Venous Thromboembolism Prophylaxis

Last updated: July 12, 2017

CMS Measure ID: CMS108v3
Version: 3
NQF Number: 0371
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 hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.

Initial Patient Population:

Patients age 18 and older discharged from hospital inpatient acute care with a diagnosis of venous thromboembolism (VTE) and a length of stay less than or equal to 120 days.

Denominator Statement:

All patients in the initial patient population

Denominator Exclusions:
  • Patients who have a length of stay less than 2 days
  • Patients with comfort measures only documented anytime between arrival and the day after hospital admission
  • Patients with comfort measures only documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission
  • Patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day
  • Patients with a principal diagnosis of mental disorders or stroke
  • Patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries
Numerator Statement:

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

  • the day of or the day after hospital admission
  • the day of or the day after surgery end date for surgeries that start the day of or the day after hospital admission
Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Patient Safety
Short Name: VTE1
Next Version: Venous Thromboembolism Prophylaxis
Measure Score: Proportion
Score Type: Process
Improvement Notation:

An increase in 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.

When low dose unfractionated heparin is not administered due to medical reasons, the intended administration route is subcutaneous.

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

Specifications

External Resources