MEASURE DESCRIPTION:
The percentage of patients who have pre-existing labor epidural or combined epidural/spinal technique who require either repeat procedural epidural or spinal, general anesthesia, or supplemental sedation as defined below for cesarean section.
NQS DOMAIN:
Efficiency and Cost Reduction
MEASURE TYPE:
Outcome
HIGH PRIORITY STATUS:
Yes
HIGH PRIORITY TYPE:
Outcome
INVERSE MEASURE:
Yes
RISK ADJUSTED:
No
INSTRUCTIONS:
This measure is to be reported each time a patient with an existing labor epidural or combined epidural/spinal requires delivery by cesarean section.
Measure Reporting via the Qualified Clinical Data Registry
Patient demographics and CPT codes are used to identify patients who are included in the measure denominator. G-codes and Registry Codes are used to capture the numerator.
DENOMINATOR:
All parturients with an existing labor epidural who require delivery by cesarean section.
-
Denominator Criteria (Eligible Cases):
Parturient
AND
Labor epidural in place (CPT code 01967)
AND
Requires delivery by cesarean section (CPT code +01968)
-
Denominator Exclusions:
Urgent/Emergent C/S for fetal well-being (Measure Response Code 1091)
NUMERATOR:
Patients who have pre-existing labor epidural or epidural/spinal technique who require either general anesthesia, repeat procedural epidural and/or spinal technique, or supplemental sedation for cesarean section. For the purposes of this measure, “supplemental sedation” is defined as any dose of propofol, etomidate, or nitrous oxide.
-
Numerator Options:
Performance Met: Patient who has pre-existing labor epidural or epidural/spinal technique who requires either general anesthetic, repeat procedural epidural and/or spinal technique, or supplemental sedation for cesarean section. (MEDNAX 54A)
OR
Performance Not Met: Patients who has pre-existing labor epidural or epidural/spinal technique who did not require either general anesthesia, repeat procedural epidural and/or spinal technique, or supplemental sedation. (MEDNAX 54B)
RELEVANT FIELDS:
- ASA CPT Code
-
Labor epidural converted to C/S
- Failed labor epidural
RATIONALE:
The Royal College of Anaesthetists states that an acceptable rate of general anesthesia in a parturient receiving labor epidural analgesia should be no more than 3%. In a 2012 systematic review, Bauer et al. found that the percentage of all cesarean deliveries performed with general anesthesia with a pre-existing labor epidural was 5% (95% CI 3.5 to 6.5%). The requirement for a second anesthetic, including repeat epidural, spinal or general anesthetic was 7.7% (95% CI 5.0 to 10.5%) and overall, 10.7% (95% CI 4.2 to 17.3) of patients were given supplementation (intravenous, inhalational or not specified) for cesarean sections.
To assess current conversion of labor epidural to either spinal or general anesthesia for cesarean section, MEDNAX conducted a random audit of 100 cesarean following labor epidural cases among all MEDNAX obstetrical anesthesia group practices participating in the MEDNAX QCDR. These cases were performed during the first 6 months of 2018. In 17% of these cases, anesthesiologists converted the labor epidural to either spinal or general anesthesia in performing the cesarean section.
Based on published literature, one notable risk factor for conversion failure was being a non-obstetrical (general) anesthesiologist. They posited that obstetrical anesthesiologists may be more aware of the quality of labor analgesia and more likely to replace dysfunctional catheters or perform manipulations of the existing catheter or performing another neuraxial technique to avoid general anesthesia. Campbell reported an 84.6% success rate of converting labor epidurals by withdrawing the catheter 1cm before further drug administration. Riley reported that obstetrical anesthesiologists had more success than general anesthesiologists in conversion. This metric could identify performance gaps and the need for dedicated obstetrical anesthesia staff rather than cross coverage by general anesthesiologists.
REPORTING CODES: