Measure Abbreviation: TOC 02 (MIPS 426)*

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Measure Abbreviation: TOC 02 (MIPS 426)* *TOC 02 is built to the specification outlined by the Merit Based Incentive Program (MIPS) 426: Post- Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) measure. MIPS measure specifications are available for download at https://qpp.cms.gov/resources/education Description: Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized. NQS Domain: Communication and Care Coordination Measure Type: Process Scope: Measured on a per case basis Measure Summary: This measure is a two-part measure: 1) Documentation of PACU or ICU handoff complete in the electronic anesthesia record as a yes/no question. The percentage of handoffs will be calculated as number of handoffs documented as yes in the electronic anesthesia record where the denominator equals the number of transfer to PACU events. 2) Development of a standardized audit process to determine quality of handoff. Each site will be expected to submit a minimum of 10 audit results per month to ASPIRE using a paper-based tool (see table below) and then submitted using a web-based password protected spreadsheet. Background NA Introduction (Provider names and roles: PACU RN and anesthesia team members) Identification of patient* Pertinent PMH/PSH Discussion of surgical/procedure course Allergies Contact Precautions Anesthetic Management Airway management (ETT/ LMA) Type of anesthetic Anesthetic Complications Medications Preoperative Meds Sedations medications & amount administered. Reversal administered? Muscle relaxants: Time/Amount administered. Reversal administered? Pain Management Plan PONV Risk & Meds Administered

(TOC 02- MIPS 426) Measure Specification Page 2 of 7 Fluids Vascular access Total Intraoperative Fluids/Blood Products Administered Intraoperative labs Expectations/Plans Identify primary anesthesia concerns for this patient. Allow opportunity for questions/acknowledgement of understanding of report from receiving PACU team *Identification of patient- In the instance the identity of the patient is unable to be confirmed, identification provided by the clinical facility would suffice toward meeting performance of the measure. Rationale (Directly quoted from MIPS 426): Hand-offs are a vulnerable moment for patient safety, but required in any 24/7 healthcare system. Anesthesia providers routinely transfer patients from the operating room (OR) to the PACU, and are responsible for transmitting knowledge about patient history, a summary of intraoperative events, and future plans for hemodynamic and pain management to the new care team. Evidence demonstrates that this process can be facilitated by use of a standardized checklist to ensure completion of all key components of the transfer, and is seen as an emerging best practice in anesthesia care. 1-3 The Agency for Healthcare Research and Quality found that current sign-out mechanisms are generally ad-hoc, varying from hospital to hospital and unit to unit. According to data published by the Joint Commission, communication errors were indicated in 59% of reported sentinel events in 2012 and in 54% of operative/post-operative complications between 2004 and 2012. 4 A 2006 survey among residents at Massachusetts General Hospital found that 59% of respondents reported one or more patients experiencing harm as a result of ineffective patient handoff practices during their most recent clinical rotation. Inclusions: All patients, regardless of age, who are cared for by an anesthesia practitioner AND directly transferred from the anesthetizing location to PACU or other non-icu location after the procedure where a transfer of care occurs. Procedures (by CPT) included: 00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00566, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650,

(TOC 02- MIPS 426) Measure Specification Page 3 of 7 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01958, 01960, 01961, 01962, 01963, 01965, 01966 Exclusions: Patients not transferred directly to a PACU or other non-icu location (i.e. ICU transfers) Cardiac surgery (CPT: 00561, 00562, 00563, 00567, 00580, 01920) Obstetric Operative Procedures (CPT: 01968, 01969) Acute Pain Management (CPT: 01996) Radical clavicle or scapula surgery (CPT: 00452) Thoracolumbar sympathectomy (CPT: 00622) Lumbar chemonucleolysis (CPT: 00634) Diagnostic arteriography/venography (CPT: 01916) Burn debridement/grafting for 9% TBSA (CPT: 01953) Organ harvest (CPT: 01990) Anesthesia for diagnostic or therapeutic nerve blocks/injections (CPT: 01991, 01992) Other anesthesia procedure (CPT: 01999) Labor Epidurals (CPT: 01967) Obstetric n-operative Procedure Rooms (Rooms tagged as OB-GYN Labor and Delivery) Obstetric n-operative Procedures with procedure text: Labor Epidural MPOG Concept IDs Required: MPOG Concept IDs 50008 AACD Patient Out of Room Date/Time 50010 AACD Recovery Room In Date/Time 50623 Compliance- PACU/ICU Handoff of care performed, report given. 50706 Categorized te- Postoperative Recovery 50734 Emergence- Patient Recovery Location Data Diagnostics Affected: Cases with Staff Tracking Staff Role Mapping Staff Sign-Ins are Timed Pro Fee Procedures Collations Used: Anesthesia End Postop Destination Procedure Type Labor Epidural

(TOC 02- MIPS 426) Measure Specification Page 4 of 7 Failed Case Grid Elements: Link to Case Procedure Operating Room Anesthesia End In PACU Time Case Viewer Template: Other Measure Build Details: This measure requires CPT codes to be transferred to the MPOG database for cases to be included. Those sites participating with this measure must have current pro fee procedure data in the MPOG Central database- refer to the flow diagram on page 6 of this specification for more details. Success: A transfer of care protocol or handoff tool/checklist that includes the key handoff elements is used. Threshold: 90%. Responsible Provider: Anesthesia provider in the room providing care at Anesthesia End.

(TOC 02- MIPS 426) Measure Specification Page 5 of 7 Method for determining Responsible Provider: 1. CRNA attributed if both a CRNA and anesthesiologist are signed in. If CRNA not signed in, Attending anesthesiologist will be attributed. 2. Resident if both a resident and attending anesthesiologist are signed in. If Resident not signed in, Attending anesthesiologist will be attributed. Risk Adjustment (for outcome measures): t applicable.

(TOC 02- MIPS 426) Measure Specification Page 6 of 7 TOC 02 Flow Diagram Start: All Patients Intraop Mortality documented? Exclude Transferred to ICU? Exclude Appropriate Case by CPT Inclusion List?* Exclude TOC Handoff Tool with Key Elem ents* Documented? Fail Pass *Refer to Page 2 of this measure specification for the complete list of included procedures by CPT code.

(TOC 02- MIPS 426) Measure Specification Page 7 of 7 References: 1. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14(6):401-407. 2. Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesthesia and analgesia. 2012;115(1):102-115. 3. Weinger MB, Slagle JM, Kuntz AH, et al. A Multimodal Intervention Improves Postanesthesia Care Unit Handovers. Anesthesia and analgesia. 2015;121(4):957-971. 4. Petrovic MA, Martinez EA, Aboumatar H. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Jt Comm J Qual Patient Saf. 2012;38(3):135-142.

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