Foundation Program Sites

COAP Quality Indicators

Cardiovascular Surgery COAP Quality Indicators








Operative Mortality CABG All in-hospital deaths, even if after 30 days post surgery, and all deaths occurring after discharge but before the end of the 30th postoperative day
Post-Operative Stroke Postoperative stroke, defined as any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain, that did not resolve within 24 hours
New Onset Renal Failure

Acute renal failure or worsening renal function resulting in ONE or BOTH of the following:

1) Increase in serum creatinine level 3.0 x greater than baseline, or serum creatinine level ≥ 4 mg/dL. Acute rise must be at least 0.5 mg/dL.

2) New requirement for dialysis

LIMA Use Left IMA used




Deep Sternal Wound Infection Within 30 days postoperatively, patient had a deep sternal infection involving muscle, bone, and/or mediastinum requiring operative intervention
Any Unplanned Return to OR Return to OR for bleeding/tamponade, graft occlusion, valvular dysfunction, or other cardiac

Early Extubation

Initial vent hours <6
RBC Transfusion Any intra- or post-op RBC units
30 Day Readmission Readmission to an acute care facility as an in-patient within 30 days from the date of initial surgery for ANY reason




Long Length of Stay LOS surgery – discharge >14 days

Prolonged Ventilation

Postop vent hours >24; vent time includes OR exit until extubation plus any additional hours following reintubation
Short Length of Stay LOS surgery – discharge <6 days
Multi-Arterial Grafting Rate of surgeries with >1 arterial grafts
Mitral Valve Repair Isolated

Rate of mitral valve repairs vs replacements



Cardiac Rehab Referral Discussion conducted/advice given regarding the importance of joining a cardiac rehabilitation program, or an appointment made
Smoking Cessation Counseling Prior to discharge, patient received smoking cessation counseling.  NA for patients who are non-smokers > 1 year

PCI COAP Quality Indicators






Mortality  STEMI  Any death during hospitalization 
Door to Balloon Time  STEMI  > 90% of patients meeting door to balloon time < 90 minutes 








Appropriate Use  Non-Acute 

% of Non-Acute PCI classified as Rarely Appropriate; % of Non-Acute PCI Unclassifiable 

Exclusion: sites with < 10 Non-Acute PCIs  


Bleeding Event w/in 72 hours  All PCIs 

Suspected or confirmed bleeding event observed and documented in the medical record that was associated with any of the following: 

1)Hemoglobin drop of ≥ 3g/dL 

2) Transfusion of whole blood or packed red blood cells 

3) Procedural intervention/surgery at the bleeding site to reverse/stop or correct the bleeding 


Unplanned CABG  All PCIs  Unplanned coronary artery bypass graft (CABG) surgery 

Post Procedure Cardiogenic Shock 




New onset or acute recurrence of cardiogenic shock. 

Sustained (>30 minutes) episode of systolic blood pressure <90 mm Hg, and/or cardiac index <2.2 L/min/m2 determined to be secondary to cardiac dysfunction, and/or the requirement for parenteral inotropic or vasopressor agents or mechanical support to maintain blood pressure and cardiac index.   

NOTE: Transient episodes of hypotension reversed with IV fluid or atropine do not constitute cardiogenic shock. The hemodynamic compromise (with or without extraordinary supportive therapy) must persist for at least 30 min. 


Radial Artery Use  STEMI 

PCI performed via radial access 


RBC/Whole Blood Transfusion  


  Post-PCI transfusion 


Level  Outcomes  Definition 








Stroke   All PCIs  Any post procedure stroke (ischemic, hemmorhagic, other) 
Tamponade  All PCIs 
Fluid in the pericardial space compromising cardiac filling and requiring intervention. Tamponade should be documented by either: 1) echocardiogram showing pericardial fluid and signs of tamponade such as right heart compromise, or 2) Systemic Hypotension due to pericardial fluid compromising cardiafunction

Acute Kidney Injury 



All PCIs 

Acute Kidney Injury Network (AKIN) stage 1 or greater or a new requirement for dialysis following PCI, excluding those on dialysis prior to procedure, those undergoing multiple PCI procedures within the same admission, those without both a pre-post procedure creatinine, and those with same day discharges:  

1. % missing pre/post creatinine  

2. Stage 1 is defined as an absolute increase of ≥ 0.3 mg/dL or a relative increase of 50% in serum creatinine (Cr)  

3. Stage 2 is defined as an increase in serum Cr to more than 200% to 300% (>2-to 3- fold) from baseline,  

4. Stage 3 is defined as increase in serum Cr to more than 300% (>3-fold) from baseline (or serum Cr of more than or equal to 4.0 mg/dl with an acute increase of at least 0.5 mg/dl 

Fluoro Dose  All PCIs 

Mean fluoro dose 


Contrast Volume  All PCIs  Mean contrast dose