diagnoses data.  This measure is explicitly not based on provider self-attestation.

Cases are grouped by surgical site using CPT groupings (see below).  Opioid equivalents are calculated using conversions derived from literature and given between anesthesia start and anesthesia end for each case.  This value is normalized to patient weight (kg) and duration of anesthetic (anesthesia end – anesthesia start, hours as a decimal).

Anesthesia Start to Anesthesia End

All patients undergoing a procedure within the following primary anesthesia CPT groupings:

Cardiac

• Cardiac surgery with pump and > 1 year old (CPT: 00562)
• Cardiac surgery with hypothermic arrest (CPT: 00563)
• CABG with pump (CPT: 00567)
• Heart Transplant (CPT: 00580)
• CABG without pump (CPT:00566)

Spine (Adult): Patients ≥ 18yo

• Cervical spine and cord; not otherwise specified (CPT: 00600)
• Cervical spine and cord; patient in sitting position (CPT: 00604)
• Thoracic spine and cord; not otherwise specified (CPT: 00620)
• Thoracic spine and cord; thoracolumbar sympathectomy (CPT: 00622)
• Thoracic spine and cord, via an anterior transthoracic approach; not utilizing 1 lung ventilation (CPT: 00625)
• Thoracic spine and cord, via an anterior transthoracic approach; utilizing 1 lung ventilation (CPT: 00626)
• Lumbar region; not otherwise specified (CPT: 00630)
• Lumbar region; lumbar sympathectomy (CPT: 00632)
• Lumbar region; diagnostic or therapeutic lumbar puncture (CPT: 00635)
• Extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures) (CPT: 00670)

Spine (Pediatric): Patients < 18yo

• Cervical spine and cord; not otherwise specified (CPT: 00600)
• Cervical spine and cord; patient in sitting position (CPT: 00604)
• Thoracic spine and cord; not otherwise specified (CPT: 00620)
• Thoracic spine and cord, via an anterior transthoracic approach; not utilizing 1 lung ventilation (CPT: 00625)
• Thoracic spine and cord, via an anterior transthoracic approach; utilizing 1 lung ventilation (CPT: 00626)
• Lumbar region; not otherwise specified (CPT: 00630)
• Extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures) (CPT: 00670)

Upper Abdomen

• Intraperitoneal - upper abdomen including laparoscopy; not otherwise specified (CPT: 00790)
• partial hepatectomy or management of liver hemorrhage (excluding liver biopsy) (CPT: 00792)
• Intraperitoneal - upper abdomen including laparoscopy; pancreatectomy, partial or total (eg, Whipple) (CPT: 00794)
• Intraperitoneal - upper abdomen including laparoscopy; gastric restrictive procedure for morbid obesity (CPT: 00797)

Lower Abdomen

• Procedures in lower abdomen including laparoscopy; not otherwise specified (CPT: 00840)
• Procedures in lower abdomen including laparoscopy; abdominoperineal resection (CPT: 00844)
• Procedures in lower abdomen including laparoscopy; pelvic exenteration (CPT: 00848)

Hysterectomy

• Intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy (00846)
• Vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); vaginal hysterectomy (00944)

Knee/Popliteal

• Open or surgical arthroscopic procedures on knee joint; total knee arthroplasty (01402)

Hip

• Open procedures involving hip joint; total hip arthroplasty (01214)

Tonsil/Adenoid (Pediatrics)

• Anesthesia for intraoral procedures, including biopsy; not otherwise specified (CPT: 00170)
• Procedure text includes "tonsil" or "adeniod"

Any procedure not listed in one of the inclusion categories above

Success is not defined for these measures- informational only

Other Measure Build Details:

Medication combinations are calculated using the medication concept IDs, route of delivery, and unit of measure as listed above.  Not all possible combinations are used as some routes or units are not used for certain medications in medical practice.  Remifentanil is not included in the opioid equivalency calculation due to its short duration of action and low context-sensitive half-time. Opioid equivalency is still calculated for these cases that use remifentanil but the cases are flagged as having “Remi”.  When an opioid dose cannot be calculated for a medication due to inadequate documentation, the opioid equivalency is returned for the remaining medications and the case is also flagged as having an opioid given with an “Unknown” dose.

If weight and/or anesthesia duration is missing for the case, the opioid equivalency is returned as NULL.

The following conversions were used for opioid equivalency conversions:

Example: A 10 kg patient receives 100mcg of fentanyl for induction (100 ug total for the case) for a 4.0 hour case.

First we calculate the /kg/hr IV OME for the case:

0.1mg fentanyl / 10 kg / 4.0 hour = 0.1/10/4 = 0.0025 OME mg/(kg*hr)

Next, we multiply by 3 to calculate PO OME:

0.0025 * 3 = 0.0075 mg/(kg*hr) PO OME

Each case grouping (Spine, Cardiac etc) a "standard" weight and case length has been assigned to help allow for case-to-case comparisons. Let’s pretend the standard chosen for this example is 20 kg patient and 3 hour case.

Then, we would report the following for this case:

0.0075 mg/(kg*hr) * 20kg * 3 hours = 0.45 PO OME 

The PO OME value is then used to convert and display the Fentanyl IV, Morphine IV and Morphine PO equivalent.

·         (ome.Value * 10.0 / 3.0)  -- Fentanyl IV

·         (ome.Value / 3.0)   --- Morphine IV

·         (ome.Value)   --- Morphine PO

Provider signed in for largest portion of case using Case Duration.

Algorithm for determining Case Duration:

Case Start:

1. Anesthesia Induction End. If not available, then

2. Anesthesia Induction Begin. If not available, then

3. Procedure Start. If not available, then

4. Patient in Room. If not available, then

5. Anesthesia Start

Case End:

1. Patient Extubated. If not available, then

2. Procedure End. If not available, then

3. Patient Out of Room. If not available, then

4. Anesthesia End.   

• Percentage of medications with a Meaningful Medication Mapping
• Percentage of medications with a Meaningful Route Mapping
• Percentage of medications with a Meaningful Unit Mapping
• Percentage of cases with Bolus Medications
• Percentage of Cases with Infusion Medications

Understanding opioid administration is important to help improve perioperative care.  There has been a dedicated focus on understanding opioid use within and outside the hospital and an equivalency is often used to compare opioid consumption.  As Oral Morphine Equivalent (OME) conversions are limited to medications routinely used outside of the operating room (OR) and omit some critical medications and routes used in the OR, a new algorithm was developed to incorporate medications used intraoperatively.  This equivalency is intended as an informational tool to help understand opioid use in the operating room. 

Not applicable

1. APS. Principles of Analgesic Use, 7th Edition. In: Christopher M. Herndon PA, Beth Darnall, Craig Hartrick, Keith Hecht, Mary Lyons, Jahangir Maleki, Renee Manworren, Christine Miaskowski, Nalini Sehgal, editor. Principles of Analgesic Use. 7th ed2016. p. Table 2.

2. Dowell D HT, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016. 2016;65(No. RR-1):1–49.

3. McPherson ML. Demystifying Opioid Conversion Calculations: A Guide to Effective Dosing. Bethesda, MD: American Society of Health-System Pharmacists; 2009. 208 p.

4. Krames ES. Intrathecal infusional therapies for intractable pain: Patient management guidelines. Journal of Pain and Symptom Management.8(1):36-46.

5. Anderson R, Saiers JH, Abram S, Schlicht C. Accuracy in Equianalgesic Dosing. Journal of Pain and Symptom Management.21(5):397-406.

6. OpenAnesthesia , https://www.openanesthesia.org/

7. Koyyalagunta, D.  Pain Management, 2007, Chapter 113: Opioid Analgesics.  Pain Management, 113(2), 2007, Pages 939-964

8. Walker, PW, et. al. Switching from Methadone to a Different Opioid: What Is the Equianalgesic Dose Ratio?  Journal of Palliative Medicine.11(8), 2008, Pages 1103-1108