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A report by the American Society of Anesthesiologists Committee on Performance and Outcomes Measurement in collaboration with the Anesthesia Quality Institute.
Reducing 30-day postoperative mortality is a critical objective in enhancing patient safety and improving the quality of perioperative care. Anesthesiologists are uniquely positioned to influence surgical outcomes across a wide range of patient populations and clinical settings. This document presents a comprehensive framework of evidence-based quality outcome indicators that anesthesiologists can directly or indirectly impact hospital and facility quality and safety goals. Hospitals, facilities, and other stakeholders should share appropriate patient and outcome data with anesthesiologists and their groups to ensure transparency in quality, patient safety, and other performance metrics. The indicators are sorted based upon surgical procedure types and patient populations, including cardiac, non-cardiac, pediatric, and obstetric care. This framework aims to guide anesthesiologists, hospitals, surgical departments, and accrediting bodies in selecting and implementing relevant indicators tailored to their specific patient demographics, procedural profiles, and resource capacities.
The indicators are categorized into key clinical domains — neurologic, cardiovascular, pulmonary, renal, hematologic, infectious, obstetric, and pediatric — and are mapped to specific postoperative intervals (24 hours, 3 days, 7 days, and 30 days) to facilitate timely monitoring and intervention. Local initiatives and clinical decision-making based upon individual patient needs may require or encourage data reporting at different intervals than those suggested in this document. These metrics encompass critical complications such as stroke, myocardial ischemia, respiratory failure, acute kidney injury, sepsis, and maternal hemorrhage. Some of the indicators are currently available in the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR). Specifically, within the cohort of general clinical indicators developed by the Committee on Performance and Outcome Measures (CPOM), 16 indicators have corresponding counterparts in AQI NACOR, while six do not. For the obstetric indicators, two have counterparts in AQI NACOR, and five do not. In contrast, all four pediatric indicators have corresponding indicators available in AQI NACOR. AQI NACOR indicators are made available to AQI NACOR practices and hospitals. Some AQI NACOR clients select a set of approximately 20 to 30 AQI indicators of interest and flag those that are applicable to a given case. When data are submitted to AQI, an indicator is recorded as “true” (indicating the event occurred). The Data Use Committee sets the definitions and time frames for AQI NACOR indicators.
This framework promotes the gathering and use of clinical and outcome data to assist anesthesiologists and their groups to adopt clinical best practices, enhance perioperative care delivery, and strive to reduce 30-day postoperative morbidity and mortality. While these recommendations are grounded in current evidence and expert consensus, the indicators are subject to ongoing revision in response to advancements in clinical practice and technology.
Neurologic: These indicators help in early detection and management of complications, guide clinical decisions, ensure patient safety, and enhance recovery and survival rates, ultimately contributing to higher health care quality and reduced costs.
Cardiovascular: These indicators help assess how well anesthesia care supports cardiovascular stability and mitigates cardiac risks during and after surgery.
Pulmonary: Pulmonary indicators involve complications affecting the lungs and respiratory system, including postoperative respiratory failure, hypoxia, pneumonia, and prolonged ventilation. Effective anesthetic management and postoperative respiratory care are critical to reducing pulmonary-related mortality.
Renal: Relevant to renal function and kidney outcomes for patients and those patients with chronic kidney disease or risk factors for kidney injury.
Hematologic: Clinical parameters related to the blood and coagulation system that reflect a patient’s risk for or presence of bleeding, clotting, or hematologic abnormalities during the perioperative period and specifically immediate postoperative recovery.
Infection: Postoperative infections can lead to delayed wound healing, prolonged hospitalizations, increased health care costs, and potentially life-threatening complications in patients, including sepsis, organ damage, and death. The application of evidence-based practices to the perioperative care of these patients can reduce the risk of postoperative infections.
Obstetrics: These metrics apply to pregnant patients receiving anesthetic care for their delivery, or peripartum patients requiring resuscitation.
Pediatrics: These metrics with their applicable inclusion and exclusion criteria apply to children (unless otherwise noted) less than 18 years of age undergoing an anesthetic event.
The table below includes suggested timing for a group to collect information on the indicator or patient outcome. Anesthesiologists and their groups should determine which indicators are most appropriate for their patient population and facility goals. Anesthesiologists and their groups should strive to work with their hospital and facility executives to ensure access to relevant patient data and outcomes.
