Intensive Care Unit Venous Thromboembolism Prophylaxis 13.2.000

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)

Measure specifications are in the Public Domain.

LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.

These performance measures are not clinical guidelines and do not establish a standard of medical care and have not been tested for all potential applications. The measures and specifications are provided without warranty.

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.

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.

Improvement noted as an increase in rate

Reference Type: CITATION

Reference Text: 'Anderson, D. R., Morgano, G. P., Bennett, C., Dentali, F., Francis, C. W., Garcia, D. A., . . . Dahm, P. (2019). American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Advances, 3(23), 3898–3944. https://doi.org/10.1182/bloodadvances.2019000975'

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention (2022). National Healthcare Safety Network (NHSN) Patient Safety Component Manual. Retrieved December 4, 2023, from https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf'

Reference Type: CITATION

Reference Text: 'Geerts, W. H., Bergqvist, D., Pineo, G. F., Heit, J. A., Samama, C. M., Lassen, M. R., & Colwell, C. W. (2008). Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest, 133(6), 381S-453s. https://doi.org/10.1378/chest.08-0656'

Reference Type: CITATION

Reference Text: 'Geerts, W. H., Pineo, G. F., Heit, J. A., Bergqvist, D., Lassen, M. R., Colwell, C. W., & Ray, J. G. (2004). Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 126(3 Suppl), 338S–400S. https://doi.org/10.1378/chest.126.3_suppl.338S'

Reference Type: CITATION

Reference Text: 'Guyatt, G. H., Akl, E. A., Crowther, M., Gutterman, D. D., Schuünemann, H. J., & American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel (2012). Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141(2 Suppl), 7S–47S. https://doi.org/10.1378/chest.1412S3'

Reference Type: CITATION

Reference Text: 'Henke, P. K., Kahn, S. R., Pannucci, C. J., Secemksy, E. A., Evans, N. S., Khorana, A. A., Creager, M. A., Pradhan, A. D., & American Heart Association Advocacy Coordinating Committee (2020). Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association. Circulation, 141(24), e914–e931. https://doi.org/10.1161/CIR.0000000000000769'

Reference Type: CITATION

Reference Text: 'Kearon, C., Akl, E. A., Comerota, A. J., Prandoni, P., Bounameaux, H., Goldhaber, S. Z., Nelson, M. E., Wells, P. S., Gould, M. K., Dentali, F., Crowther, M., & Kahn, S. R. (2012). Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141(2 Suppl), e419S–e496S. https://doi.org/10.1378/chest.11-2301'

Reference Type: CITATION

Reference Text: 'Maynard G. (2016). Preventing hospital-associated venous thromboembolism: a guide for effective
quality improvement, 2nd ed. Rockville, MD: Agency for Healthcare Research and Quality; AHRQ Publication No. 16-0001-EF.'

Reference Type: CITATION

Reference Text: 'Schünemann, H. J., Cushman, M., Burnett, A. E., Kahn, S. R., Beyer-Westendorf, J., Spencer, F. A., . . . Wiercioch, W. (2018). American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Advances, 2(22), 3198–3225. https://doi.org/10.1182/bloodadvances.2018022954'

Reference Type: CITATION

Reference Text: 'Stevens, S. M., Woller, S. C., Baumann Kreuziger, L., Bounameaux, H., Doerschug, K., Geersing, G. J., Huisman, M. V., Kearon, C., King, C. S., Knighton, A. J., Lake, E., Murin, S., Vintch, J. R. E., Wells, P. S., & Moores, L. K. (2021). Executive Summary: Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest, 160(6), 2247–2259. https://doi.org/10.1016/j.chest.2021.07.056'

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 eCQI Resource Center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

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 directly admitted or transferred to ICU during the hospitalization

- 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

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)

Inpatient hospitalizations for patients with ICU LOS less than one day

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Initial Population

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions"

- Denominator
  - "Encounter with ICU Location"

Denominator Exclusions

"Encounter with ICU Location And Encounter Less Than 2 Days"
  union "Encounter with First ICU Stay with Principal Procedure of SCIP VTE Selected Surgery"
  union "Encounter with Intervention Comfort Measures From Day Of Start of Hospitalization To Day After First ICU Stay"
  union "Encounter with Intervention Comfort Measures on Day of or Day After Procedure"

Numerator

"Encounter with VTE Prophylaxis Received on Day of or Day After First ICU Stay or Procedure"
  union ( "Encounter with Medication Oral Factor Xa Inhibitor Administered on Day of or Day After First ICU Stay or Procedure"
      intersect ( "Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Prior Diagnosis of 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"

- Numerator Exclusions
  - None

Denominator Exceptions

"Encounter with First ICU Location Stay Less Than 1 day"

- Stratification
  - None

Denominator
- - "Encounter with ICU Location"

Denominator Exceptions

"Encounter with First ICU Location Stay Less Than 1 day"

Denominator Exclusions

"Encounter with ICU Location And Encounter Less Than 2 Days"
  union "Encounter with First ICU Stay with Principal Procedure of SCIP VTE Selected Surgery"
  union "Encounter with Intervention Comfort Measures From Day Of Start of Hospitalization To Day After First ICU Stay"
  union "Encounter with Intervention Comfort Measures on Day of or Day After Procedure"

Encounter with First ICU Location Stay Less Than 1 day

"Encounter with ICU Location" QualifyingEncounterICU
  where Global."LengthInDays" ( VTE."FirstICULocationPeriod" ( QualifyingEncounterICU ) ) < 1

Encounter with First ICU Stay with Principal Procedure of SCIP VTE Selected Surgery

"Encounter with ICU Location" QualifyingEncounterICU
  with ( "SCIP VTE Selected Surgery" Procedure
    where Procedure.rank = 1 ) SelectedSCIPProcedure
    such that Global."NormalizeInterval" ( SelectedSCIPProcedure.relevantDatetime, SelectedSCIPProcedure.relevantPeriod ) ends during day of TJC."CalendarDayOfOrDayAfter" ( VTE."StartOfFirstICU" ( QualifyingEncounterICU ) )

Encounter with ICU Location

VTE."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 Location.locationPeriod during QualifyingEncounter.relevantPeriod
  )

Encounter with ICU Location And Encounter Less Than 2 Days

"Encounter with ICU Location" QualifyingEncounterICU
  where Global."LengthInDays" ( QualifyingEncounterICU.relevantPeriod ) < 2

Encounter with Intervention Comfort Measures From Day Of Start of Hospitalization To Day After First ICU Stay

"Encounter with ICU Location" QualifyingEncounterICU
  with "Intervention Comfort Measures" ComfortMeasures
    such that Coalesce(start of Global."NormalizeInterval"(ComfortMeasures.relevantDatetime, ComfortMeasures.relevantPeriod), ComfortMeasures.authorDatetime) during day of VTE."FromDayOfStartOfHospitalizationToDayAfterFirstICU" ( QualifyingEncounterICU )

Encounter with Intervention Comfort Measures on Day of or Day After Procedure

from
  "Encounter with ICU Location" QualifyingEncounterICU,
  ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  "Intervention Comfort Measures" ComfortMeasures
  where Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of VTE."StartOfFirstICU" ( QualifyingEncounterICU )
    and Coalesce(start of Global."NormalizeInterval"(ComfortMeasures.relevantDatetime, ComfortMeasures.relevantPeriod), ComfortMeasures.authorDatetime) during day of TJC."CalendarDayOfOrDayAfter" ( end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
  return QualifyingEncounterICU

Encounter with Low Risk for VTE or Anticoagulant Administered

"Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After First ICU Stay"
  union "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure"

Encounter with Medication Oral Factor Xa Inhibitor Administered on Day of or Day After First ICU Stay or Procedure

( "Encounter with ICU Location" QualifyingEncounterICU
    with ["Medication, Administered": "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication
      such that Global."NormalizeInterval" ( FactorXaMedication.relevantDatetime, FactorXaMedication.relevantPeriod ) starts during day of TJC."CalendarDayOfOrDayAfter" ( VTE."StartOfFirstICU" ( QualifyingEncounterICU ) )
)
  union ( from
      "Encounter with ICU Location" QualifyingEncounterICU,
      ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
      ["Medication, Administered": "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication
      where Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of VTE."StartOfFirstICU" ( QualifyingEncounterICU )
        and Global."NormalizeInterval" ( FactorXaMedication.relevantDatetime, FactorXaMedication.relevantPeriod ) starts during day of TJC."CalendarDayOfOrDayAfter" ( end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
      return QualifyingEncounterICU
  )

Encounter with No VTE Prophylaxis Due to Medical Reason

( "No VTE Prophylaxis Medication Due to Medical Reason From Day Of Start of Hospitalization To Day After First ICU Stay"
    intersect "No Mechanical VTE Prophylaxis Due to Medical Reason From Day Of Start of Hospitalization To Day After First ICU Stay"
)
  union ( "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure"
      intersect "No Mechanical VTE Prophylaxis Due to Medical Reason on Day of or Day After Procedure"
  )

Encounter with No VTE Prophylaxis Due to Patient Refusal

"No VTE Prophylaxis Due to Patient Refusal From Day Of Start of Hospitalization To Day After First ICU Stay"
  union "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure"

Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Prior Diagnosis of VTE

( "Encounter with ICU Location" QualifyingEncounterICU
    with ["Diagnosis": "Atrial Fibrillation or Flutter"] AtrialFibrillation
      such that AtrialFibrillation.prevalencePeriod starts on or before end of QualifyingEncounterICU.relevantPeriod
)
  union ( "Encounter with ICU Location" QualifyingEncounterICU
      where exists ( QualifyingEncounterICU.diagnoses QualifyingEncounterDiagnoses
          where QualifyingEncounterDiagnoses.code in "Atrial Fibrillation or Flutter"
      )
  )
  union ( "Encounter with ICU Location" QualifyingEncounterICU
      with ["Diagnosis": "Venous Thromboembolism"] VTEDiagnosis
        such that VTEDiagnosis.prevalencePeriod starts before start of QualifyingEncounterICU.relevantPeriod
  )

Encounter with Prior or Present Procedure of Hip or Knee Replacement Surgery

"Encounter with ICU Location" QualifyingEncounterICU
  with ( ["Procedure, Performed": "Hip Replacement Surgery"]
    union ["Procedure, Performed": "Knee Replacement Surgery"] ) HipKneeProcedure
    such that Global."NormalizeInterval" ( HipKneeProcedure.relevantDatetime, HipKneeProcedure.relevantPeriod ) starts on or before end of QualifyingEncounterICU.relevantPeriod

Encounter with VTE Prophylaxis Received on Day of or Day After First ICU Stay or Procedure

( "Encounter with ICU Location" QualifyingEncounterICU
    with "Pharmacological or Mechanical VTE Prophylaxis Received" VTEProphylaxis
      such that Global."NormalizeInterval" ( VTEProphylaxis.relevantDatetime, VTEProphylaxis.relevantPeriod ) starts during day of TJC."CalendarDayOfOrDayAfter" ( VTE."StartOfFirstICU" ( QualifyingEncounterICU ) )
)
  union ( from
      "Encounter with ICU Location" QualifyingEncounterICU,
      ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
      "Pharmacological or Mechanical VTE Prophylaxis Received" VTEProphylaxis
      where Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of VTE."StartOfFirstICU" ( QualifyingEncounterICU )
        and Global."NormalizeInterval" ( VTEProphylaxis.relevantDatetime, VTEProphylaxis.relevantPeriod ) starts during day of TJC."CalendarDayOfOrDayAfter" ( end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
      return QualifyingEncounterICU
  )

Initial Population

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions"

Intervention Comfort Measures

["Intervention, Order": "Comfort Measures"]
  union ["Intervention, Performed": "Comfort Measures"]

Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After First ICU Stay

"Encounter with ICU Location" QualifyingEncounterICU
  with "Low Risk Indicator For VTE" LowRiskForVTE
    such that LowRiskForVTE.LowRiskDatetime during day of VTE."FromDayOfStartOfHospitalizationToDayAfterFirstICU" ( QualifyingEncounterICU )

Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure

from
  "Encounter with ICU Location" QualifyingEncounterICU,
  ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  "Low Risk Indicator For VTE" LowRiskForVTE
  where Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of VTE."StartOfFirstICU" ( QualifyingEncounterICU )
    and LowRiskForVTE.LowRiskDatetime during day of TJC."CalendarDayOfOrDayAfter" ( end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
  return QualifyingEncounterICU

Low Risk Indicator For VTE

/*The variable "LowRiskDatetime" is to hold VTE Risk Assessment relevant dateTime, INR Laboratory Test result dateTime, and Anticoagulant Medication administration start dateTime.
*/

( ["Assessment, Performed": "Risk for venous thromboembolism"] VTERiskAssessment
    where VTERiskAssessment.result in "Low Risk"
    return {
      id: VTERiskAssessment.id,
      LowRiskDatetime: Global."EarliestOf" ( VTERiskAssessment.relevantDatetime, VTERiskAssessment.relevantPeriod )
    }
)
  union ( ["Laboratory Test, Performed": "INR"] INRLabTest
      where INRLabTest.result > 3.0
      return {
        id: INRLabTest.id,
        LowRiskDatetime: 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 {
        id: AnticoagulantMedication.id,
        LowRiskDatetime: start of Global."NormalizeInterval" ( AnticoagulantMedication.relevantDatetime, AnticoagulantMedication.relevantPeriod )
      }
  )

Global.Inpatient Encounter

["Encounter, Performed": "Encounter Inpatient"] EncounterInpatient
  where EncounterInpatient.relevantPeriod ends during day of "Measurement Period"

No Mechanical or Pharmacological VTE Prophylaxis Due to Patient Refusal

( "No VTE Prophylaxis Medication Administered or Ordered"
  union "No Mechanical VTE Prophylaxis Performed or Ordered" ) NoVTEProphylaxis
  where NoVTEProphylaxis.negationRationale in "Patient Refusal"

No Mechanical VTE Prophylaxis Due to Medical Reason From Day Of Start of Hospitalization To Day After First ICU Stay

"Encounter with ICU Location" QualifyingEncounterICU
  with "No Mechanical VTE Prophylaxis Performed or Ordered" NoMechanicalProphylaxis
    such that NoMechanicalProphylaxis.negationRationale in "Medical Reason For Not Providing Treatment"
      and NoMechanicalProphylaxis.authorDatetime during day of VTE."FromDayOfStartOfHospitalizationToDayAfterFirstICU" ( QualifyingEncounterICU )

No Mechanical VTE Prophylaxis Due to Medical Reason on Day of or Day After Procedure

from
  "Encounter with ICU Location" QualifyingEncounterICU,
  ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  "No Mechanical VTE Prophylaxis Performed or Ordered" NoMechanicalProphylaxis
  where NoMechanicalProphylaxis.negationRationale in "Medical Reason For Not Providing Treatment"
    and Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of VTE."StartOfFirstICU" ( QualifyingEncounterICU )
    and NoMechanicalProphylaxis.authorDatetime during day of TJC."CalendarDayOfOrDayAfter" ( end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
  return QualifyingEncounterICU

No Mechanical VTE Prophylaxis Performed or Ordered

["Procedure, Not Performed": "Application of Intermittent Pneumatic Compression Devices"]
  union ["Procedure, Not Performed": "Application of Venous Foot Pumps"]
  union ["Procedure, Not Performed": "Application of Graduated Compression Stockings"]
  union ["Device, Not Ordered": "Intermittent pneumatic compression devices"]
  union ["Device, Not Ordered": "Venous foot pumps"]
  union ["Device, Not Ordered": "Graduated compression stockings"]

No VTE Prophylaxis Due to Patient Refusal From Day Of Start of Hospitalization To Day After First ICU Stay

"Encounter with ICU Location" QualifyingEncounterICU
  with "No Mechanical or Pharmacological VTE Prophylaxis Due to Patient Refusal" PatientRefusal
    such that PatientRefusal.authorDatetime during day of VTE.FromDayOfStartOfHospitalizationToDayAfterFirstICU ( QualifyingEncounterICU )

No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure

from
  "Encounter with ICU Location" QualifyingEncounterICU,
  ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  "No Mechanical or Pharmacological VTE Prophylaxis Due to Patient Refusal" PatientRefusal
  where Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of VTE."StartOfFirstICU" ( QualifyingEncounterICU )
    and PatientRefusal.authorDatetime during day of TJC."CalendarDayOfOrDayAfter" ( end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
  return QualifyingEncounterICU

No VTE Prophylaxis Medication Administered or Ordered

["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 Administered": "Rivaroxaban for VTE Prophylaxis"]
  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"]
  union ["Medication, Not Ordered": "Rivaroxaban for VTE Prophylaxis"]

No VTE Prophylaxis Medication Due to Medical Reason From Day Of Start of Hospitalization To Day After First ICU Stay

"Encounter with ICU Location" QualifyingEncounterICU
  with "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
    such that NoVTEMedication.negationRationale in "Medical Reason For Not Providing Treatment"
      and NoVTEMedication.authorDatetime during day of VTE."FromDayOfStartOfHospitalizationToDayAfterFirstICU" ( QualifyingEncounterICU )

No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure

from
  "Encounter with ICU Location" QualifyingEncounterICU,
  ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
  where NoVTEMedication.negationRationale in "Medical Reason For Not Providing Treatment"
    and Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of VTE."StartOfFirstICU" ( QualifyingEncounterICU )
    and NoVTEMedication.authorDatetime during day of TJC."CalendarDayOfOrDayAfter" ( end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
  return QualifyingEncounterICU

Numerator

"Encounter with VTE Prophylaxis Received on Day of or Day After First ICU Stay or Procedure"
  union ( "Encounter with Medication Oral Factor Xa Inhibitor Administered on Day of or Day After First ICU Stay or Procedure"
      intersect ( "Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Prior Diagnosis of 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"

Pharmacological or Mechanical VTE Prophylaxis Received

( ["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 ["Medication, Administered": "Rivaroxaban for VTE Prophylaxis"]
  union ["Procedure, Performed": "Application of Intermittent Pneumatic Compression Devices"]
  union ["Procedure, Performed": "Application of Venous Foot Pumps"]
  union ["Procedure, Performed": "Application of Graduated Compression Stockings"]

SCIP VTE Selected Surgery

//'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"]

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer Type"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

VTE.Admission without VTE or Obstetrical Conditions

Global."Inpatient Encounter" InpatientEncounter
  where not ( exists ( InpatientEncounter.diagnoses EncounterDiagnoses
        where ( EncounterDiagnoses.code in "Obstetrical or Pregnancy Related Conditions"
            or EncounterDiagnoses.code in "Venous Thromboembolism"
            or EncounterDiagnoses.code in "Obstetrics VTE"
        )
    )
  )

VTE.Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions

"Admission without VTE or Obstetrical Conditions" EncounterWithoutConditions
  where AgeInYearsAt(date from start of EncounterWithoutConditions.relevantPeriod)>= 18

Global.Earliest(period Interval<DateTime>)

if ( HasStart(period)) then start of period 
  else 
end of period

Global.EarliestOf(pointInTime DateTime, period Interval<DateTime>)
- - Earliest(NormalizeInterval(pointInTime, period))

Global.FirstInpatientIntensiveCareUnit(Encounter "Encounter, Performed")

First((Encounter.facilityLocations)HospitalLocation
    where HospitalLocation.code in "Intensive Care Unit"
      and HospitalLocation.locationPeriod during Encounter.relevantPeriod
    sort by start of locationPeriod
)

Global.HasStart(period Interval<DateTime>)

not ( start of period is null
    or start of period = minimum DateTime
)

Global.HospitalizationWithObservation(Encounter "Encounter, Performed")

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]

Global.LengthInDays(Value Interval<DateTime>)

difference in days between start of Value and end of Value

Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

if pointInTime is not null then Interval[pointInTime, pointInTime]
  else if period is not null then period 
  else null as Interval<DateTime>

TJC.CalendarDayOfOrDayAfter(StartValue DateTime)

Interval[date from ( StartValue ), date from ( StartValue ) + 1 day]

VTE.FirstICULocationPeriod(Encounter "Encounter, Performed")

Global."FirstInpatientIntensiveCareUnit" ( Encounter ).locationPeriod

VTE.FromDayOfStartOfHospitalizationToDayAfterFirstICU(Encounter "Encounter, Performed")

Interval[date from ( start of Global."HospitalizationWithObservation" ( Encounter ) ), date from ( StartOfFirstICU(Encounter) ) + 1 day]

VTE.StartOfFirstICU(Encounter "Encounter, Performed")
- - start of "FirstICULocationPeriod"(Encounter)

code "Risk for venous thromboembolism" ("LOINC Code (72136-5)")
valueset "Application of Graduated Compression Stockings" (2.16.840.1.113762.1.4.1110.66)
valueset "Application of Intermittent Pneumatic Compression Devices" (2.16.840.1.113762.1.4.1110.65)
valueset "Application of Venous Foot Pumps" (2.16.840.1.113762.1.4.1110.64)
valueset "Atrial Fibrillation or Flutter" (2.16.840.1.113883.3.117.1.7.1.202)
valueset "Comfort Measures" (1.3.6.1.4.1.33895.1.3.0.45)
valueset "Direct Thrombin Inhibitor" (2.16.840.1.113883.3.117.1.7.1.205)
valueset "Emergency Department Visit" (2.16.840.1.113883.3.117.1.7.1.292)
valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "General or Neuraxial Anesthesia" (2.16.840.1.113883.3.666.5.1743)
valueset "General Surgery" (2.16.840.1.113883.3.117.1.7.1.255)
valueset "Glycoprotein IIb IIIa Inhibitors" (2.16.840.1.113762.1.4.1045.41)
valueset "Graduated compression stockings" (2.16.840.1.113883.3.117.1.7.1.256)
valueset "Gynecological Surgery" (2.16.840.1.113883.3.117.1.7.1.257)
valueset "Hip Fracture Surgery" (2.16.840.1.113883.3.117.1.7.1.258)
valueset "Hip Replacement Surgery" (2.16.840.1.113883.3.117.1.7.1.259)
valueset "Injectable Factor Xa Inhibitor for VTE Prophylaxis" (2.16.840.1.113883.3.117.1.7.1.211)
valueset "INR" (2.16.840.1.113883.3.117.1.7.1.213)
valueset "Intensive Care Unit" (2.16.840.1.113762.1.4.1029.206)
valueset "Intermittent pneumatic compression devices" (2.16.840.1.113883.3.117.1.7.1.214)
valueset "Intracranial Neurosurgery" (2.16.840.1.113883.3.117.1.7.1.260)
valueset "Intravenous route" (2.16.840.1.113883.3.117.1.7.1.222)
valueset "Knee Replacement Surgery" (2.16.840.1.113883.3.117.1.7.1.261)
valueset "Low Dose Unfractionated Heparin for VTE Prophylaxis" (2.16.840.1.113762.1.4.1045.39)
valueset "Low Molecular Weight Heparin for VTE Prophylaxis" (2.16.840.1.113883.3.117.1.7.1.219)
valueset "Low Risk" (2.16.840.1.113883.3.117.1.7.1.400)
valueset "Medical Reason For Not Providing Treatment" (2.16.840.1.113883.3.117.1.7.1.473)
valueset "Observation Services" (2.16.840.1.113762.1.4.1111.143)
valueset "Obstetrical or Pregnancy Related Conditions" (2.16.840.1.113883.3.117.1.7.1.263)
valueset "Obstetrics VTE" (2.16.840.1.113883.3.117.1.7.1.264)
valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
valueset "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment" (2.16.840.1.113883.3.117.1.7.1.134)
valueset "Patient Refusal" (2.16.840.1.113883.3.117.1.7.1.93)
valueset "Payer Type" (2.16.840.1.114222.4.11.3591)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "Rivaroxaban for VTE Prophylaxis" (2.16.840.1.113762.1.4.1110.50)
valueset "Subcutaneous route" (2.16.840.1.113883.3.117.1.7.1.223)
valueset "Unfractionated Heparin" (2.16.840.1.113883.3.117.1.7.1.218)
valueset "Urological Surgery" (2.16.840.1.113883.3.117.1.7.1.272)
valueset "Venous foot pumps" (2.16.840.1.113883.3.117.1.7.1.230)
valueset "Venous Thromboembolism" (2.16.840.1.113883.3.117.1.7.1.279)
valueset "Warfarin" (2.16.840.1.113883.3.117.1.7.1.232)

