eCQM Title | Venous Thromboembolism Prophylaxis |
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eCQM Identifier (Measure Authoring Tool) | 108 | eCQM Version number | 8.2.000 |
NQF Number | Not Applicable | 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 | None | ||
Description | |||
Copyright | |||
Disclaimer | |||
Measure Scoring | Proportion | ||
Measure Type | Process | ||
Stratification | |||
Risk Adjustment | |||
Rate Aggregation | |||
Rationale | |||
Clinical Recommendation Statement | |||
Improvement Notation | |||
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Definition | |||
Guidance | |||
Transmission Format | |||
Initial Population | |||
Denominator | |||
Denominator Exclusions | |||
Numerator | |||
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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 "Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission" union "Encounter With Intervention Comfort Measures on Day of or Day After Procedure"
"Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure" union ( "Encounter With 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 "Encounter With Low Risk for VTE or Anticoagulant Administered" union "Encounter With No VTE Prophylaxis Due to Medical Reason" union "Encounter With 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" ) ) )
"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 "Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission" union "Encounter With Intervention Comfort Measures on Day of or Day After Procedure"
"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": "Birth date"] 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 Interval[start of QualifyingEncounter.relevantPeriod, Global."ToDate"(start of QualifyingEncounter.relevantPeriod + 2 days)) )
"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)during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)
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)during TJC."CalendarDayOfOrDayAfter"( end of AnesthesiaProcedure.relevantPeriod ) return QualifyingEncounter
"Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission" union "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure"
( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with ["Medication, Administered": "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication such that FactorXaMedication.relevantPeriod starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.relevantPeriod) ) 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 TJC."CalendarDayOfOrDayAfter"( end of AnesthesiaProcedure.relevantPeriod ) return QualifyingEncounter )
( "No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission" intersect "No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To 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 From Day of Start of Hospitalization To Day After Admission" union "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure"
"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" ) SelectedSCIPProcedure such that SelectedSCIPProcedure.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 QualifyingEncounterDiagnosis where QualifyingEncounterDiagnosis 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" QualifyingEncounter with "VTE Prophylaxis by Medication Administered or Device Applied" VTEProphylaxis such that VTEProphylaxis.relevantPeriod starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.relevantPeriod) ) 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" VTEProphylaxis where AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of QualifyingEncounter.relevantPeriod and VTEProphylaxis.relevantPeriod starts during TJC."CalendarDayOfOrDayAfter"( end of AnesthesiaProcedure.relevantPeriod ) return QualifyingEncounter )
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions"
["Intervention, Order": "Comfort Measures"] union ["Intervention, Performed": "Comfort Measures"]
( ["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 } )
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with "Is In Low Risk for VTE or On Anticoagulant" LowRiskForVTE such that LowRiskForVTE.authorDatetime during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)
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" LowRiskForVTE where AnesthesiaProcedure.relevantPeriod ends 1 day after day of start of QualifyingEncounter.relevantPeriod and LowRiskForVTE.authorDatetime during TJC."CalendarDayOfOrDayAfter"( end of AnesthesiaProcedure.relevantPeriod ) return QualifyingEncounter
["Encounter, Performed": "Encounter Inpatient"] EncounterInpatient where "LengthInDays"(EncounterInpatient.relevantPeriod)<= 120 and EncounterInpatient.relevantPeriod ends during "Measurement Period"
["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)"]
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with "No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice such that NoVTEDevice.negationRationale in "Medical Reason" and NoVTEDevice.authorDatetime during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(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 TJC."CalendarDayOfOrDayAfter"( end of AnesthesiaProcedure.relevantPeriod ) return QualifyingEncounter
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with "No VTE Prophylaxis Medication or Device Due to Patient Refusal" PatientRefusal such that PatientRefusal.authorDatetime during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(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 TJC."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"]
"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter with "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication such that NoVTEMedication.negationRationale in "Medical Reason" and NoVTEMedication.authorDatetime during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(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 TJC."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"
"Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure" union ( "Encounter With 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 "Encounter With Low Risk for VTE or Anticoagulant Administered" union "Encounter With No VTE Prophylaxis Due to Medical Reason" union "Encounter With No VTE Prophylaxis Due to Patient Refusal"
//'SCIP' stands for surgical care improvement Project ["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)"]
years between ToDate(BirthDateTime)and ToDate(AsOf)
Encounter Visit let ObsVisit: Last(["Encounter, Performed": "Observation Services"] LastObs where LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod sort by end of relevantPeriod ), VisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod), EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED where LastED.relevantPeriod ends 1 hour or less on or before VisitStart sort by end of relevantPeriod ) return Interval[Coalesce(start of EDVisit.relevantPeriod, VisitStart), end of Visit.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[Global."ToDate"(StartValue), Global."ToDate"(StartValue + 2 days))
Interval[Global."ToDate"(start of Global."HospitalizationWithObservation"(Encounter)), Global."ToDate"(start of Encounter.relevantPeriod + 2 days))
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |