VTE Confirmed (v2020A2)

Specifications Manual for Joint Commission National Quality Measures (v2020A2)

Posted: 10/30/2019

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Release Notes:
Data Element
Version 2020A2

Name:

VTE Confirmed

Collected For:

VTE-6

Definition:

Documentation by a physician/APN/PA that a diagnosis of new/acute VTE [deep vein thrombosis (DVT) and/or pulmonary embolism (PE)] was confirmed in a defined location on the day of arrival or anytime during the hospitalization.

Question:

Is there physician/APN/PA documentation that a new/acute VTE was confirmed in one of the defined locations on the day of arrival or anytime during the hospitalization?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is physician/APN/PA documentation that a new/acute VTE was confirmed in one of the defined locations on the day of arrival or anytime during the hospitalization.

N (No) There is no physician/APN/PA documentation that a new/acute VTE was confirmed in one of the defined locations on the day of arrival or anytime during the hospitalization, or unable to determine from medical record documentation.

Notes for Abstraction:

If the patient had a new or acute VTE in one of the defined locations which was confirmed by a physician/APN/PA following an acceptable VTE Diagnostic Test, select “Yes.” Refer to the data element VTE Diagnostic Test for a list of acceptable tests.
Examples:
- Physician/ APN/PA documentation states that PE was confirmed with a VQ scan on Day 4 of the hospital stay, select “Yes.”
- Physician/APN/PA documentation states that the patient arrived without prior DVT confirmation, but two days after admission, there is documentation based on a venous Doppler that the patient has an acute right popliteal DVT, select “Yes.”
- Physician/APN/PA documentation states that a CT abdomen with IV contrast was done during the hospital stay and noted an extensive IVC thrombus, select “Yes.”
- Physician/APN/PA documentation states that the patient had an MRI of the lower extremity leg veins which confirmed the development of the VTE during the hospital stay without mention of the VTE location, select “No.”
If the patient was transferred from another acute care hospital with a VTE, and there is no documentation indicating the VTE location, select “No.”
Physician/APN/PA documentation of VTE described as either occlusive or non-occlusive is acceptable.

In cases where VTE is documented in a defined location, consider it a new or acute VTE unless described as otherwise, e.g., chronic. The terms “new” or “acute” do not need to be explicitly documented to select “Yes.”

Recurrent, chronic, sub-acute, indeterminate age, or history of VTE, select “No.”
Example:
Venous Doppler is performed on the day of admission. The results document DVT in the right popliteal vein which appears to be chronic. MD note states “no calf tenderness or swelling.” No other documentation of a new or acute VTE in the medical record, select “No.”
EXCEPTION:
Documentation of an acute or new VTE in a defined location is also present in the medical record.
Example:
If a patient had a history of lower extremity DVT, but vascular ultrasound done after hospital admission found a new DVT in the popliteal vein of the right lower extremity, select “Yes.”
If more than one acceptable VTE Diagnostic Test was performed, review the chart for the earliest acceptable VTE Diagnostic Test that confirmed the VTE in one of the defined locations.
Example:
Patient had CT of chest with contrast in the emergency department on 02/01/20xx for shortness of breath, no PE confirmed. The patient was admitted on 02/02/20XX. The patient had venous ultrasound with confirmed proximal left common iliac DVT on 02/04/20XX. Select “Yes.”
If conflicting documentation between providers is present, select “Yes.”
Example:
PCP documents acute deep femoral DVT but oncologist states that DVT appears to be chronic.
For patients with radiology reports that state “low probability” or “inconclusive test results” on any of the acceptable VTE Diagnostic Tests, select “No.”
For patients with a nuclear medicine VQ scan to rule-out PE; if the result was documented as “high probability,” select “Yes.” For all other impressions (e.g., “low probability,” “intermediate,” “intermediate to high probability” or “inconclusive test results”), select “No.”
If there is questionable physician/APN/PA documentation regarding whether the patient had VTE, select “Yes.”
Example:
If the radiologist interpretation of the exam did not confirm DVT, but there is documentation of a DVT in physician’s progress notes, select “Yes.”
If there is physician/APN/PA documentation that the patient had a VTE, select “Yes.”
If the record indicates ONLY a radiology report, and that report is questionable regarding whether the patient had a VTE, select “No.”
Examples:
- If the radiology report of a CTA indicates, “possible” or “suggestive of” common femoral clot, select “No.”
- If the radiology report of an angiogram indicates, distal vein clot that may extend into the greater saphenous vein, select “No.”

Documentation in sources other than radiology reports:

The physician/APN/PA documentation must indicate the clinician’s confirmation of an acute VTE in a defined location.
Examples:
- Physician Notes: Venous Doppler on day of admission positive for DVT left popliteal vein clot, select “Yes.”
- Emergency Notes: Venogram positive for VTE, select “No.”
The physician/APN/PA documentation must reflect the time frame from arrival to hospital discharge.

Suggested Data Sources:

PHYSICIAN/APN/PA DOCUMENTATION ONLY

Admission notes
Consult notes
Discharge summary
Emergency Department record
History and physical
Physician notes
Radiology report

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

Patients with VTE in the following areas:

Confirmed sites of venous thrombosis without a proximal leg DVT or PE also involved.
History of VTE without documentation of a new/acute event
Not in the defined locations
Amniotic fluid embolism / emboli
Anterior tibial vein
Cement embolism / emboli
Cerebral venous thrombosis (CVT)
Chronic thromboembolic pulmonary hypertension (CTEPH)
Gastrocnemius vein
Hepatic/portal/splenic/mesenteric thrombosis
Ovarian vein thrombosis
Peroneal vein
Posterior tibial vein
Renal vein thrombosis
Saphenofemoral junction
Saphenofemoral junction WITHOUT extension into the common femoral vein
Septic emboli
Soleal vein
Stroke / ischemic stroke
Thrombus in the heart
Upper extremity thrombosis

Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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