eCQM Title | Venous Thromboembolism Prophylaxis |
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eCQM Identifier (Measure Authoring Tool) | 108 | eCQM Version number | 7.4.000 |
NQF Number | 0371 | GUID | 38b0b5ec-0f63-466f-8fe3-2cd20ddd1622 |
Measurement Period | January 1, 20XX through December 31, 20XX | ||
Measure Steward | The Joint Commission | ||
Measure Developer | The Joint Commission | ||
Endorsed By | National Quality Forum | ||
Description | |||
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Disclaimer | |||
Measure Scoring | Proportion | ||
Measure Type | Process | ||
Stratification | |||
Risk Adjustment | |||
Rate Aggregation | |||
Rationale | |||
Clinical Recommendation Statement | |||
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Definition | |||
Guidance | |||
Transmission Format | |||
Initial Population | |||
Denominator | |||
Denominator Exclusions | |||
Numerator | |||
Numerator Exclusions | |||
Denominator Exceptions | |||
Supplemental Data Elements |
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions"
"Initial Population"
"Encounter Less Than 2 Days" union "Encounter With ICU Location Stay 1 Day or More" union "Encounter With Principal Diagnosis of Mental Disorder or Stroke" union "Encounter With Principal Procedure of SCIP VTE Selected Surgery" union "Intervention Comfort Measures on Day of or Day After Start of Hospitalization" union "Intervention Comfort Measures on Day of or Day After Procedure"
"VTE Prophylaxis Received on Day of or Day After Admission or Procedure" union ( "Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure" intersect ( "Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE" union "Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery" ) ) union "Low Risk for VTE or Anticoagulant Administered" union "No VTE Prophylaxis Due to Medical Reason" union "No VTE Prophylaxis Due to Patient Refusal"
( Global."Inpatient Encounter" InpatientEncounter where not ( exists ( InpatientEncounter.diagnoses EncounterDiagnoses where ( EncounterDiagnoses in "Obstetrics" or EncounterDiagnoses in "Venous Thromboembolism" or EncounterDiagnoses in "Obstetrics VTE" ) ) ) ) intersect ( Global."Inpatient Encounter" InpatientEncounter without ( ["Diagnosis": "Obstetrics"] union ["Diagnosis": "Venous Thromboembolism"] union ["Diagnosis": "Obstetrics VTE"] ) Diagnosis such that Diagnosis.prevalencePeriod starts during Global."Hospitalization"(InpatientEncounter) )
"Initial Population"
"Encounter Less Than 2 Days" union "Encounter With ICU Location Stay 1 Day or More" union "Encounter With Principal Diagnosis of Mental Disorder or Stroke" union "Encounter With Principal Procedure of SCIP VTE Selected Surgery" union "Intervention Comfort Measures on Day of or Day After Start of Hospitalization" union "Intervention Comfort Measures on Day of or Day After Procedure"
["Encounter, Performed": "Emergency Department Visit"]
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter where Global."LengthInDays"(QualifyingEncounter.relevantPeriod)< 2
( Global."Inpatient Encounter" InpatientEncounter with ["Patient Characteristic Birthdate"] BirthDate such that Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of InpatientEncounter.relevantPeriod)>= 18 ) intersect "Admission Without VTE or Obstetrical Conditions"
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter where exists ( QualifyingEncounter.facilityLocations Location where Location.code in "Intensive Care Unit" and Global."LengthInDays"(Location.locationPeriod)>= 1 and Location.locationPeriod starts during VTEICU."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.relevantPeriod) )
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter where QualifyingEncounter.principalDiagnosis in "Mental Health Diagnoses" or QualifyingEncounter.principalDiagnosis in "Hemorrhagic Stroke" or QualifyingEncounter.principalDiagnosis in "Ischemic Stroke"
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with ( "SCIP VTE Selected Surgery" Procedure where Procedure.ordinality in "Principal" ) SelectedProcedure such that SelectedProcedure.relevantPeriod during QualifyingEncounter.relevantPeriod
( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with ["Diagnosis": "Atrial Fibrillation/Flutter"] AtrialFibrillation such that AtrialFibrillation.prevalencePeriod starts on or before end of QualifyingEncounter.relevantPeriod ) union ( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter where exists ( QualifyingEncounter.diagnoses EncounterDiagnosis where EncounterDiagnosis in "Atrial Fibrillation/Flutter" ) ) union ( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with ["Diagnosis": "Venous Thromboembolism"] VTEDiagnosis such that VTEDiagnosis.prevalencePeriod starts before start of QualifyingEncounter.relevantPeriod )
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with ( ["Procedure, Performed": "Hip Replacement Surgery"] union ["Procedure, Performed": "Knee Replacement Surgery"] ) HipKneeProcedure such that HipKneeProcedure.relevantPeriod starts on or before end of QualifyingEncounter.relevantPeriod
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions"
["Intervention, Order": "Comfort Measures"] union ["Intervention, Performed": "Comfort Measures"]
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure, "Intervention Comfort Measures" ComfortMeasures where AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of QualifyingEncounter.relevantPeriod and Coalesce(start of ComfortMeasures.relevantPeriod, ComfortMeasures.authorDatetime)1 day or less on or after day of end of AnesthesiaProcedure.relevantPeriod return QualifyingEncounter
