Intensive Care Unit Venous Thromboembolism Prophylaxis

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Measure Information	2023 Reporting Period	2024 Reporting Period	2025 Reporting Period	2026 Reporting Period
Title	Intensive Care Unit Venous Thromboembolism Prophylaxis	Intensive Care Unit Venous Thromboembolism Prophylaxis	Intensive Care Unit Venous Thromboembolism Prophylaxis	Intensive Care Unit Venous Thromboembolism Prophylaxis
CMS eCQM ID	CMS190v11	CMS190v12	CMS190v13	CMS190v14
Short Name	VTE-2	VTE-2	VTE-2	VTE-2
CBE ID*	Not Applicable	Not Applicable	Not Applicable	Not Applicable
Measure Steward	The Joint Commission	The Joint Commission	The Joint Commission	The Joint Commission
Description	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) Show more > 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) Show less	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) Show more > 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) Show less	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) Show more > 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) Show less	This measure assesses the number of patients who received Venous Thromboembolism (VTE) prophylaxis on the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or on the day of or the day after surgery end date for surgeries that end the day after... ICU admission (or transfer) or have documentation 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) or on the day of or the day after surgery end date for surgeries that end the day after ICU admission (or transfer) Show more > This measure assesses the number of patients who received Venous Thromboembolism (VTE) prophylaxis on the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or on the day of or the day after surgery end date for surgeries that end the day after ICU admission (or transfer) or have documentation 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) or on the day of or the day after surgery end date for surgeries that end the day after ICU admission (or transfer) Show less
Measure Scoring	Proportion measure	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process	Process	Process	Process
Stratification	*See CMS190v11.html	None	None	None
Risk Adjustment	*See CMS190v11.html	None	None	None
Rationale	*See CMS190v11.html	Venous Thromboembolism (VTE) is a known complication of hospitalization, frequently extending the length of stay and increasing hospital mortality (Maynard, 2016). Approximately 20% of VTE are associated with a surgical procedure (Henke et al., 2020). Almost all hospitalized patients have... at least one risk factor for VTE, and approximately 40% have three or more risk factors. Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired deep-vein thrombosis (DVT) is approximately 10% to 40% among medical or general surgical patients and 40% to 60% following major orthopedic surgery (Geerts et al., 2008). Commonly, criteria for admission to the Intensive Care Unit (ICU) itself puts patients at an increased risk for developing VTE and subsequent increased risk of morbidity from pulmonary embolism (PE). Some risk factors are related to the acute illness present that allowed for the admission to the ICU unit, and some risk factors may be acquired during the ICU admission due to subsequent medical treatments, for example limitations of mobility, presence of central venous lines or mechanical ventilation and subsequent pharmacological paralysis. Reports of DVT in the population of ICU patients vary in relation to the acuity of the illness in this population. DVT in ICU patients diagnosed with routine venography or Doppler ultrasound found ranges between 10% to 100%. Five studies prospectively screened patients who were not receiving thromboprophylaxis during their ICU stays. The rates of DVT using Fibrinogen Uptake Test, Doppler Ultrasound or venography ranged from 13 to 31% (Geerts et al., 2008). It is essential for all ICUs to assess each patient upon admission to the ICU unit, a change in level of status, for the need for VTE prophylaxis due to the above increased development of risk factors (Geerts et al., 2004). American Society of Hematology (ASH) 2018 VTE prophylaxis guidelines strongly recommend pharmacological prophylaxis using unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux for acutely and critically ill hospitalized medical patients, unless contraindicated. The use of mechanical prophylaxis is an acceptable alternative for patients with increased risk of bleeding and preferred over no prophylaxis. ASH 2019 guidelines for surgical patients similarly recommend pharmacological or mechanical prophylaxis over no VTE prophylaxis. Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure. Show more > Venous Thromboembolism (VTE) is a known complication of hospitalization, frequently extending the length of stay and increasing hospital mortality (Maynard, 2016). Approximately 20% of VTE are associated with a surgical procedure (Henke et al., 2020). Almost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors. Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired deep-vein thrombosis (DVT) is approximately 10% to 40% among medical or general surgical patients and 40% to 60% following major orthopedic surgery (Geerts et al., 2008). Commonly, criteria for admission to the Intensive Care Unit (ICU) itself puts patients at an increased risk for developing VTE and subsequent increased risk of morbidity from pulmonary embolism (PE). Some risk factors are related to the acute illness present that allowed for the admission to the ICU unit, and some risk factors may be acquired during the ICU admission due to subsequent medical treatments, for example limitations of mobility, presence of central venous lines or mechanical ventilation and subsequent pharmacological paralysis. Reports of DVT in the population of ICU patients vary in relation to the acuity of the illness in this population. DVT in ICU patients diagnosed with routine venography or Doppler ultrasound found ranges between 10% to 100%. Five studies prospectively screened patients who were not receiving