download chevron-down chevron-right chevron-with-circle-down chevron-with-circle-up check circle-with-minus circle-with-plus export help-with-circle inbox link mail old-phone star-outlined star user v-card close close close Back to top
Top

Intensive Care Unit Venous Thromboembolism Prophylaxis

CMS Measure ID
CMS190v8
Version
8
NQF Number
Not Applicable
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 Population

Inpatient hospitalizations for patients age 18 and older, discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period

Denominator Statement

Inpatient hospitalizations for patients directly admitted or transferred to ICU during the hospitalization

Denominator Exclusions

* Inpatient hospitalizations for patients who have a hospital length of stay (LOS) less than 2 days

* Inpatient hospitalizations for patients with comfort measures documented anytime between the day of arrival and the day after ICU admission or transfer

* Inpatient hospitalizations for patients with comfort measures documented by the day after surgery end date for surgeries that end the day of or the day after hospital admission

* Inpatient hospitalizations for patients with a principal procedure of surgical care improvement Project (SCIP) VTE selected surgeries that end the day of or the day after ICU admission or transfer

Numerator Statement

Inpatient hospitalizations for patients who received VTE prophylaxis:

- the day of or the day after ICU admission (or transfer)

- the day of or the day after surgery end date for surgeries that end the day of or the day after ICU admission (or transfer)

Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:

- between the day of arrival and the day after ICU admission (for patients directly admitted as inpatients to the ICU)

- the day of or the day after surgery end date (for surgeries that end the day of or the day after ICU admission (or transfer)

Numerator Exclusions

Not Applicable

Denominator Exceptions

Inpatient hospitalizations for patients with ICU LOS less than one day

Measure Steward
Short Name
VTE-2
Previous Version
Measure Scoring
Measure Type
Improvement Notation

Improvement noted as an increase in rate

Guidance

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.

Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."

Meaningful Measure

Specifications

Attachment Size
CMS190v8.html 100.67 KB
CMS190v8.zip 119.72 KB
CMS190v8-TRN.xlsx 24.8 KB

Release Notes

 

Header

  • Updated eCQM version number.

    Measure Section: eCQM Version number

    Source of Change: Annual Update

  • Updated NQF number to 'Not Applicable.'

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated endorsed by field to 'None.'

    Measure Section: Endorsed By

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated initial population statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated denominator statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Denominator

    Source of Change: Measure Lead

  • Updated denominator exclusions statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated denominator exclusions statement to align with logic changes to capture patients with documentation of comfort measures between the day of arrival and the day after ICU admission or transfer.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated numerator statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated numerator statement bullets under 'Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:' for clarity and to improve alignment with measure intent.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated denominator exceptions statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

 

Logic

  • Removed the diagnosis datatypes for 'Obstetrics', 'Venous Thromboembolism', and 'Obstetrics VTE' to remove redundancy and align with QDM v5.4 changes.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Replaced local function 'Length In Days'() with Global.'LengthInDays'() to align with tooling updates and improve logic efficiencies.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Replaced function VTEICU.'CalendarDayOfOrDayAfter'() with TJC.'CalendarDayOfOrDayAfter'() to indicate the change in the local library location.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Replaced local function 'Length In Days'() with Global.'LengthInDays'() to align with tooling updates and improve logic efficiencies.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Replaced function VTEICU.'CalendarDayOfOrDayAfter'() with TJC.'CalendarDayOfOrDayAfter'() to indicate the change in the local library location.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Added a parenthesis around the last union clause of the 'Is In Low Risk for VTE or On Anticoagulant' definition statement to properly group all medications.

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (JIRA): CQM-3259

  • Replaced '… AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of Global.'First Inpatient Intensive Care Unit'(QualifyingEncounterICU).locationPeriod' with '…AnesthesiaProcedure.relevantPeriod ends 1 day after day of VTEICU.'StartOfFirstICU'(QualifyingEncounterICU)' to align with Functions updates.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Replaced long repetitive logic expressions with the VTEICU function 'FromDayOfStartOfHospitalizationToDayAfterFirstICU' in five definitions: 'Encounter With Intervention Comfort Measures From Day Of Start of Hospitalization To Day After First ICU Stay', 'Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After First ICU Stay', 'No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After First ICU Stay', 'No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After First ICU Stay', and 'No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After First ICU Stay'.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Replaced '… AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of Global.'First Inpatient Intensive Care Unit'(QualifyingEncounterICU).locationPeriod' with '…AnesthesiaProcedure.relevantPeriod ends 1 day after day of VTEICU.'StartOfFirstICU'(QualifyingEncounterICU)' to align with Functions updates.