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with "Intervention Comfort Measures" ComfortMeasures such that Coalesce(start of ComfortMeasures.relevantPeriod, ComfortMeasures.authorDatetime)1 day or less on or after day of start of Global."Hospitalization"(QualifyingEncounter)
( ["Assessment, Performed": "Risk for venous thromboembolism"] VTERiskAssessment where VTERiskAssessment.result in "Low Risk" ) union ( ["Laboratory Test, Performed": "INR"] INRLabTest where INRLabTest.result > 3.0 return "Assessment, Performed" { id: INRLabTest.id, authorDatetime: INRLabTest.resultDatetime } ) union ( ( ["Medication, Administered": "Unfractionated Heparin"] UnfractionatedHeparin where UnfractionatedHeparin.route in "Intravenous route" ) union ["Medication, Administered": "Direct Thrombin Inhibitor"] union ["Medication, Administered": "Glycoprotein IIb/IIIa Inhibitors"] AnticoagulantMedication return "Assessment, Performed" { id: AnticoagulantMedication.id, authorDatetime: start of AnticoagulantMedication.relevantPeriod } )
"Low Risk for VTE or Anticoagulant Administered During ED Visit" union "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Admission" union "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure"
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, "ED Visit" EDVisit, "Is In Low Risk for VTE or On Anticoagulant" VTERiskAssessment where EDVisit.relevantPeriod ends 1 hour or less on or before start of QualifyingEncounter.relevantPeriod and VTERiskAssessment.authorDatetime during EDVisit.relevantPeriod return QualifyingEncounter
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with "Is In Low Risk for VTE or On Anticoagulant" VTERiskAssessment such that VTERiskAssessment.authorDatetime during VTEICU."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.relevantPeriod)
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure, "Is In Low Risk for VTE or On Anticoagulant" VTERiskAssessment where AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of QualifyingEncounter.relevantPeriod and VTERiskAssessment.authorDatetime during VTEICU."CalendarDayOfOrDayAfter"(end of AnesthesiaProcedure.relevantPeriod) return QualifyingEncounter
["Encounter, Performed": "Encounter Inpatient"] EncounterInpatient where "LengthInDays"(EncounterInpatient.relevantPeriod)<= 120 and EncounterInpatient.relevantPeriod ends during "Measurement Period"
( from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, ["Medication, Administered": "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication where FactorXaMedication.relevantPeriod starts during VTEICU."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.relevantPeriod) return QualifyingEncounter ) union ( from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure, ["Medication, Administered": "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication where AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of QualifyingEncounter.relevantPeriod and FactorXaMedication.relevantPeriod starts during VTEICU."CalendarDayOfOrDayAfter"(end of AnesthesiaProcedure.relevantPeriod) return QualifyingEncounter )
["Device, Not Applied": "Intermittent pneumatic compression devices (IPC)"] union ["Device, Not Applied": "Venous foot pumps (VFP)"] union ["Device, Not Applied": "Graduated compression stockings (GCS)"] union ["Device, Not Ordered": "Intermittent pneumatic compression devices (IPC)"] union ["Device, Not Ordered": "Venous foot pumps (VFP)"] union ["Device, Not Ordered": "Graduated compression stockings (GCS)"]
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, "ED Visit" EDVisit, "No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice where EDVisit.relevantPeriod ends 1 hour or less on or before start of QualifyingEncounter.relevantPeriod and NoVTEDevice.negationRationale in "Medical Reason" and NoVTEDevice.authorDatetime during EDVisit.relevantPeriod return QualifyingEncounter
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, "No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice where NoVTEDevice.negationRationale in "Medical Reason" and NoVTEDevice.authorDatetime during VTEICU."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.relevantPeriod) return QualifyingEncounter
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure, "No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice where NoVTEDevice.negationRationale in "Medical Reason" and AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of QualifyingEncounter.relevantPeriod and NoVTEDevice.authorDatetime during VTEICU."CalendarDayOfOrDayAfter"(end of AnesthesiaProcedure.relevantPeriod) return QualifyingEncounter
( "No VTE Prophylaxis Medication Due to Medical Reason During ED Visit" intersect "No VTE Prophylaxis Device Due to Medical Reason During ED Visit" ) union ( "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Admission" intersect "No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Admission" ) union ( "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure" intersect "No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Procedure" )
"No VTE Prophylaxis Due to Patient Refusal During ED Visit" union "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Admission" union "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure"
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, "ED Visit" EDVisit, "No VTE Prophylaxis Medication or Device Due to Patient Refusal" PatientRefusal where EDVisit.relevantPeriod ends 1 hour or less on or before start of QualifyingEncounter.relevantPeriod and PatientRefusal.authorDatetime during EDVisit.relevantPeriod return QualifyingEncounter
