VTE Present at Admission (v2020A)

Specifications Manual for Joint Commission National Quality Measures (v2020A)

Posted: August 1, 2019

Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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Release Notes:
Data Element
Version 2020A

Name:

VTE Present at Admission

Collected For:

VTE-6

Definition:

Documentation by a physician/APN/PA that VTE was diagnosed or suspected on arrival to the day after admission.

Question:

Was there any documentation by the physician/APN/PA that VTE was diagnosed or suspected on arrival to the day after admission?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation by the physician/APN/PA that VTE was diagnosed or suspected from hospital arrival to the day after admission.

N (No) There is no documentation by the physician/APN/PA that VTE was diagnosed or suspected from hospital arrival to the day after admission or unable to determine from medical record documentation.

Notes for Abstraction:

The time frame for this data element includes any documentation dated from hospital arrival to the day after admission. It is not necessary to review documentation outside of this time frame to answer this data element.
Documentation of suspicion or a diagnosis of a pulmonary embolism (PE) or venous thromboembolism (VTE) in a confirmed location is acceptable. Only accept terms identified in the list of inclusions.
Note: It is not necessary for a VTE Diagnostic Test to be linked with the physician/APN/PA documented diagnosis of PE or VTE.
Acceptable Examples:
- A patient arrived on 10/1/20xx with shortness of breath. On 10/2/20XX, there is physician documentation that a PE is suspected, select “Yes.”
- Results of a venous Doppler performed the day after admission are positive for VTE in the common femoral vein, select “Yes.”
- Results of a Doppler are positive for an acute nonocclusive LLE thrombus on the day after admission, select “Yes.”
- Day of admission physician includes PE on the problem list, select “Yes.”
- Patient admitted with a diagnosis of left popliteal deep vein thrombus, select “Yes.”
- Patient arrived on 01/05/20XX with documentation from an outside transferring hospital indicating vascular ultrasound was performed on 01/02/20XX and positive for VTE, select “Yes.”
- Physician documents in H&P on day of admission, “DVT right lower extremity,” select “Yes.”
  Unacceptable Examples:
- H&P on day of admission notes that the patient has an occlusion of the subclavian vein. Subclavian vein is not a defined location, select “No.”
- A patient arrives to the hospital emergency department with C/O severe headache. Differential diagnosis on the day of arrival includes cerebral venous thrombosis (CVT) versus SAH, select “No.”
- Physician admitting note documents DVT prophylaxis under the treatment plan, select “No.”
- Patient admitted with a diagnosis of left upper extremity deep vein thrombus, select “No.”
- Patient has a CT chest with IV contrast on the day of arrival to R/O PE and test results are negative and received by 2359 the day after admission, select “No.”
An order for a VTE diagnostic test is acceptable ONLY if it is explicitly documented that VTE/PE is the reason for the test. Only accept terms identified in the list of inclusions. If an acceptable test is ordered for a PE or VTE indication and results are documented as negative by 2359 the day after admission, then suspicion of PE or VTE has been ruled out. Select “No.”
Acceptable Examples:
- A patient presents to the hospital emergency department with a chief complaint of pain and swelling in the right calf. A vascular ultrasound of the lower extremities is ordered to R/O DVT, select “Yes” UNLESS results are negative and received by 2359 the day after admission.
- Bilateral venous Doppler of the lower extremities is ordered on the day after admission for redness and swelling left calf, select “Yes.”
- A patient arrives on 06/01/20XX. Admitting diagnosis is fever. On 06/02/20XX patient admitted and physician documents “if cough continues may require evaluation for PE.” On 06/03/20XX, CTA chest is ordered and positive for PE. Select “Yes.”
  Unacceptable Examples:
- Physician orders a bilateral lower extremity arterial duplex on the day after admission. Arterial duplex is not an acceptable test. Select "No" for VTE Present on Admission.
- Patient presents to the emergency room with complaints of pain all over after sustaining a fall. ED MD orders multiple tests including a CT of the chest with IV contrast. ED MD documents fall as the reason for the test. No mention of PE/VTE, select “No.”
- A patient is admitted after a motor vehicle accident. On arrival, a CT of the abd/pelvis with IV contrast was done to R/O internal injuries. No mention of PE/VTE, select “No.”
- Bilateral venous Doppler of the lower extremities is ordered on the day of arrival for redness and swelling left calf. Results returned the same day document no acute VTE in left common femoral vein or popliteal vein, select “No.”
Patients who are under treatment and receiving anticoagulation therapy for PE/VTE at the time of hospital arrival, select “Yes.”
Examples:
- Patient admitted 04/30/20XX. Physician documents on 04/30/20XX that Coumadin was started on 04/20/20XX for a recently diagnosed PE, select “Yes.”
- Patient presents with a documented diagnosis of PE on the day of arrival. Coumadin placed on hold to evaluate for GI bleed, select “Yes.”
Patients on anticoagulation therapy for another condition (e.g., atrial fibrillation, mitral valve replacement) at the time of hospital arrival, select “Yes.”
Examples:
- Patient with a history of stroke and taking dabigatran as a home medication prior to arrival, select “YES.”
- H&P documents chronic VTE. Taking Coumadin, select “Yes.”
  EXCEPTION:
  Patient on apixaban prior to arrival for a history of atrial fibrillation. Apixaban discontinued on arrival for surgery the day after admission, select “No”.
For patients with only a past history of VTE documented, select “No.”
Example:
- Problem list includes PE 199X, select “No.”
Recurrent, chronic, sub-acute, indeterminate age, select “No,” unless there is also documentation of an acute or new VTE.
If the patient was admitted and had surgery on day of or day after hospital admission or ICU admission and there was no documentation of diagnosed/suspected VTE prior to surgery, the VTE is not considered present on admission. Select “No.”
Disregard diagnostic procedures performed, e.g., cardiac catheterization, endoscopy, ERCP.

Suggested Data Sources:

PHYSICIAN/APN/PA DOCUMENTATION ONLY

Consultation notes
Discharge summary
Emergency Department record
History and physical
Radiology report
Observation notes
Outpatient surgery notes
Physician notes

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

THIS LIST IS ALL INCLUSIVE VTE Location VTE Confirmed is defined as: Pulmonary Emboli (PE), pulmonary artery embolism, pulmonary trunk embolism, saddle embolism Or DVT Located in:

Common femoral vein
Common Iliac
External Iliac vein
Femoral/superficial femoral vein
Inferior vena cava (IVC)
Infrarenal IVC
Intrahepatic IVC
Internal iliac
Popliteal vein
Profunda / deep femoral vein
Saphenofemoral junction WITH extension into the common femoral vein
Tumor thrombus in the IVC or another defined location

VTE Diagnostic test:
THIS LIST IS ALL INCLUSIVE

Compression Ultrasound of lower extremities
Venous Ultrasound of lower extremities
Duplex Ultrasound (DUS) of lower extremities
Venous Doppler of lower extremities
Vascular vein mapping of the lower extremities
Computed tomography angiography (CTA) / Angiogram of Chest
Computed tomography angiography (CTA) / Pulmonary Angiogram of Chest
Computed tomography (CT) of thorax (chest) with IV contrast
Computed tomography angiography (CTA) / Angiogram of the abdomen
Computed tomography (CT) of the abdomen/abdominal aorta with IV contrast
Computed tomography (CT) of the pelvis with IV contrast
Computed tomography angiography (CTA) / Angiogram of the pelvis
Computed tomography (CT) of the lower extremity leg veins with IV contrast
CT pulmonary angiogram (CTPA) / CTPA Scan / CT pulmonary embolism (CTPE)
Magnetic resonance imaging (MRI or MRV) of the thorax (chest, cardiac)
Magnetic resonance imaging (MRI or MRV) of the abdomen
Magnetic resonance imaging (MRI or MRV) of the pelvis
Magnetic resonance imaging (MRI or MRV) of the lower extremity leg veins
Nuclear Medicine Pulmonary Scan/ventilation/perfusion (V/Q) lung scan
Pulmonary arteriography/angiography/angiogram
Cavagram/cavogram
Inferior venocavagram
Venography/Venogram of pelvis using IV contrast material
Venography/Venogram of femoral using IV contrast material
Venography/Venogram of other lower extremity veins using IV contrast material

Refer to Appendix H, Table 2.7 Anticoagulation Therapy for a list of acceptable anticoagulant medications

VTE Confirmed:

History of PE or VTE without documentation of a new/acute event
VTE not in a defined location
Chronic thromboembolic pulmonary hypertension (CTEPH)

VTE Diagnostic Test: Patients with PE or VTE diagnosed by tests not listed

Specifications Manual for Joint Commission National Quality Measures (v2020A)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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