    Measure Section: Numerator Exclusions

    Source of Change: Measure Lead

  • Replaced '… AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of Global.'First Inpatient Intensive Care Unit'(QualifyingEncounterICU).locationPeriod' with '…AnesthesiaProcedure.relevantPeriod ends 1 day after day of VTEICU.'StartOfFirstICU'(QualifyingEncounterICU)' to align with Functions updates.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Replaced local function 'Length In Days'() with Global.'LengthInDays'() to align with tooling updates and improve logic efficiencies.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Changed six definition names from '…From Start of…' to '…From Day Of Start of…' to align with logic changes. Updated definition names include 'Encounter With Intervention Comfort Measures From Day Of Start of Hospitalization To Day After First ICU Stay', 'Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After First ICU Stay', 'No VTE Prophylaxis Medication Due to Medical Reason From Day Of Start of Hospitalization To Day After First ICU Stay', 'No VTE Prophylaxis Device Due to Medical Reason From Day Of Start of Hospitalization To Day After First ICU Stay', 'No VTE Prophylaxis Due to Patient Refusal From Day Of Start of Hospitalization To Day After First ICU Stay', and 'Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After First ICU Stay'.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced ‘Global.Hospitalization’ with new function ‘Global.Hospitalization with Observation’ to capture assessments performed during observation status prior to inpatient admission.

    Measure Section: Functions

    Source of Change: ONC Project Tracking System (JIRA): CQM-2835

  • Replaced function VTEICU.ToDate() and function 'To Date'() with function Global.ToDate() to align with tooling updates and make the logic more efficient.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Replaced local function 'Day of or Day After' with  TJC.'CalendarDayOfOrDayAfter'() to capture all eligible same date events regardless of time stamps.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Replaced timing interval '1 day or less on or after day of' with function TJC.'CalendarDayOfOrDayAfter'() in the 'Encounter With Intervention Comfort Measures on Day of or Day After Procedure' definition to capture all eligible same date events regardless of time stamps.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Added VTEICU.'First ICULocationPeriod'() and VTEICU.'StartOfFirstICU'() to the VTEICU local library to align with standards or tooling updates.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Removed function VTEICU.'First Intensive Care Unit'() from the VTEICU library because this function is now included in the Global.'FirstInpatientIntensiveCareUnit'() library.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Removed 'Start of First ICU' and 'First ICU Location Period' as they are no longer used in the measure.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Removed local function 'Length In Days' because the 'Length In Days' function is included in the Global library.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Added VTEICU library function 'FromDayOfStartOfHospitalizationToDayAfterFirstICU' to simplify the logic by replacing lengthy repeating expressions with a reusable function.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Replaced Global.'First Inpatient Intensive Care Unit' with VTEICU.FirstInpatientIntensiveCareUnit, to ensure OID 2.16.840.1.113762.1.4.1029.206 is used since the OID is not included in the Global Common Library v4.0.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • ​Updated version number of the VTEICU Library (VTEICU-3.1.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Update to TJC_Overall Library version number (TJC_Overall-3.6.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

 

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (2.16.840.1.113883.3.117.1.7.1.134): Added 3 RxNorm codes (1549682, 1992427, 2059015).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Atrial Fibrillation/Flutter (2.16.840.1.113883.3.117.1.7.1.202): Added 5 SNOMED CT codes (120041000119109, 15964901000119107, 706923002, 715395008, 720448006).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219): Deleted 1 RxNorm code (978738).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Added 1 SNOMED CT code (764677008) and deleted 3 SNOMED CT codes (27056009, 274032001, 428784009).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205): Deleted 1 RxNorm code (1798389).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Added 1 SNOMED CT code (769087009) and deleted 7 SNOMED CT codes (111443000, 111444006, 111445007, 199032005, 199033000, 288207006, 38331001).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Observation Services (2.16.840.1.113762.1.4.1111.143): Added Observation Services.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45): Changed Exclusion Criteria description from ‘None’ to ‘Palliative Care’ for clarity and to align with chart-abstracted measures.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (JIRA): CQM-3396

  • Created Intensive Care Unit (2.16.840.1.113762.1.4.1029.204) value set with 25 HSLOC codes.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Created Intensive Care Unit (2.16.840.1.113762.1.4.1029.206) grouping value set that includes HSLOC and SNOMED CT extensional value sets (2.16.840.1.113762.1.4.1029.204 and 2.16.840.1.113762.1.4.1110.23).

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Intensive Care Unit (2.16.840.1.113762.1.4.1110.23) with value set Intensive Care Unit (2.16.840.1.113762.1.4.1029.206) to align with terminology updates.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code system versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measure Logic and Implementation Guidance document for a list of code system versions used in the eCQM specifications for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • ​Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Oct 10, 2019