Release Notes:
Data Element
Version 2016B1
Data Element Name: | Reason for No VTE Prophylaxis – Hospital Admission |
Collected For: | STK-1, |
Definition: | Physician/APN/PA or pharmacist documentation why mechanical AND pharmacological VTE prophylaxis was not administered at hospital admission.
- Explicit documentation of a contraindication to BOTH mechanical prophylaxis AND pharmacological prophylaxis is needed.
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Suggested Data Collection Question: | Is there physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission?
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Format: | Length: | 1 | Type: | Alphanumeric | Occurs: | 1 |
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Allowable Values: |
Y (Yes) There is physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission.
N (No) There is no physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission or unable to determine from medical record documentation.
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Notes for Abstraction: |
- If a patient received prophylaxis as per the data element VTE Prophylaxis, select “No.”
- To select “Yes” for this data element, documentation must be dated from arrival to the day after hospital admission. Documentation written after arrival but prior to admission is acceptable.
- Reasons for not prescribing mechanical and pharmacological VTE prophylaxis must be documented by a physician/APN/PA or pharmacist.
EXCEPTIONS:
- Patient/family refusal may be documented by a nurse, but should be documented within the same time frame as the reason for no VTE prophylaxis. Patient/family refusal of any form of prophylaxis is acceptable.
Example: Patient refused heparin, select “Yes.”
- For patients on anticoagulants:
- For patients on continuous IV heparin therapy the day of or day after hospital admission, select “Yes.”
- If warfarin is listed as a home or current medication, select “Yes” regardless of other documentation.
- For patients receiving anticoagulant therapy for atrial fibrillation or for other conditions (e.g. angioplasty), with anticoagulation administered on the day of or the day after hospital admission, select “Yes.”
- If reasons are not mentioned in the context of VTE prophylaxis, do not make inferences (e.g., do not assume that VTE Prophylaxis was not administered because of a bleeding disorder unless documentation explicitly states so).
Example: Physician/APN/PA or pharmacist documentation of bleeding risk, review the chart for documentation about reasons for no mechanical AND reasons for no pharmacological VTE prophylaxis.
- Physician/APN/PA or pharmacist documentation that the patient is ambulating without mention of VTE prophylaxis is insufficient. Do not infer that VTE prophylaxis is not needed unless explicitly documented.
Examples:
- There is documentation of “No VTE Prophylaxis, patient ambulating,” select “Yes.”
- There is documentation of “Patient low risk for VTE, ambulating,” select “Yes.”
- For patients with a reason for no pharmacologic or no mechanical prophylaxis and an order for ANY prophylaxis that was NOT administered without a reason, select “No.”
Example:
- Patient has documentation of an order for IPCs and no documentation that IPCs were applied, select “No.”
- If two physicians/APN/PA or pharmacists document conflicting or questionable risk/ needs for prophylaxis, select “No.”
- If a risk assessment is used, and notes anything other than low risk (e.g. intermediate risk, moderate risk, or high risk), additional documentation must be present to answer “Yes.” Explicit documentation of a contraindication to mechanical AND contraindication to pharmacological prophylaxis must be addressed.
- If there is physician documentation of “bleeding, no pharmacologic prophylaxis” the chart must be reviewed for documentation about a reason for no mechanical prophylaxis in order to select “Yes.”
Examples:
- Bleeding, no pharmacologic prophylaxis, no mechanical prophylaxis.
- Active GI bleed – low molecular weight heparin contraindicated, no mechanical prophylaxis needed.
- "No VTE Prophylaxis", "No VTE Prophylaxis needed" [no reason given].
- If Comfort Measures Only (CMO) was documented after the day after arrival (Day 1) but by the day after hospital admission, select “Yes.”
Example:
- Patient arrives in the ED on 06/01/20xx but is in observation until admission to the hospital on 06/03/20xx. If CMO is documented by 06/04/20xx, select “Yes.”
- Documentation that the patient is adequately anticoagulated or already anticoagulated on warfarin, select “Yes.”
Examples:
- Patient is already anticoagulated, taking Coumadin at home prior to admission.
- INR therapeutic and adequately anticoagulated at this time.
- Documentation synonymous with “abruptly reversed anticoagulation for major bleeding,” select “Yes.”
Examples:
- INR reversal for major bleeding.
- Reverse anticoagulation for intracranial hemorrhage.
- Documentation of administration of IV tPA is NOT a stand-alone reason for no VTE prophylaxis.
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Suggested Data Sources: |
ONLY PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION OF A REASON FOR NOT ADMINISTERING VTE PROPHYLAXIS:
- Consultation notes
- Emergency Department record
- History and physical
- Physician orders
- Physician progress notes
- Risk assessment form
- Transfer form
- Medication administration record
- Nurses notes
- Risk Assessment
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Additional Notes: |
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Guidelines for Abstraction: |
Inclusion | Exclusion |
None
Refer to Appendix H, Table 2.7 Anticoagulation Therapy for Atrial Fibrillation and Other Conditions.
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None |
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Reason for No VTE Prophylaxis – Hospital Admission
Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Discharges 01-01-17 (1Q17) through 06-30-17 (2Q17)
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