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, "No VTE Prophylaxis Medication or Device Due to Patient Refusal" PatientRefusal where PatientRefusal.authorDatetime during VTEICU."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.relevantPeriod) return QualifyingEncounter
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure, "No VTE Prophylaxis Medication or Device Due to Patient Refusal" PatientRefusal where AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of QualifyingEncounter.relevantPeriod and PatientRefusal.authorDatetime during VTEICU."CalendarDayOfOrDayAfter"(end of AnesthesiaProcedure.relevantPeriod) return QualifyingEncounter
["Medication, Not Administered": "Low Dose Unfractionated Heparin for VTE Prophylaxis"] union ["Medication, Not Administered": "Low Molecular Weight Heparin for VTE Prophylaxis"] union ["Medication, Not Administered": "Injectable Factor Xa Inhibitor for VTE Prophylaxis"] union ["Medication, Not Administered": "Warfarin"] union ["Medication, Not Ordered": "Low Dose Unfractionated Heparin for VTE Prophylaxis"] union ["Medication, Not Ordered": "Low Molecular Weight Heparin for VTE Prophylaxis"] union ["Medication, Not Ordered": "Injectable Factor Xa Inhibitor for VTE Prophylaxis"] union ["Medication, Not Ordered": "Warfarin"]
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, "ED Visit" EDVisit, "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication where EDVisit.relevantPeriod ends 1 hour or less on or before start of QualifyingEncounter.relevantPeriod and NoVTEMedication.negationRationale in "Medical Reason" and NoVTEMedication.authorDatetime during EDVisit.relevantPeriod return QualifyingEncounter
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication where NoVTEMedication.negationRationale in "Medical Reason" and NoVTEMedication.authorDatetime during VTEICU."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.relevantPeriod) return QualifyingEncounter
from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure, "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication where NoVTEMedication.negationRationale in "Medical Reason" and AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of QualifyingEncounter.relevantPeriod and NoVTEMedication.authorDatetime during VTEICU."CalendarDayOfOrDayAfter"(end of AnesthesiaProcedure.relevantPeriod) return QualifyingEncounter
( "No VTE Prophylaxis Medication Administered or Ordered" union "No VTE Prophylaxis Device Applied or Ordered" ) NoVTEProphylaxis where NoVTEProphylaxis.negationRationale in "Patient Refusal"
"VTE Prophylaxis Received on Day of or Day After Admission or Procedure" union ( "Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure" intersect ( "Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE" union "Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery" ) ) union "Low Risk for VTE or Anticoagulant Administered" union "No VTE Prophylaxis Due to Medical Reason" union "No VTE Prophylaxis Due to Patient Refusal"
["Procedure, Performed": "General Surgery"] union ["Procedure, Performed": "Gynecological Surgery"] union ["Procedure, Performed": "Hip Fracture Surgery"] union ["Procedure, Performed": "Hip Replacement Surgery"] union ["Procedure, Performed": "Intracranial Neurosurgery"] union ["Procedure, Performed": "Knee Replacement Surgery"] union ["Procedure, Performed": "Urological Surgery"]
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
( ["Medication, Administered": "Low Dose Unfractionated Heparin for VTE Prophylaxis"] VTEMedication where VTEMedication.route in "Subcutaneous route" ) union ["Medication, Administered": "Low Molecular Weight Heparin for VTE Prophylaxis"] union ["Medication, Administered": "Injectable Factor Xa Inhibitor for VTE Prophylaxis"] union ["Medication, Administered": "Warfarin"] union ["Device, Applied": "Intermittent pneumatic compression devices (IPC)"] union ["Device, Applied": "Venous foot pumps (VFP)"] union ["Device, Applied": "Graduated compression stockings (GCS)"]
( from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, "VTE Prophylaxis by Medication Administered or Device Applied" HasVTEProphylaxis where HasVTEProphylaxis.relevantPeriod starts during VTEICU."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.relevantPeriod) return QualifyingEncounter ) union ( from "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter, ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure, "VTE Prophylaxis by Medication Administered or Device Applied" HasVTEProphylaxis where AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of QualifyingEncounter.relevantPeriod and HasVTEProphylaxis.relevantPeriod starts during VTEICU."CalendarDayOfOrDayAfter"(end of AnesthesiaProcedure.relevantPeriod) return QualifyingEncounter )
years between ToDate(BirthDateTime)and ToDate(AsOf)
( singleton from ( ["Encounter, Performed": "Emergency Department Visit"] EDVisit where EDVisit.relevantPeriod ends 1 hour or less on or before start of Encounter.relevantPeriod ) ) X return if X is null then Encounter.relevantPeriod else Interval[start of X.relevantPeriod, end of Encounter.relevantPeriod]
difference in days between start of Value and end of Value
DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezone from Value)
Interval[StartValue, ToDate(StartValue + 2 days))
DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezone from Value)
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |