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). This measure is part of a set of six prevention and treatment measures that address VTE (VTE-1: VTE Prophylaxis, VTE-3: VTE Patients with Anticoagulation Overlap Therapy, VTE-4: VTE Patients Receiving UFH with Dosages/Platelet Count Monitoring by Protocol, VTE-5: VTE Warfarin Therapy Discharge Instructions and VTE-6: Hospital Acquired Potentially-Preventable VTE).
Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given:
• the day of or the day after ICU admission (or transfer)
• the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer)
Denominator
1.15 Denominator
Patients directly admitted or transferred to ICU
Exclusions
Exclusions
• Patients less than 18 years of age • Patients who have a hospital 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 with ICU LOS less than one day without VTE prophylaxis administered and documentation for no VTE prophylaxis • Patients with ICD-9-CM Principal or Other Diagnosis Code 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 that start the day of or the day after ICU admission or transfer.
Measure Record
Most Recent Endorsement Activity
Measure Retired and Endorsement Removed Patient Safety Spring Cycle 2018
Initial Endorsement
Last Updated
Removal Date
Point of Contact
Steward Organization
The Joint Commission
Steward POC email
jalban@jointcommission.org
Steward 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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