Intensive Care Unit Venous Thromboembolism Prophylaxis

Last updated: May 3, 2018

CMS Measure ID: CMS190v6
Version: 6
NQF Number: 0372
Measure Description:

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

Initial Patient Population:

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:

Patients directly admitted or transferred to ICU during the hospitalization

Denominator Exclusions:

* Patients who have a hospital length of stay (LOS) less than 2 days

* Patients with comfort measures documented anytime between arrival and the day after ICU admission or transfer

* 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

* 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:

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)

Patients who have documentation of a reason why no VTE prophylaxis was given:

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

- 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)

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Patients with ICU LOS less than one day

Measure Steward: The Joint Commission
Short Name: VTE2
Next Version:
Previous Version:
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.

Notes: Value Set content updated Sept 2017

Specifications

Release Notes

Header

  • Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added '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' to the Initial Population narrative statement to better align with the logic.

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-2520)

Logic

  • Replaced 'Unfractionated Heparin for VTE prophylaxis ingredient specific' value set with 'Low Dose Unfractionated Heparin for VTE Prophylaxis' semantic clinical drug value set to ease implementation burden.

    Measure Section: Numerator (QDM Variable)

    Source of Change: JIRA (CQM-1835)

  • Replaced 'Low Molecular Weight Heparin for VTE prophylaxis ingredient specific' value set with 'Low Molecular Weight Heparin for VTE Prophylaxis' semantic clinical drug value set to ease implementation burden.

    Measure Section: Numerator (QDM Variable)

    Source of Change: JIRA (CQM-1835)

  • Replaced 'Injectable factor Xa inhibitor for VTE prophylaxis ingredient specific' value set with 'Injectable Factor Xa Inhibitor for VTE Prophylaxis' semantic clinical drug value set to ease implementation burden.

    Measure Section: Numerator (QDM Variable)

    Source of Change: JIRA (CQM-1835)

  • Replaced 'Warfarin-only ingredient specific' value set with 'Warfarin' semantic clinical drug value set to ease implementation burden.

    Measure Section: Numerator (QDM Variable)

    Source of Change: JIRA (CQM-1835)

  • Replaced temporal operator 'starts after start of' with 'starts after or concurrent with start of' to allow for concurrent data capture.

    Measure Section: Denominator Exclusions

    Source of Change: JIRA (CQM-2125)

  • Replaced temporal operator 'starts after end of' with 'starts after or concurrent with end of' to allow for concurrent data capture.

    Measure Section: Denominator Exclusions

    Source of Change: JIRA (CQM-2125)

  • Replaced temporal operator 'ends after start of' with 'ends after or concurrent with start of' to allow for concurrent data capture.

    Measure Section: Denominator Exclusions

    Source of Change: JIRA (CQM-2125)

  • Replaced temporal operator 'starts after start of' with 'starts after or concurrent with start of' to allow for concurrent data capture.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-2125)

  • Replaced temporal operator 'starts after end of' with 'starts after or concurrent with end of' to allow for concurrent data capture.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-2125)

  • Replaced temporal operator 'ends after start of' with 'ends after or concurrent with start of' to allow for concurrent data capture.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-2125)

  • Replaced 'Risk Category Assessment' datatype with 'Assessment, Performed' datatype to conform with QDM 4.3 changes.

    Measure Section: Numerator

    Source of Change: QDM Standards

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 Glycoprotein IIb/IIIa Inhibitors (2.16.840.1.113762.1.4.1045.41): Added 5 RXNORM codes (1736470, 1736477, 1737466, 1737471, 1813035) and deleted 3 RXNORM codes (200326, 200348, 205253).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Obstetrics VTE (2.16.840.1.113883.3.117.1.7.1.264): Deleted 35 ICD9CM codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Venous Thromboembolism (2.16.840.1.113883.3.117.1.7.1.279): Deleted 14 ICD9CM codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Added 3 SNOMEDCT codes (183946001, 183956002, 609589008).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205): Added 3 RXNORM codes (1804735, 1804737, 1804738) and deleted 1 RXNORM code (1110708).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Added 78 ICD10CM codes and deleted 8 ICD10CM codes (O00.0, O00.1, O00.2, O00.8, O00.9, O33.7, O34.21, O70.2). Added 4 SNOMEDCT codes (459166009, 459167000, 713575004, 713576003) and deleted 4 SNOMEDCT codes (200074009, 200080001, 237088009, 237246007).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Replaced Warfarin-only ingredient specific value set (2.16.840.1.113762.1.4.1021.10) with Warfarin (2.16.840.1.113883.3.117.1.7.1.232) value set.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Replaced Injectable factor Xa inhibitor for VTE prophylaxis ingredient specific value set (2.16.840.1.113762.1.4.1021.11) with Injectable factor Xa inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211) value set.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Replaced Low Molecular Weight Heparin for VTE prophylaxis ingredient specific value set (2.16.840.1.113762.1.4.1021.12) with Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219) value set.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Replaced Unfractionated Heparin for VTE prophylaxis ingredient specific value set (2.16.840.1.113762.1.4.1021.13) with Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39) value set.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Deleted 48 ICD10PCS codes. Deleted 1 SNOMEDCT code (45608007).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260): Deleted 4 ICD10PCS codes (0N9200Z, 0N920ZZ, 0N9800Z, 0N980ZZ).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set General or Neuraxial Anesthesia (2.16.840.1.113883.3.666.5.1743): Deleted 6 ICD10PCS codes (3E0F7DZ, 3E0F8DZ, 3E0R3CZ, 3E0S3CZ, 3E0T3CZ, 3E0X3CZ).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Deleted 4 ICD10CM codes (O00.10, O00.11, O00.20, O00.21). Deleted 2 SNOMEDCT codes (199094009, 66064007).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources