Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to airs@asahq.org. Report incidents or download the AIRS mobile app at www.aqiairs.org.
Case 2017-6: A Hot issue – What Does MACRA Have to Do With AIRS?
A 36-year-old female had a cricothyrotomy placed in the field and was adequately oxygenated and ventilated through this emergency airway. On arrival to the emergency department, a decision was made to proceed emergently to the operating room to convert this airway to a formal tracheostomy. After prepping the patient with alcohol-based chlorhexidine solution, the patient was draped. Shortly thereafter, some contamination was noted in the surgical area and she was re-prepped with alcohol-based chlorhexidine solution. The prep was reportedly dry but when electrocautery was used shortly thereafter, the surgical drapes caught fire. The drapes were removed, all ventilatory gases were stopped and saline was irrigated into the cricothyrotomy tube to extinguish any airway fire that might be present. Upon examination, the cricothyroid tube never caught fire due to the quick actions of the care team.
Case Discussion
This case represents the successful treatment of a fire in the O.R. Fortunately, the fire did not ignite the tracheal tube and there was no reported harm to the patient. The February 2016 AIRS case report www.aqihq.org/files/airscases/AIRS_Report_February2016.pdf presents a similar surgical fire and has a comprehensive review of how to prevent and react to these events.
Unfortunately, the case presented this month is indicative of a trend in the AIRS database surrounding fires, burns and other ignitions during the course of anesthesia care. In fact, there are multiple cases in the database where it appears the use of alcohol-based prep, and specifically not allowing it to completely dry, may have been the precipitating cause.
This case, and the others reported in the database, serve as an example of why AIRS exists. Our goal is to provide the anesthesia community with a place where adverse events can be reported, analyzed and trended. The AQI AIRS Committee uses multiple avenues, such as these case reports, to report back to the anesthesiology community what adverse events we are observing in practice and how to reduce and prevent patient harm. In this specific case, the committee is monitoring fires related to surgical prep agents, and if the trend continues, we will continue to draw attention to this important patient safety issue.
Fortunately, the federal government and the Centers for Medicare & Medicaid Services (CMS) also see the value in participating in patient safety activities. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the Medicare Sustainable Growth Rate formula and replaced it with the Quality Payment Program. This program provides for two avenues to financially reward high-quality care. The first is the Merit-based Incentive Payment System (MIPS), and the second is the Advanced Alternative Payment Model (APM). MIPS consolidates the prior activities of the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM) and the Electronic Health Record (EHR) incentive programs. Part of receiving full credit for MIPS requires eligible clinicians to engage in improvement activities designed to improve care coordination, beneficiary engagement and patient safety.
CMS has finalized a list of 92 improvement activities for the 2017 reporting year. Each individual improvement activity is assigned a weight of either medium or high. Medium activities receive 10 points and high activities receive 20 points. To receive full credit for improvement activities, eligible clinicians must receive a score of 40 points or more. However, there are two exceptions to this point structure: First, eligible clinicians participating in MIPS APMs will receive the equivalent of the base score of 40 points for this component. Second, small practices, rural practices, or practices located in geographic health professional shortage areas (HPSAs), and non-patient facing MIPS-eligible clinicians who choose to report, will have their medium-weighted activities count for 20 points and their high-weighted activities count for 40 points. They are still required to reach a minimum of 40 points to receive full credit for this component.
Participation in an Agency for Healthcare Research and Quality (AHRQ)-listed Patient Safety Organization (PSO), such as AQI’s AIRS, is one of the “medium-weighted” quality improvement activities listed by the U.S. Department of Health and Human Services (Activity ID: IA_PSPA_1). The AQI AIRS PSO program allows for cases reported to be held as privileged and confidential. By reporting cases to AIRS, you are participating in a PSO and fulfilling part of the improvement activities component of MIPS. Anesthesiologists can report incidents via the AIRS website, the AIRS mobile application or the AQI Quality Capture app, which can be integrated into your electronic anesthesia record.
“CMS has finalized a list of 92 improvement activities for the 2017 reporting year. Each individual improvement activity is assigned a weight of either medium or high. Medium activities receive 10 points and high activities receive 20 points. To receive full credit for improvement activities, eligible clinicians must receive a score of 40 points or more.”
The committee has been looking for other ways to allow members to participate in the AQI PSO and is excited to announce it will be hosting “Safe Tables” at ANESTHESIOLOGY® 2017 in Boston. This is a forum endorsed by AHRQ to allow members to network and exchange patient safety experiences in a secure, legally protected environment. After a series of short presentations by experts in the field of anesthesia patient safety, participants will review actual AIRS cases and discuss oppor-tunities for improvements in systems of care. Each table will be moderated by a member of the AIRS committee.
Over the coming months, we will be reviewing and reporting trends with the purpose of highlighting ways to reduce harm and improve the safety of the patients under our care. In the meantime, please ensure that alcohol-based surgical prep agents are completely dry before draping and allowing surgical cases to proceed. In addition to improving the care that our patients receive, reporting cases to AIRS is a valuable way to meet MIPS requirements.
The committee thanks Randall M. Clark, M.D., Chair of the ASA Section on Professional Standards, for his contributions to this report.
Previous AIRS case reports may be found at: https://www.aqihq.org/casereportsandcommittee.aspx
Additional information on MACRA and MIPS can be found at:
■ American Society of Anesthesiologists. MACRA resources. April 2017. Available at: http://www.asahq.org/quality-and-practice-management/macra
■ Centers for Medicare & Medicaid Services. Quality Payment Program Final Rule 42 CFR Parts 414 and 495. October 2016. Available at: https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf
