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 hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. This measure is part of a set of six nationally implemented prevention and treatment measures that address VTE (VTE-2: ICU VTE Prophylaxis, VTE-3: VTE Patients with Anticoagulation Overlap Therapy, VTE-4: VTE Patients Receiving UFH with Dosages/Platelet Count Monitoring, VTE-5: VTE Warfarin Therapy Discharge Instructions and VTE-6:
Hospital Acquired Potentially-Preventable VTE) that are used in The Joint Commission’s accreditation process.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.9 Care Setting1.20 Testing Data Sources
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1.14 Numerator
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
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1.15 Denominator
All discharged hospital inpatients
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Exclusions
• Patients less than 18 years of age
• Patients who have a length of stay (LOS) less than two days and greater than 120 days
• Patients with Comfort Measures Only documented on day of or day after hospital arrival
• Patients enrolled in clinical trials related to VTE
• 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 LOS greater than or equal to one day
• Patients with ICD-9-CM Principal Diagnosis Code of Mental Disorders or Stroke as defined in Appendix A, Table 7.01, 8.1 or 8.2
• Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics or VTE as defined in Appendix A, Table 7.02, 7.03 or 7.04
• Patients with ICD-9-CM Principal Procedure Code of Surgical Care Improvement Project (SCIP) VTE selected surgeries as defined in Appendix A, Tables 5.17, 5.19, 5.20, 5.21, 5.22, 5.23, 5.24
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Patient Safety Spring Cycle 2018Initial EndorsementLast UpdatedRemoval Date
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StewardThe Joint CommissionSteward Organization POC EmailSteward Organization Copyright
The Specifications Manual for National Hospital Inpatient Quality Measures (Specifications Manual) is the result of the collaborative efforts of the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission to publish a uniform set of national hospital quality measures. A primary objective of this collaborative effort is to promote and enhance the utility of these measures for all hospitals.
No royalty or use fee is required for copying or reprinting this manual, but the following are required as a condition of usage: 1) disclosure that the Specifications Manual is periodically updated, and that the version being copied or reprinted may not be up-to-date when used unless the copier or printer has verified the version to be up-to-date and affirms that, and 2) users participating in the QIO supported initiatives, the Hospital Inpatient Quality Reporting Program, and Joint Commission accreditation; including performance measures systems; are required to update their software and associated documentation based on the published manual production timelines.
Example Acknowledgement: The Specifications Manual for National Hospital Inpatient Quality Measures [Version xx, Month, Year] is the collaborative work of the Centers for Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is periodically updated by the Centers for Medicare & Medicaid Services and The Joint Commission. Users of the Specifications Manual for National Hospital Inpatient Quality Measures must update their software and associated documentation based on the published manual production timelines.
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Risk Adjustment
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