Table 1
| Neurologic Indicators | ||||
| 24 hours | 3 days | 7 Days | 30 Days | |
| Acute delirium | x | |||
| Stroke | x | x | x | x |
| Failure to continue methadone and buprenorphine perioperatively | x | x | x | |
| Cardiovascular Indicators | ||||
| Myocardial ischemia | x | x | x | x |
| Cardiac arrest | x | x | x | x |
| Pulmonary embolism | x | x | x | x |
| Deep vein thrombosis | x | x | x | x |
| Low blood pressure (case dependent, below a certain number for a certain period) | x | x | x | x |
| Pulmonary Indicators | ||||
| Failure to cease smoking | x | x | x | |
| Unplanned intubation/reintubation | x | x | x | x |
| Failure to assess risk of ventilator dependence >48 hours | x | x | x | |
| Renal Indicators | ||||
| Acute kidney injury | x | x | x | x |
| Acute renal failure | x | x | x | |
| Acute kidney disease | x | x | x | |
| Hyperglycemia | x | x | ||
| Hematologic Indicators | ||||
| Failure to effectively monitor patient blood transfusions and ensure acceptable hemoglobin levels | x | x | x | x |
| Infection Indicators | ||||
| Surgical site infections (SSI) | x | x | x | |
| Central line associated blood stream infections (CLABSI) | x | x | x | |
| Catheter associated urinary tract infections (CAUTI) | x | x | x | |
| Pneumonia (non-mechanically ventilated patients) | x | x | x | |
| Ventilator associated pneumonia (VAP) | x | x | x | |
| Sepsis/severe sepsis/septic shock | x | x | x | |
| Obstetric Indicators | ||||
| Postdural puncture headache | x | x | x | x |
| Blood pressure monitoring after neuraxial anesthesia until fetal delivery | x | |||
| Use of vasopressor(s) to maintain maternal systolic blood pressure until delivery | x | |||
| Failure to rescue during postpartum hemorrhage and/or coagulopathy | x | x | ||
| General anesthesia rate < 5% | x | |||
| Pediatric Indicators | ||||
| Cardiac arrest | x | x | x | x |
| Unplanned admission after ambulatory surgery | x | x | x | x |
| Unplanned intubation/reintubation | x | x | x | x |
| Death | x | x | x | x |
CPOM welcomes feedback on this document and will be reviewing the list yearly after publication. Should you have questions or proposed revisions, please send them to qra@asahq.org.
This document has been developed by the ASA Committee on Performance and Outcomes Measurement (CPOM) in collaboration with the Anesthesia Quality Institute (AQI) and AQI NACOR. The recommendations are designed to promote the delivery of high-quality patient care but do not guarantee specific outcomes. Recommendations are subject to revision as dictated by the evolution of technology and clinical practice.
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Neurologic:
Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Annals of Internal Medicine. 2006;144(2):127-134. doi: 10.7326/0003-4819-144-2-200601170-00010
ASA recommendations target postoperative delirium in older patients - OR Manager. OR Manager. Published December 12, 2024. https://www.ormanager.com/briefs/asa-recommendations-target-postoperative-delirium-in-older-patients/
Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. Journal of Addiction Medicine. 2015;9(5):358-367. doi: 10.1097/adm.0000000000000166
Kornfeld H, Manfredi L. Effectiveness of Full Agonist Opioids in Patients Stabilized on Buprenorphine Undergoing Major Surgery: A Case Series. American Journal of Therapeutics. 2010;17(5):523-528. doi: 10.1097/mjt.0b013e3181be0804
Nice Clinical Guidelines. Delirium: Prevention, Diagnosis and Management. National Institute for Health and Care Excellence (UK); 2023. https://www.ncbi.nlm.nih.gov/books/NBK553009/
Practice Advisory for Intraoperative Awareness and Brain Function Monitoring. Anesthesiology. 2006;104(4):847-864. doi: 10.1097/00000542-200604000-00031
Rudolph JL, Marcantonio ER. Postoperative Delirium. Anesthesia & Analgesia. 2011;112(5):1202-1211. doi: 10.1213/ane.0b013e3182147f6d
Stanford Health Care. (2022). Perioperative management of buprenorphine. Retrieved from https://stanfordhealthcare.org/medical-clinics/anesthesia/pain-management/buprenorphine.html
Cardiovascular:
Anderson FA. Risk Factors for Venous Thromboembolism. Circulation. 2003;107(90231):9I--16. doi: 10.1161/01.cir.0000078469.07362.e6
Bijker JB, van Klei WA, Kappen TH, van Wolfswinkel L, Moons KG, Kalkman CJ. Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology. 2007;107(2):213-220. doi: 10.1097/01.anes.0000270724.40897.8e
Botto F, Alonso-Coello P, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014 Mar;120(3):564-78. doi: 10.1097/ALN.0000000000000113. PMID: 24534856.
Callaway CW, Donnino MW, Fink EL, et al. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S465-82. doi: 10.1161/CIR.0000000000000262.
Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005 Feb-Mar;51(2-3):70-8. doi: 10.1016/j.disamonth.2005.02.003.
Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):381S-453S. doi: 10.1378/chest.08-0656.
London, M. J., Hur, K., Schwartz, G. G., Henderson, W. G., & Veterans Affairs National Surgical Quality Improvement Program. (2010). Association of perioperative myocardial infarction with long-term survival after major noncardiac surgery. Annals of Surgery, 252(1), 178-183.
Nolan JP, Neumar RW, Adrie C, et al. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation. 2008;79(3):350-379. doi:10.1016/j.resuscitation.2008.09.017
Sandroni, C., Cariou, A., Cavallaro, F., & Cronberg, T. (2021). Prognostication in comatose survivors of cardiac arrest: an update. Intensive Care Medicine, 47(1), 1-15.
Sessler DI, Meyhoff CS, Zimmerman NM, et al. Period-dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death: A Substudy of the POISE-2 Trial. Anesthesiology. 2018;128(2):317-327. doi: 10.1097/ALN.0000000000001985
Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators; Devereaux PJ, Chan MT, Alonso-et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012 Jun 6;307(21):2295-304. doi: 10.1001/jama.2012.5502.
Wesselink EM, Kappen TH, Torn HM, Slooter AJC, van Klei WA. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth. 2018;121(4):706-721. doi: 10.1016/j.bja.2018.04.036.
Pulmonary:
Awada WN, et al. (2020). Noninvasive hemoglobin monitoring reduces unnecessary transfusions during surgery. J Clin Monit Comput.
Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA. 2016;316(19):2025-2035. doi: 10.1001/jama.2016.9185
Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):381S-453S. doi: 10.1378/chest.08-0656
Goodnough LT, Shander A, Spivak JL, et al. Detection, evaluation, and management of anemia in the elective surgical patient. Anesth Analg. 2005;101(6):1858-1861. doi: 10.1213/01.ANE.0000184124.29397.EB
Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409-417. doi: 10.1056/NEJM199902113400601
Katz, D., Beilin, Y., & Cohen, J. (2020). Pulmonary embolism in the perioperative period: Diagnosis and management. Anesthesiology Clinics, 38(1), 109–123.
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315-352. doi: 10.1016/j.chest.2015.11.026
Kheterpal, S., Martin, L., Shanks, A., Tremper, K. K., & O'Reilly, M. (2009). Predictors and outcomes of intraoperative reintubation in general surgery. Anesthesiology, 110(3), 545–553. https://doi.org/10.1097/ALN.0b013e31819793b3
Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011;124(2):144-154.e8. doi: 10.1016/j.amjmed.2010.09.013
Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017;118(3):317-334. doi: 10.1093/bja/aex002
Ramachandran, S. K., Nafiu, O. O., & Ghaferi, A. A. (2011). Independent predictors and outcomes of unplanned reintubation after general and vascular surgery. Anesthesia & Analgesia, 112(1), 13–20. https://doi.org/10.1213/ANE.0b013e3181fe424a
Warner DO. Perioperative abstinence from cigarettes: physiologic and clinical consequences. Anesthesiology. 2006;104(2):356-367. doi: 10.1097/00000542-200602000-00023
Wong J, Abrishami A, et al. The effects of smoking cessation on anesthetic and surgical outcomes. Anesth Analg. 2012;115(2):402-418.
Renal:
American Diabetes Association. Standards of Care in Diabetes—2023. American Diabetes Association. Published 2023. https://diabetesjournals.org/care/issue/46/Supplement_1
Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care. 2010;33(8):1783-1788. doi: 10.2337/dc10-0304
KDIGO. KDIGO Clinical Practice Guideline for Acute Kidney Injury.; 2012. https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf
Kellum JA, Lameire N; KDIGO AKI Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care. 2013;17(1):204. Published 2013 Feb 4. doi: 10.1186/cc11454
Khor CS, Wang WJ. The role of acute kidney injury duration in clinical practice. Ann Transl Med. 2019;7(Suppl 3):S88. doi: 10.21037/atm.2019.04.32
Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31. doi: 10.1186/cc5713
Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978-982. doi: 10.1210/jcem.87.3.8341
Xing J, Loh SKN. Perioperative acute kidney injury: Current knowledge and the role of anaesthesiologists. Proceedings of Singapore Healthcare. 2023;32. doi: 10.1177/20101058231163406
Zeng B, Liu Y, Xu J, et al. Future Directions in Optimizing Anesthesia to Reduce Perioperative Acute Kidney Injury. Am J Nephrol. 2023;54(9-10):434-450. doi: 10.1159/000533534
Hematologic:
Carson JL, Stanworth SJ, Guyatt G, et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA. 2023;330(19):1892-1902. doi:10.1001/jama.2023.12914
Joint Commission. Specifications Manual for Joint Commission National Quality Measures (v2024A1): Blood Management (BM). Performance Measurement Network. Published 2024. https://manual.jointcommission.org/
Practice Guidelines for Perioperative Blood Management: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*. Anesthesiology 122(2):p 241-275, February 2015. doi: 10.1097/ALN.0000000000000463
Tibi P, McClure RS, Huang J, et al. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. Ann Thorac Surg. 2021;112(3):981-1004. doi: 10.1016/j.athoracsur.2021.03.033
World Health Organisation. WHO Guidelines for safe surgery: safe surgery saves lives. www.who.int. Published April 3, 2009. https://www.who.int/publications/i/item/9789241598552
Infection:
Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017;118(3):317-334. doi: 10.1093/bja/aex002.
Neto AS, Simonis FD, Barbas CS, et al. Lung-Protective Ventilation With Low Tidal Volumes and the Occurrence of Pulmonary Complications in Patients Without Acute Respiratory Distress Syndrome: A Systematic Review and Individual Patient Data Analysis. Crit Care Med. 2015;43(10):2155-2163. doi: 10.1097/CCM.0000000000001189
Warner MA, Warner ME, Warner DO, Warner LO, Warner EJ. Perioperative pulmonary aspiration in infants and children. Anesthesiology. 1999;90(1):66-71. doi: 10.1097/00000542-199901000-00011
Obstetrics:
American Society of Anesthesiologists & Society for Obstetric Anesthesia and Perinatology. Guidelines for Neuraxial Analgesia or Anesthesia in Obstetrics; 2021. https://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/guidelines-for-neuraxial-anesthesia-in-obstetrics.pdf
Bauer ME, Arendt K, Beilin Y, et al. The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients with Thrombocytopenia. Anesth Analg. 2021;132(6):1531-1544. doi: 10.1213/ANE.0000000000005355
Escobar MF, Nassar AH, Theron G, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet. 2022;157 Suppl 1(Suppl 1):3-50. doi: 10.1002/ijgo.14116
Muñoz M, Stensballe J, Ducloy-Bouthors AS, et al. Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfus. 2019;17(2):112-136. doi: 10.2450/2019.0245-18
Pediatrics:
Bhananker SM, Ramamoorthy C, Geiduschek JM, et al. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg. 2007;105(2):344-350. doi: 10.1213/01.ane.0000268712.00756.dd
Cheon EC, Palac HL, Paik KH, et al. Unplanned, Postoperative Intubation in Pediatric Surgical Patients: Development and Validation of a Multivariable Prediction Model. Anesthesiology. 2016;125(5):914-928. doi: 10.1097/ALN.0000000000001343
Foz C, Staffa SJ, Brown ML, DiNardo JA, Nasr VG. Predictors and outcomes of perioperative cardiac arrest in children undergoing noncardiac surgery. BJA Open. 2023;8:100244. Published 2023 Dec 3. doi: 10.1016/j.bjao.2023.100244
Gonzalez LP, Pignaton W, Kusano PS, Módolo NS, Braz JR, Braz LG. Anesthesia-related mortality in pediatric patients: a systematic review. Clinics (Sao Paulo). 2012;67(4):381-387. doi: 10.6061/clinics/2012(04)12
Molla MT, Anley NS, Zewdie BW, Endeshaw AS, Kumie FT. 28-day perioperative pediatric mortality and its predictors in a tertiary teaching hospital in Ethiopia: a prospective cohort study. Eur J Med Res. 2024;29(1):24. Published 2024 Jan 5. doi: 10.1186/s40001-023-01613-6
Morray JP, Geiduschek JM, Ramamoorthy C, et al. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology. 2000;93(1):6-14. doi: 10.1097/00000542-200007000-00007
Wake Up Safe Investigators. (2016). Wake Up Safe: Quality improvement and patient safety registry for pediatric anesthesia. Anesth Analg, 123(2), 443–449. https://doi.org/10.1213/ANE.0000000000001401
Whippey A, Kostandoff G, Ma HK, Cheng J, Thabane L, Paul J. Predictors of unanticipated admission following ambulatory surgery in the pediatric population: a retrospective case-control study. Paediatr Anaesth. 2016;26(8):831-837. doi: 10.1111/pan.12937
These indicators were developed by the Committee on Performance and Outcomes Measurement. Please note that the definitions provided may differ from those used by AQI NACOR.
Curated by: Committee on Performance and Outcomes Measurement
Date of last update: February 11, 2026
You do not have to make a payment at this time, but you can reach out to your practice/group leader to find out when they plan to pay your dues. Email or call the ASA Support team for assistance: (630) 912-2552 or info@asahq.org.
