Measure ID
PAIN-02
Domain
Description

Percentage of adult patients receiving at least one non-opioid adjunct preoperatively or intraoperatively.

Measure Type
Process
Available for Provider Feedback
Yes
Threshold
85%
Rationale

Effective pain management during the perioperative time frame can decrease postoperative pain, improve patient outcomes 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) has published guidelines and recommendations which endorse the routine use of multimodal analgesia whenever possible. Current evidence supports the use of opioid sparing analgesics in adult surgical populations that act through different mechanisms. This list includes (but is not limited to) acetaminophen, NSAIDs, ketamine, and clonidine. There is a lack of clear evidence on using Lidocaine infusion as an opioid sparing anagesic.

Measure Time Period
Inclusions

Patients ≥ 18 years old who undergo any procedure requiring care by anesthesia providers.

Exclusions
  • Age < 18 years 
  • ASA 5 and 6 including Organ Procurement (CPT: 01990)
  • Patients who remained intubated postoperatively *See Other Measure Build Details
  • Procedures
Success Criteria

At least one non-opioid adjunct (medication, regional block, neuraxial block, or local injection) was administered to the patient during the measure time 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). Lidocaine given IV is not considered.

Local Anesthetic ConsiderationsDocumentation must occur between Preop 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 
  • Volumes of < 1mL are not considered.
  • Intraop notes mapped to ‘Misc - Local Infiltration of surgical site by surgical team’ (ID:50626) are also considered. 

Regional/Neuraxial Block is determined by the Peripheral Nerve Block and Neuraxial phenotypes respectively. Documentation considered from Preop Start through PACU End. See specifications for more details

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

*This measure will include valid MPOG cases defined by the Is Valid Case phenotype.

Risk Adjustment

Not applicable

Provider Attribution

Any provider(s) signed into the case between Anesthesia Start and Anesthesia End 

MPOG Concept Used

OPIOID SPARING MEDICATION

  • 10007 Acetaminophen
  • 10222 Ibuprofen
  • 10747 Naproxen
  • 10116 Celecoxib
  • 10765 Meloxicam
  • 10239 Ketorolac
  • 10132 Clonidine
  • 10149 Dexmedetomidine
  • 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

MEDICATION ROUTES

  • 2001  Intravenous
  • 2008  Oral
  • 2009  Nasal
  • 2023  Enteric Tube

LOCAL ANESTHETIC

  • 10516  OTHER - LOCAL INFILTRATION MEDICATION
  • 50626   Misc - Local Infiltration of surgical site by surgical team

PACU PAIN SCORE

  • 3086  Pain Score (Generic)
  • 3087  Pain Score (FLACC)
  • 3088  Pain Score (Visual Analog Scale)
  • 3089  Pain Score (Faces)
MPOG Phenotypes Used
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. Beloeil H, Garot M, Lebuffe G, et al. Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery. Anesthesiology. 2021;134(4):541-551.
  3. Dunn LK, Durieux ME. Perioperative Use of Intravenous Lidocaine. Anesthesiology. 2017;126(4):729-737.
  4. Kharasch ED, David Clark J, Kheterpal S. Perioperative GabapentinoidsDeflating the Bubble. Anesthesiology. Published online June 26, 2020. doi:10.1097/ALN.0000000000003394
  5. Kharasch ED, David Clark J. Opioid-free Anesthesia: Time to Regain Our Balance. Anesthesiology. 2021;134(4):509-514. doi:10.1097/aln.0000000000003705
  6. Weibel S, Jelting Y, Pace NL, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev. 2018;6:CD009642.
Measure Authors
 Measure Author  Institution
 Nirav Shah, MD  University of Michigan
 Kate Buehler, MS, RN  University of Michigan
 Meridith Wade, MSN  University of Michigan
 Rob Coleman  University of Michigan
 MPOG Quality Committee  

 

 

Measure Reviewer(s)
Next Review: 2024
 Date Reviewed  Reviewer  Institution  Summary  QC Vote
 July 2024  Roya Saffary, MD  Stanford University  TBD  TBD

 

Version
Published Date: 2021
 Date  Criteria  Revision
02/1/2024 Exclusion IR/INR Cases
08/11/2023  Exclusion  

 Replaced MRI phenotype with Diagnostic Imaging Procedures 

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)
03/21/2022 Success Modified local medication bounds, Preop Start to Anesthesia End; Updated dose amount to include 1mL doses
01/04/2022 Multiple Modified to exclude cases using new Cardiac phenotype; Exclude eye procedures (CPT 00145; Meloxicam added as non-opioid; Added local anesthetic routes (2006, 2024, 2034); Removed lidocaine documented in mg from medication list.
09/20/2021 Exclusion Modified to use new ECT phenotype
07/01/2021 Success Added Dexmedetomidine to medication list
06/08/2021   Initial Publication