Intensive Care Unit Venous Thromboembolism Prophylaxis

Last updated: May 4, 2017

CMS Measure ID: CMS190v3
Version: 3
NQF Number: 0372
Measure Description:

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).

Initial Patient Population:

Patient age 18 and older discharged from hospital inpatient acute care with no diagnosis for obstetrics or venous thromboembolism (VTE) and a length of stay less than or equal to 120 days.

Denominator Statement:

Patients directly admitted or transferred to ICU during the hospitalization.

Denominator Exclusions:
  • Patients who have a hospital length of stay (LOS) less than two days.
  • Patients with comfort measures only documented during the specified date range.
  • Patients with a principal procedure of surgical care improvement Project (SCIP) VTE selected surgeries that start the day of or the day after ICU admission or transfer.
Numerator Statement:

Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given:

  • the day of or the day after ICU admission (or transfer)
  • the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer)
Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Patients with ICU LOS less than one day without VTE prophylaxis administered and documentation for no VTE prophylaxis.

Measure Steward: The Joint Commission
Domain: Patient Safety
Short Name: VTE2
Next Version: Intensive Care Unit Venous Thromboembolism Prophylaxis
Measure Score: Proportion
Score Type: Process
Improvement Notation:

An increase in the rate

Guidance:

The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.

The definition of an ICU for the purpose of the measures noted above is that used by the CDC in the NHSN Patient Safety Project. An intensive care unit can be defined as a nursing care area that provides intensive observation, diagnosis, and therapeutic procedures for adults and/or children who are critically ill. An ICU excludes nursing areas that provide step-down, intermediate care or telemetry only and specialty care areas.

The construct of Unfractionated Heparin (route: 'Intravenous route') intends to capture continually infused heparin rather than heparin flushes or pushes.

Specifications

External Resources