"Assessment, Performed: Risk for venous thromboembolism" using "Risk for venous thromboembolism (LOINC Code 72136-5)"
"Device, Not Ordered: Graduated compression stockings" using "Graduated compression stockings (2.16.840.1.113883.3.117.1.7.1.256)"
"Device, Not Ordered: Intermittent pneumatic compression devices" using "Intermittent pneumatic compression devices (2.16.840.1.113883.3.117.1.7.1.214)"
"Device, Not Ordered: Venous foot pumps" using "Venous foot pumps (2.16.840.1.113883.3.117.1.7.1.230)"
"Diagnosis: Atrial Fibrillation or Flutter" using "Atrial Fibrillation or Flutter (2.16.840.1.113883.3.117.1.7.1.202)"
"Diagnosis: Venous Thromboembolism" using "Venous Thromboembolism (2.16.840.1.113883.3.117.1.7.1.279)"
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.117.1.7.1.292)"
"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
"Encounter, Performed: Observation Services" using "Observation Services (2.16.840.1.113762.1.4.1111.143)"
"Intervention, Order: Comfort Measures" using "Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45)"
"Intervention, Performed: Comfort Measures" using "Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45)"
"Laboratory Test, Performed: INR" using "INR (2.16.840.1.113883.3.117.1.7.1.213)"
"Medication, Administered: Direct Thrombin Inhibitor" using "Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205)"
"Medication, Administered: Glycoprotein IIb IIIa Inhibitors" using "Glycoprotein IIb IIIa Inhibitors (2.16.840.1.113762.1.4.1045.41)"
"Medication, Administered: Injectable Factor Xa Inhibitor for VTE Prophylaxis" using "Injectable Factor Xa Inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211)"
"Medication, Administered: Low Dose Unfractionated Heparin for VTE Prophylaxis" using "Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39)"
"Medication, Administered: Low Molecular Weight Heparin for VTE Prophylaxis" using "Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219)"
"Medication, Administered: Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment" using "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (2.16.840.1.113883.3.117.1.7.1.134)"
"Medication, Administered: Rivaroxaban for VTE Prophylaxis" using "Rivaroxaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50)"
"Medication, Administered: Unfractionated Heparin" using "Unfractionated Heparin (2.16.840.1.113883.3.117.1.7.1.218)"
"Medication, Administered: Warfarin" using "Warfarin (2.16.840.1.113883.3.117.1.7.1.232)"
"Medication, Not Administered: Injectable Factor Xa Inhibitor for VTE Prophylaxis" using "Injectable Factor Xa Inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211)"
"Medication, Not Administered: Low Dose Unfractionated Heparin for VTE Prophylaxis" using "Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39)"
"Medication, Not Administered: Low Molecular Weight Heparin for VTE Prophylaxis" using "Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219)"
"Medication, Not Administered: Rivaroxaban for VTE Prophylaxis" using "Rivaroxaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50)"
"Medication, Not Administered: Warfarin" using "Warfarin (2.16.840.1.113883.3.117.1.7.1.232)"
"Medication, Not Ordered: Injectable Factor Xa Inhibitor for VTE Prophylaxis" using "Injectable Factor Xa Inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211)"
"Medication, Not Ordered: Low Dose Unfractionated Heparin for VTE Prophylaxis" using "Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39)"
"Medication, Not Ordered: Low Molecular Weight Heparin for VTE Prophylaxis" using "Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219)"
"Medication, Not Ordered: Rivaroxaban for VTE Prophylaxis" using "Rivaroxaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50)"
"Medication, Not Ordered: Warfarin" using "Warfarin (2.16.840.1.113883.3.117.1.7.1.232)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer Type" using "Payer Type (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
"Procedure, Not Performed: Application of Graduated Compression Stockings" using "Application of Graduated Compression Stockings (2.16.840.1.113762.1.4.1110.66)"
"Procedure, Not Performed: Application of Intermittent Pneumatic Compression Devices" using "Application of Intermittent Pneumatic Compression Devices (2.16.840.1.113762.1.4.1110.65)"
"Procedure, Not Performed: Application of Venous Foot Pumps" using "Application of Venous Foot Pumps (2.16.840.1.113762.1.4.1110.64)"
"Procedure, Performed: Application of Graduated Compression Stockings" using "Application of Graduated Compression Stockings (2.16.840.1.113762.1.4.1110.66)"
"Procedure, Performed: Application of Intermittent Pneumatic Compression Devices" using "Application of Intermittent Pneumatic Compression Devices (2.16.840.1.113762.1.4.1110.65)"
"Procedure, Performed: Application of Venous Foot Pumps" using "Application of Venous Foot Pumps (2.16.840.1.113762.1.4.1110.64)"
"Procedure, Performed: General or Neuraxial Anesthesia" using "General or Neuraxial Anesthesia (2.16.840.1.113883.3.666.5.1743)"
"Procedure, Performed: General Surgery" using "General Surgery (2.16.840.1.113883.3.117.1.7.1.255)"
"Procedure, Performed: Gynecological Surgery" using "Gynecological Surgery (2.16.840.1.113883.3.117.1.7.1.257)"
"Procedure, Performed: Hip Fracture Surgery" using "Hip Fracture Surgery (2.16.840.1.113883.3.117.1.7.1.258)"
"Procedure, Performed: Hip Replacement Surgery" using "Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259)"
"Procedure, Performed: Intracranial Neurosurgery" using "Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260)"
"Procedure, Performed: Knee Replacement Surgery" using "Knee Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.261)"
"Procedure, Performed: Urological Surgery" using "Urological Surgery (2.16.840.1.113883.3.117.1.7.1.272)"

["Patient Characteristic Ethnicity": "Ethnicity"]

["Patient Characteristic Payer": "Payer Type"]

```
["Patient Characteristic Race": "Race"]
```

["Patient Characteristic Sex": "ONC Administrative Sex"]

eMeasure Venous Thromboembolism (eVTE)

Intensive Care Unit Venous Thromboembolism Prophylaxis

Table of Contents

Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables