Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

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.
Suggested Data Collection Question:Is there physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission?

Format:
Length:1
Type:Alphanumeric
Occurs:1
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.
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.
    EXCEPTION:
    • Documentation within the timeframe specified that the patient is a bilateral lower extremity amputee is an acceptable reason for no mechanical 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.

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

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None
Refer to Appendix H, Table 2.7 Anticoagulation Therapy for Atrial Fibrillation and Other Conditions.
  • Unchecked checkbox next to a reason (e.g., blank checkbox on a form or electronic template next to “cogulapathy” or "bilateral amputee").
  • Checked checkbox next to "other reason" with a blank space for the specific reason.

Reason for No VTE Prophylaxis – Hospital Admission
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
Questions? Ask Question to Joint Commission staff Copyright © 2018 by The Joint Commission.
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