Performance Measurement Network

Question: What is the purpose of the Missing Branch ('X' Category Assignment) for VTE Prophylaxis Date?

If VTE prophylaxis was initiated in the ED prior to admission, and the only documented date of prophylaxis is prior to admission, how should the case be abstracted? Will the case be assigned to Measure Category X beginning with April 1, 2011 discharges, if the VTE Prophylaxis Date is after hospital arrival but prior to hospital admission?

For example, a patient arrives in the ED 4/1/2011, and IPC started 4/1/2011. The patient is admitted to the hospital on 4/2/2011, but the only documented date of VTE prophylxis in the medical record is 4/1/2011. What documentation needs to be present in order to avoid a Measure Category Assignment of X?

Also, should all documentation prior to admission be disregarded? If VTE prophylaxis is started in the ED on the day prior to admission, is the expectation that there must be additional documentation on the day of admission or day after hospital admission in order to pass the measure?

Answer:

Yes, the expectation is that there will be documentation of VTE prophylaxis administered on the day of or day after hospital admission, even when VTE prophylaxis was initially administered in the ED or observation prior to hospital admission. When the "VTE Prophylaxis Date" is the admission date or the date of the day after hospital admission, the Measure Category Assignment will be E (numerator) and not X (missing/invalid).

The following rationale supports this measure category assignment: A single dose of SQ heparin or application of mechanical IPC/SCD is insufficient therapy and should not pass as VTE prophylaxis. If VTE prophylaxis is initiated prior to hospital admission, i.e. ED or observation, it is expected that it will be continued on admission. If prophylaxis is continued on admission, then documentation reflecting its continuation should be present in the medical record. The data element definition for "VTE Prophylaxis" stroke-specific 'Notes for Abstraction' state to abstract only prophylaxis given after hospital admission. In other words, abstract the first VTE prophylaxis given after admission and the corresponding date ("VTE Prophylaxis Date"). If there was 'None'/no VTE prophylaxis given after admission, select 'A' and answer "Reason for NO VTE Prophylaxis-Hospital Admission".

The abstractor may use documentation prior to hospital admission to determine if there was a "Reason For No VTE Prophylaxis-Hospital Admission". The following guideline has been added to the data element definition found in Version 3.3_1 of the specifications manual, effective April 1, 2011: “Documentation of the reason for no VTE Prophylaxis must be written by the day after hospital admission or surgery end date. Documentation written after arrival but prior to admission is acceptable.” For example, if the patient was in ED 4/1/2011 and a reason for no prophylaxis, e.g. “No VTE Prophylaxis needed’; “INR 3.5”, documented on 4/1/2011 prior to admission on 4/2/2011, that documentation could be used to select ‘Yes’ for "Reason for No VTE Prophylaxis-Hospital Admission".

For complete abstraction guidelines for all data elements referenced in this response, please see the Specifications Manual for National Hospital Inpatient Quality Measures, Version 3.3_1 Aplhabetical Data Dictionary and STK-1 MIF pdf.

http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures/.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-01, VTE Prophylaxis Date
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