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Intensive Care Unit Venous Thromboembolism Prophylaxis

Compare Versions of: "Intensive Care Unit Venous Thromboembolism Prophylaxis"

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Measure Information 2022 Reporting Period 2023 Reporting Period 2024 Reporting Period
Title Intensive Care Unit Venous Thromboembolism Prophylaxis Intensive Care Unit Venous Thromboembolism Prophylaxis Intensive Care Unit Venous Thromboembolism Prophylaxis
CMS eCQM ID CMS190v10 CMS190v11 CMS190v12
Short Name

VTE-2

VTE-2

VTE-2

NQF Number Not Applicable Not Applicable Not Applicable
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)

This measure assesses the number of patients who received Venous Thromboembolism (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)

This measure assesses the number of patients who received Venous Thromboembolism (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

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

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

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

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

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 * Inpatient hospitalizations for patients who have a hospital length of stay (LOS) less than 2 days * 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 * 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 who have a hospital length of stay (LOS) less than 2 days- 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- 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 ICU admission or transfer
Numerator

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)

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)

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

Not Applicable

Not Applicable

Denominator Exceptions

Inpatient hospitalizations for patients with ICU LOS less than one day

Inpatient hospitalizations for patients with ICU LOS less than one day

Inpatient hospitalizations for patients with ICU LOS less than one day

Measure Steward The Joint Commission The Joint Commission The Joint Commission
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure
Improvement Notation

Improvement noted as an increase in rate

Improvement noted as an increase in rate

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."

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

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."

The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

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 (2022). 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."

The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Next Version No Version Available
Previous Version No Version Available

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated exclusion language in the narrative to align with measure intent and current CQL timing requirements.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section: Multiple Sections

    Source of Change: Annual Update

Logic

  • Consolidated and simplified the initial population definitions to improve clarity and efficiency.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Changed the alias names from 'NoVTEDevice' to 'NoMechanicalProphylaxis' because the definition was renamed because the QDM data element associated with the name is no longer a valid QDM data element.

    Measure Section: Numerator

    Source of Change: Standards/Technical Update

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

    Measure Section: Definitions

    Source of Change: Standards/Technical Update

  • Updated the version number of the TJC Overall Library to v7.1.000.

    Measure Section: Definitions

    Source of Change: Annual Update

  • Updated the version number of the VTE Library to v7.2.000.

    Measure Section: Definitions

    Source of Change: Annual Update

  • Updated the version number of the TJC Overall Library to v7.1.000.

    Measure Section: Functions

    Source of Change: Annual Update

  • Updated the version number of the VTE Library to v7.2.000.

    Measure Section: Functions

    Source of Change: Annual 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 Atrial Fibrillation or Flutter (2.16.840.1.113883.3.117.1.7.1.202): Added 2 SNOMED CT codes (312442005, 428076002) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205): Added 6 RxNorm codes (2590616, 2590620, 2590623, 2590627, 2590631, 2590635) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Deleted 4 SNOMED CT codes (119884008, 235288004, 238215005, 315323003) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Glycoprotein IIb IIIa Inhibitors (2.16.840.1.113762.1.4.1045.41): Deleted 1 RxNorm code (241162) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Gynecological Surgery (2.16.840.1.113883.3.117.1.7.1.257): Added 7 ICD-10-PCS codes (0UT90ZL, 0UT97ZL, 0UT98ZL, 0U508ZZ, 0U518ZZ, 0U528ZZ, 0U548ZZ) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Added 8 ICD-10-PCS codes (0SR9069, 0SR906A, 0SR906Z, 0SR90EZ, 0SRB069, 0SRB06A, 0SRB06Z, 0SRB0EZ) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Intermittent pneumatic compression devices (2.16.840.1.113883.3.117.1.7.1.214): Added 1 SNOMED CT code (432441000124100) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260): Added 1 SNOMED CT code (1201979001) based on terminology update. Deleted 3 SNOMED CT codes (171446006, 244238001, 82443007) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Knee Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.261): Added 20 ICD-10-PCS codes based on terminology update.

    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): Added 1 RxNorm code (2618839) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.117.1.7.1.473): Renamed to Medical Reason For Not Providing Treatment based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.117.1.7.1.263): Renamed to Obstetrical or Pregnancy Related Conditions based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Obstetrical or Pregnancy Related Conditions (2.16.840.1.113883.3.117.1.7.1.263): Added 21 SNOMED CT codes based on terminology update. Deleted 44 SNOMED CT codes based on terminology update. Added 177 ICD-10-CM codes based on terminology update. Deleted 14 ICD-10-CM codes based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Obstetrics VTE (2.16.840.1.113883.3.117.1.7.1.264): Added 3 SNOMED CT codes (609449004, 609459003, 609480009) based on terminology update. Deleted 6 SNOMED CT codes (51096002, 57734001, 21604008, 26743002, 37787009, 55589000) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Added 2 SNOMED CT codes (1162745003, 895451009) based on terminology update. Deleted 5 SNOMED CT codes (183944003, 413312003, 183947005, 371138003, 609589008) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jan 22, 2024