Percentage of patients, ≥18 years age, who undergo open cardiac surgical procedures using cardiopulmonary bypass under general anesthesia of 120 minutes case duration (anesthesia start to anesthesia end) or longer for whom the temperature did not rise above 37.5 degrees Celsius (99.5 degrees Fahrenheit) while on bypass for over 5 consecutive minutes.

Consistent with the 2020 Updates from the Adult Cardiac Anesthesiology Section of STS,¹ guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery,^2,3 STS practice guidelines for temperature management while on bypass,⁴ and the Anesthesia Quality Improvement measure, AQI65, for cerebral hyperthermia avoidance for cardiac surgery,⁵ this proposed measure defines hyperthermia as ≥37C while on bypass. Hyperthermia while on bypass and during rewarming has been associated with respiratory failure, acute kidney injury, and mortality after cardiac surgery.^6,7

Measure Start: 

1. Cardiopulmonary Bypass Initiated (ID:50410), if not present, 
2. Cardiopulmonary Bypass Start Phenotype

Measure End: 

1. Cardiopulmonary Bypass Terminated (ID: 50409), if not present, 
2. Cardiopulmonary Bypass End Phenotype. If not present,
3. Anesthesia End 

All patients, 18 years of age or older, who undergo open cardiac surgical procedures (as determined by Procedure Type: Cardiac phenotype) under general anesthesia of 120 minutes duration or longer of cardiopulmonary bypass. See other measure build details section for bypass duration calculation.

• Cases with age <18
• Cases <120 minutes duration between anesthesia start and anesthesia end.
• ASA 6 
• Organ harvest (CPT: 01990)
• Non-cardiac, Transcatheter/Endovascular, EP/Cath, and Other Cardiac cases as defined by the Procedure Type: Cardiac phenotype
• Open Cardiac cases performed without bypass (Open cardiac cases as defined by the Procedure Type: Cardiac phenotype, without any bypass start or end concepts or phenotypes)
• Invalid cases where Measure End results prior to Measure Start

Less than 5 consecutive minutes of non-artifact body temperature measure between cardiopulmonary bypass start and end, prioritizing core temperature measurements, greater than or equal to 37.5 degrees Celsius.

• Temperature documented within the anesthetic record or temperatures documented and mapped to the temperature physiologic concepts are acceptable sources for this measure. 

• Conversion algorithm for F to C:    F=32 +9/5 (°C)

• Artifact algorithm:
  • Less than 32.0°C (89.6F)
  • Greater than 40.0°C (104.0F)
  • Any minute-to-minute jumps >1.0°C equivalent. 
    • Example: 0.25°C /15s, 0.5°C / 30s, 1°C / 1min

• All core temperature measurements will be prioritized over near-core temperature measurements with hierarchy applied in the following order:
  • Arterial Bypass Cannula Temperature (Concept ID: 3263) 
  • Nasopharyngeal (Concept ID: 3059)
  • Esophageal (Concept ID: 3055)
  • Blood (Concept ID: 3056) or keyword 'PA catheter'
  • Bladder (Concept ID: 3058)
  • Rectal (Concept ID: 3061)
  • Zero flux thermometer (non-core) - via keyword search of temperature routes
  • Other non-core routes (axillary, oral, skin, temporal, tympanic, unspecified)
• If the last temp within 5 minutes before cardiopulmonary bypass start is >37.5, exclude the first 30 minutes after cardiopulmonary bypass start.
• For minutes without a temperature recorded, the most recent temperature value counts for a maximum of 5 minutes if there isn’t another temperature documented within that time frame. 
  • Examples: If a temperature is recorded at 1200 of 37.6 and no other temperature is recorded until 1210, we would count that single value (37.6 at 1200) as 5 minutes but it wouldn’t ‘flag’ the measure since the measure is looking for >5 consecutive minutes. If there was a temperature of 37.6 at 1159 and another temp of 37.6 at 1200 and no other temperatures until 1210, this would be a flagged case. If there is a temperature at 1200 and not another temperature until 1202, the temperature at 1200 only counts for 2 minutes (1200 and 1201).

Algorithm for determining Measure Attribution Duration:

Attribution Start Time:

1. Cardiopulmonary bypass start (Concept ID: 50410) - will take the first time if documented more than once on the case. 
2. Cardiopulmonary Bypass Start Phenotype.

Attribution End Time:

1. Cardiopulmonary bypass terminated (Concept ID: 50409) - will take the latest time if documented more than once in the case.
2. Cardiopulmonary Bypass End. If not available, then
3. Anesthesia End. If not available, then
4. Procedure End. If not available, then
5. Patient Out of Room.

Not applicable.

Any provider signed in for ≥40 minutes from bypass start until bypass end (or the provider signed in for the greatest number of minutes during this period, if this period is <40 minutes) per staff role. If bypass was not used, the case will be excluded. See ‘Other Measure Build Details’ section of this specification to view the algorithm used for determining measure attribution window duration. 

In the event that two or more providers in the same class are signed in for the same duration, all providers signed in for the longest duration will be attributed.

1. Del Rio JM, Abernathy JJ 3rd, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV 3rd, Mackensen GB, Vener DF, Kertai MD: The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Anesth Analg 2020 doi:10.1213/ANE.0000000000005093
2. Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM: Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg 2019 doi:10.1001/jamasurg.2019.1153
3. Gregory AJ, Grant MC, Manning MW, Cheung AT, Ender J, Sander M, Zarbock A, Stoppe C, Meineri M, Grocott HP, Ghadimi K, Gutsche JT, Patel PA, Denault A, Shaw A, Fletcher N, Levy JH: Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Recommendations: An Important First Step-But There Is Much Work to Be Done. J Cardiothorac Vasc Anesth 2020; 34:39–47
4. Engelman R, Baker RA, Likosky DS, Grigore A, Dickinson TA, Shore-Lesserson L, Hammon JW: The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass--Temperature Management During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2015; 29:1104–13
5. Anesthesia Quality Institute cardiac hyperthermia avoidance measure, AQI65 https://www.aqihq.org/files/MIPS/2020/2020%20QCDR%20Measure%20Book.pdf
6. Hannan EL, Samadashvili Z, Wechsler A, Jordan D, Lahey SJ, Culliford AT, Gold JP, Higgins RSD, Smith CR: The relationship between perioperative temperature and adverse outcomes after off-pump coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2010; 139:1568–75.e1
7. Newland RF, Tully PJ, Baker RA: Hyperthermic perfusion during cardiopulmonary bypass and postoperative temperature are independent predictors of acute kidney injury following cardiac surgery. Perfusion 2013; 28:223–31
8. Groom RC, Rassias AJ, Cormack JE, DeFoe GR, DioDato C, Krumholz CK, Forest RJ, Pieroni JW, O’Connor B, Warren CS, Olmstead EM, Ross CS, O’Connor GT, Northern New England Cardiovascular Disease Study Group: Highest core temperature during cardiopulmonary bypass and rate of mediastinitis. Perfusion 2004; 19:119–25