thromboprophylaxis during their ICU stays. The rates of DVT using Fibrinogen Uptake Test, Doppler Ultrasound or venography ranged from 13 to 31% (Geerts et al., 2008). It is essential for all ICUs to assess each patient upon admission to the ICU unit, a change in level of status, for the need for VTE prophylaxis due to the above increased development of risk factors (Geerts et al., 2004). American Society of Hematology (ASH) 2018 VTE prophylaxis guidelines strongly recommend pharmacological prophylaxis using unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux for acutely and critically ill hospitalized medical patients, unless contraindicated. The use of mechanical prophylaxis is an acceptable alternative for patients with increased risk of bleeding and preferred over no prophylaxis. ASH 2019 guidelines for surgical patients similarly recommend pharmacological or mechanical prophylaxis over no VTE prophylaxis. Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure. Show less	Venous Thromboembolism (VTE) is a known complication of hospitalization, frequently extending the length of stay and increasing hospital mortality (Maynard, 2016). Approximately 20% of VTE are associated with a surgical procedure (Henke et al., 2020). Almost all hospitalized patients have... at least one risk factor for VTE, and approximately 40% have three or more risk factors. Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired deep-vein thrombosis (DVT) is approximately 10% to 40% among medical or general surgical patients and 40% to 60% following major orthopedic surgery (Geerts et al., 2008). Commonly, criteria for admission to the Intensive Care Unit (ICU) itself puts patients at an increased risk for developing VTE and subsequent increased risk of morbidity from pulmonary embolism (PE). Some risk factors are related to the acute illness present that allowed for the admission to the ICU unit, and some risk factors may be acquired during the ICU admission due to subsequent medical treatments, for example limitations of mobility, presence of central venous lines or mechanical ventilation and subsequent pharmacological paralysis. Reports of DVT in the population of ICU patients vary in relation to the acuity of the illness in this population. DVT in ICU patients diagnosed with routine venography or Doppler ultrasound found ranges between 10% to 100%. Five studies prospectively screened patients who were not receiving thromboprophylaxis during their ICU stays. The rates of DVT using Fibrinogen Uptake Test, Doppler Ultrasound or venography ranged from 13 to 31% (Geerts et al., 2008). It is essential for all ICUs to assess each patient upon admission to the ICU unit, a change in level of status, for the need for VTE prophylaxis due to the above increased development of risk factors (Geerts et al., 2004). American Society of Hematology (ASH) 2018 VTE prophylaxis guidelines strongly recommend pharmacological prophylaxis using unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux for acutely and critically ill hospitalized medical patients, unless contraindicated. The use of mechanical prophylaxis is an acceptable alternative for patients with increased risk of bleeding and preferred over no prophylaxis. ASH 2019 guidelines for surgical patients similarly recommend pharmacological or mechanical prophylaxis over no VTE prophylaxis. Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure. Show more > Venous Thromboembolism (VTE) is a known complication of hospitalization, frequently extending the length of stay and increasing hospital mortality (Maynard, 2016). Approximately 20% of VTE are associated with a surgical procedure (Henke et al., 2020). Almost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors. Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired deep-vein thrombosis (DVT) is approximately 10% to 40% among medical or general surgical patients and 40% to 60% following major orthopedic surgery (Geerts et al., 2008). Commonly, criteria for admission to the Intensive Care Unit (ICU) itself puts patients at an increased risk for developing VTE and subsequent increased risk of morbidity from pulmonary embolism (PE). Some risk factors are related to the acute illness present that allowed for the admission to the ICU unit, and some risk factors may be acquired during the ICU admission due to subsequent medical treatments, for example limitations of mobility, presence of central venous lines or mechanical ventilation and subsequent pharmacological paralysis. Reports of DVT in the population of ICU patients vary in relation to the acuity of the illness in this population. DVT in ICU patients diagnosed with routine venography or Doppler ultrasound found ranges between 10% to 100%. Five studies prospectively screened patients who were not receiving thromboprophylaxis during their ICU stays. The rates of DVT using Fibrinogen Uptake Test, Doppler Ultrasound or venography ranged from 13 to 31% (Geerts et al., 2008). It is essential for all ICUs to assess each patient upon admission to the ICU unit, a change in level of status, for the need for VTE prophylaxis due to the above increased development of risk factors (Geerts et al., 2004). American Society of Hematology (ASH) 2018 VTE prophylaxis guidelines strongly recommend pharmacological prophylaxis using unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux for acutely and critically ill hospitalized medical patients, unless contraindicated. The use of mechanical prophylaxis is an acceptable alternative for patients with increased risk of bleeding and preferred over no prophylaxis. ASH 2019 guidelines for surgical patients similarly recommend pharmacological or mechanical prophylaxis over no VTE prophylaxis. Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure. Show less	Venous Thromboembolism (VTE) is a known complication of hospitalization, frequently extending the length of stay and increasing hospital mortality (Maynard, 2016). Approximately 20% of VTE are associated with a surgical procedure (Henke et al., 2020). Almost all hospitalized patients have... at least one risk factor for VTE, and approximately 40% have three or more risk factors. Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired deep-vein thrombosis (DVT) is approximately 10% to 40% among medical or general surgical patients and 40% to 60% following major orthopedic surgery (Geerts et al., 2008). Commonly, criteria for admission to the Intensive Care Unit (ICU) itself puts patients at an increased risk for developing VTE and subsequent increased risk of morbidity from pulmonary embolism (PE). Some risk factors are related to the acute illness present that allowed for the admission to the ICU unit, and some risk factors may be acquired during the ICU admission due to subsequent medical treatments, for example limitations of mobility, presence of central venous lines or mechanical ventilation and subsequent pharmacological paralysis. Reports of DVT in the population of ICU patients vary in relation to the acuity of the illness in this population. DVT in ICU patients diagnosed with routine venography or Doppler ultrasound found ranges between 10% to 100%. Five studies prospectively screened patients who were not receiving thromboprophylaxis during their ICU stays. The rates of DVT using Fibrinogen Uptake Test, Doppler Ultrasound or venography ranged from 13 to 31% (Geerts et al., 2008). It is essential for all ICUs to assess each patient upon admission to the ICU unit, a change in level of status, for the need for VTE prophylaxis due to the above increased development of risk factors (Geerts et al., 2004). American Society of Hematology (ASH) 2018 VTE prophylaxis guidelines strongly recommend pharmacological prophylaxis using unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux for acutely and critically ill hospitalized medical patients, unless contraindicated. The use of mechanical prophylaxis is an acceptable alternative for patients with increased risk of bleeding and preferred over no prophylaxis. ASH 2019 guidelines for surgical patients similarly recommend pharmacological or mechanical prophylaxis over no VTE prophylaxis. (NOTE: Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure.) Show more > Venous Thromboembolism (VTE) is a known complication of hospitalization, frequently extending the length of stay and increasing hospital mortality (Maynard, 2016). Approximately 20% of VTE are associated with a surgical procedure (Henke et al., 2020). Almost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors. Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired deep-vein thrombosis (DVT) is approximately 10% to 40% among medical or general surgical patients and 40% to 60% following major orthopedic surgery (Geerts et al., 2008). Commonly, criteria for admission to the Intensive Care Unit (ICU) itself puts patients at an increased risk for developing VTE and subsequent increased risk of morbidity from pulmonary embolism (PE). Some risk factors are related to the acute illness present that allowed for the admission to the ICU unit, and some risk factors may be acquired during the ICU admission due to subsequent medical treatments, for example limitations of mobility, presence of central venous lines or mechanical ventilation and subsequent pharmacological paralysis. Reports of DVT in the population of ICU patients vary in relation to the acuity of the illness in this population. DVT in ICU patients diagnosed with routine venography or Doppler ultrasound found ranges between 10% to 100%. Five studies prospectively screened patients who were not receiving thromboprophylaxis during their ICU stays. The rates of DVT using Fibrinogen Uptake Test, Doppler Ultrasound or venography ranged from 13 to 31% (Geerts et al., 2008). It is essential for all ICUs to assess each patient upon admission to the ICU unit, a change in level of status, for the need for VTE prophylaxis due to the above increased development of risk factors (Geerts et al., 2004). American Society of Hematology (ASH) 2018 VTE prophylaxis guidelines strongly recommend pharmacological prophylaxis using unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux for acutely and critically ill hospitalized medical patients, unless contraindicated. The use of mechanical prophylaxis is an acceptable alternative for patients with increased risk of bleeding and preferred over no prophylaxis. ASH 2019 guidelines for surgical patients similarly recommend pharmacological or mechanical prophylaxis over no VTE prophylaxis. (NOTE: Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure.) Show less
Clinical Recommendation Statement	*See CMS190v11.html	Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for critically ill hospitalized patients for developing a deep vein thrombosis or dying from a pulmonary embolism. Screening all patients is the only evidence based practice in... reducing incidence of disease. All intensive care unit (ICU) patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated. Show more > Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for critically ill hospitalized patients for developing a deep vein thrombosis or dying from a pulmonary embolism. Screening all patients is the only evidence based practice in reducing incidence of disease. All intensive care unit (ICU) patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated. Show less	Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for critically ill hospitalized patients for developing a deep vein thrombosis or dying from a pulmonary embolism. Screening all patients is the only evidence-based practice in... reducing incidence of disease. All intensive care unit (ICU) patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated. Show more > Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for critically ill hospitalized patients for developing a deep vein thrombosis or dying from a pulmonary embolism. Screening all patients is the only evidence-based practice in reducing incidence of disease. All intensive care unit (ICU) patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated. Show less	Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for critically ill hospitalized patients for developing a deep vein thrombosis or dying from a pulmonary embolism. Screening all patients is the only evidence-based practice in... reducing incidence of disease. All intensive care unit (ICU) patients should be evaluated for primary VTE prophylaxis and given appropriate prophylaxis when indicated. Show more > Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for critically ill hospitalized patients for developing a deep vein thrombosis or dying from a pulmonary embolism. Screening all patients is the only evidence-based practice in reducing incidence of disease. All intensive care unit (ICU) patients should be evaluated for primary VTE prophylaxis and given appropriate prophylaxis when indicated. Show less
Improvement Notation	Improvement noted as an increase in rate	Improvement noted as an increase in rate	Improvement noted as an increase in rate	Increased score indicates improvement
Definition	*See CMS190v11.html	None	None	None
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." 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. Show more > 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. Show less	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. Show more > 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. Show less	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 (CDC, 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. Show more > 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 (CDC, 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. Show less	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 (CDC, 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 medical doctor, advanced practice registered nurse, physician assistant, or pharmacist and linked with VTE prophylaxis. The only exception is patient refusal may be documented by a nurse. 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 measure does not require the use of a specific risk assessment model or tool (e.g., Caprini, Padua, and IMPROVE) to determine VTE risk. 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. Inpatient hospitalizations for patients with a principal procedure of selected surgeries are excluded from the measure’s denominator. Selected surgeries include general surgery, gynecological surgery, hip fracture surgery, hip/knee replacement surgery, intracranial neurosurgery, and urological surgery. Inpatient hospitalizations for patients administered apixaban or edoxaban, medications included in the “Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment” value set, would be counted in the numerator population only when the patients also have either a prior or present diagnosis of atrial fibrillation, a prior diagnosis of VTE, or a prior or present procedure of hip/knee replacement surgery. 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. Show more > 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 (CDC, 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 medical doctor, advanced practice registered nurse, physician assistant, or pharmacist and linked with VTE prophylaxis. The only exception is patient refusal may be documented by a nurse. 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 measure does not require the use of a specific risk assessment model or tool (e.g., Caprini, Padua, and IMPROVE) to determine VTE risk. 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. Inpatient hospitalizations for patients with a principal procedure of selected surgeries are excluded from the measure’s denominator. Selected surgeries include general surgery, gynecological surgery, hip fracture surgery, hip/knee replacement surgery, intracranial neurosurgery, and urological surgery. Inpatient hospitalizations for patients administered apixaban or edoxaban, medications included in the “Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment” value set, would be counted in the numerator population only when the patients also have either a prior or present diagnosis of atrial fibrillation, a prior diagnosis of VTE, or a prior or present procedure of hip/knee replacement surgery. 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. Show less
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 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 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	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 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 Show more > * 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 Show less	- 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 Show more > - 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 Show less	- 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 Show more > - 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 Show less	- 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 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 after ICU admission or transfer Show more > - 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 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 after ICU admission or transfer Show less
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) Show more > 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) Show less	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) Show more > 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) Show less	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) Show more > 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) Show less	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 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 after ICU admission or transfer) Show more > 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 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 after ICU admission or transfer) Show less
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable	None
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	Inpatient hospitalizations for patients with ICU LOS less than one day
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Specifications

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CMS190v12-TRN.xlsx

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