Measure ID
PAIN-01-Peds
Domain
Description

Percentage of patients < 18 years old who undergo a surgical or therapeutic procedure and receive a non-opioid adjunct preoperatively or intraoperatively.

Measure Type
Process
Threshold
None - Informational Only
Rationale

Multimodal pain management in children during the perioperative time frame can decrease postoperative pain, improve clinical outcomes, and patient satisfaction after surgery. Opioids hold a prominent role in acute pain management yet carry significant risk of perioperative complications including postoperative nausea and vomiting (PONV), respiratory depression, and increased recovery time after surgery. The American Society of Anesthesiologists (ASA) and Society for Pediatric Anesthesia (SPA) have published guidelines and recommendations which endorse the routine use of multimodal analgesia whenever possible to reduce opioid administration and its side effects. Current evidence supports the use of opioid sparing analgesics in pediatric surgical populations that act through different mechanisms. This list includes (but is not limited to) acetaminophen, NSAIDs, ketamine, clonidine, and dexmedetomidine.

Measure Time Period

Preop Start to Anesthesia End

Inclusions

Patients < 18 years old who undergo any procedure including surgical, therapeutic, or diagnostic requiring care by anesthesia providers.

Exclusions
Success Criteria

At least one non-opioid adjunct (medication, local, regional block, caudal, or epidural) was administered to the patient during the preoperative or intraoperative period.

Other Measure Details

Dexamethasone given alone is not considered a non-opioid adjunct to prevent multiple false positives that may skew measure performance.

Opioid Sparing Medications must be administered between Preop Start and Anesthesia End via a valid route (see MPOG route concepts listed above). Systemic lidocaine administered via IV infusion is considered as an alternative to regional anesthesia techniques.

Local Anesthetic ConsiderationsDocumentation must occur between Anesthesia Start and Anesthesia End 

  • Captured through administration of medications with text including ‘-caine’ via medication routes NOT including
    • 2001  Intravenous 
    • 2034  Laryngotracheal
    • 2006  Inhalational
    • 2024  Endotracheal 
    • 2004  Intramuscular (Ketorolac only)
  • Intraop notes mapped to ‘Misc - Local Infiltration of surgical site by surgical team’ (ID:50626) are also considered. 

Algorithm for determining patients who remained intubated postoperatively:

  1. Was the patient transported to PACU? If Yes, Include.  If No, then 
  2. Was extubation time prior to Anesthesia End? If Yes, Include. If No or missing, then,
  3. Was MPOG concept 50380 ‘Emergence - ETT in place, patient manually ventilated’ documented between procedure end and anesthesia end? If Yes, exclude. If no, then,
  4. Were sedation medication infusions continued after Anesthesia End? If Yes, exclude. If no, then include

 

Scenario

Non-Opioid (Medication)

Neuraxial (Caudal, Epidural, Spinal)

Regional Block

Case Attribute

Result

 A

 Yes

 Yes

 Yes

INCLUDE

PASS

 B

 Yes

 Yes

 No

INCLUDE

PASS

 C

 Yes

 No

 No

INCLUDE

PASS

 D

 No

 No

 No

INCLUDE

FLAG

 E

 No

 No

 Yes

INCLUDE

PASS

 F

 No

 Spinal/CSE/Unknown

 No

EXCLUDE

-----

 F2

 No

 Caudal

 No

INCLUDE

PASS

 F3

 No

 Epidural

 No

INCLUDE

PASS

 F4

 No

 Neuraxial-Multiple

 No

INCLUDE

PASS

 G

 No

 Yes

 Yes

INCLUDE

PASS

Risk Adjustment

Not Applicable

Provider Attribution

Any provider signed into the case between Anesthesia Start and Anesthesia End 

MPOG Concept Used

 

Route

  • 2001  Intravenous
  • 2003  Intramuscular (*Ketorolac only)
  • 2008  Oral
  • 2009  Nasal
  • 2023  Enteric Tube
  • 2012  Rectal

LOCAL ANESTHETIC

  • 2007  Local Infiltration (route)
  • 2027  Intradermal (must contain text ‘-caine’)
  • 50626 Misc - Local Infiltration of surgical site by surgical team

ACETAMINOPHEN

  • 10007 Acetaminophen
  • 10009 Acetaminophen / Butalbital / Caffeine
  • 10041 Aspirin / Acetaminophen / Caffeine

NSAIDS

  • 10040 Aspirin
  • 10222 Ibuprofen
  • 10747 Naproxen
  • 10116 Celecoxib

KETOROLAC

  • 10239 Ketorolac

KETAMINE

  • 10238 Ketamine
  • 10453 PROPOFOL W/ KETAMINE 10 MG/ML + 1 MG/ML
  • 10572 PROPOFOL W/ KETAMINE 10MG/ML + UNSPECIFIED KETAMINE
  • 10577 PROPOFOL W/ KETAMINE 10 MG/ML + 0.5 MG/ML
  • 10578 PROPOFOL W/ KETAMINE 10 MG/ML + 1.5 MG/ML
  • 10579 PROPOFOL W/ KETAMINE 10 MG/ML + 2 MG/ML

OTHER

  • 10149 Dexmedetomidine
  • 10199 Gabapentin
  • 10570 Pregabalin
  • 10132 Clonidine
  • 10180 Esmolol (*Infusion only)
  • 10705 Magnesium

LIDOCAINE (IV Infusion only)

  • 10477 LIDOCAINE
  • 10589 LIDOCAINE 0.4%
  • 10247 LIDOCAINE 0.5%
  • 10248 LIDOCAINE 1%
  • 10249 LIDOCAINE 1.5%
  • 10250 LIDOCAINE 2%
  • 10691 LIDOCAINE 2% W/ BICARBONATE
  • 10251 LIDOCAINE 3%
  • 10252 LIDOCAINE 4%

REGIONAL BLOCK

  • Value Code: 1-22  Peripheral Nerve Blocks

NEURAXIAL ANESTHESIA

  • Value Code: 4     Caudal
  • Value Code: 2     Epidural
  • Value Code: 6     Neuraxial - Multiple Types Listed
  • Value Code: 1,3,5  Spinal, Combined Spinal/Epidural, Neuraxial - Unknown

PACU PAIN SCORE

  • 3086  Pain Score (Generic)
  • 3087  Pain Score (FLACC)
  • 3088  Pain Score (Visual Analog Scale)
  • 3089  Pain Score (Faces)
References
  1. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-273.
  2. Cravero JP, Agarwal R, Berde C, et al. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth. 2019;29(6):547-571.
  3. Franz AM, Dahl JP, Huang H, et al. The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery-A quality improvement project. Paediatr Anaesth. 2019;29(7):682-689.
  4. Zhu A, Benzon HA, Anderson TA. Evidence for the Efficacy of Systemic Opioid-Sparing Analgesics in Pediatric Surgical Populations: A Systematic Review. Anesth Analg. 2017;125(5):1569-1587.
Measure Authors
 Measure Author  Institution
 Bishr Haydar, MD  University of Michigan
 Meridith Wade, MSN, RN  University of Michigan
 Rob Coleman  University of Michigan
 MPOG Pediatric Subcommittee  

 

 

 

Measure Reviewer(s)
Next Review: 2023
 Date Reviewed  Reviewer  Institution  Summary  QC Vote

 First Review: 12/2023

       
Version
Published Date: 12/2020
 Date  Criteria  Revision
07/24/2023  Exclusion  Updated radiology procedure exclusion to use new Diagnostic Imaging Procedures phenotype
 04/19/2023  Exclusion  Bronchoscopy Procedures
 03/16/2023  Exclusion  Replaced Non-Operative phenotype with Intubation Only as exclusion
 10/12/2022  Exclusion  Modified to use TEE/Cardioversion and Endoscopy
 04/07/2022  Success  Modified local anesthetic to check 10516 (other-local infiltration medication)
 02/11/2022  Multiple  Exclude 'Other' Cardiac cases; Removed 1mL medication volumne check
 01/17/2022  Exclusion  Modified to use new Cardiac phenotype to exclude open cardiac cases
 09/20/2021  Exclusion  Modified to use new ECT phenotype