Reason for No Administration of VTE Prophylaxis (v2023A1)

Specifications Manual for Joint Commission National Quality Measures (v2023A1)

Posted: 10/17/2022

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Release Notes:
Data Element
Version 2023A1

Name:

Reason for No Administration of VTE Prophylaxis

Collected For:

VTE-6

Definition:

Physician/APN/PA or pharmacist documentation why mechanical AND pharmacological VTE prophylaxis were not administered on the day(s) between arrival and the day before the VTE Diagnostic Test order date. Both mechanical and pharmacological prophylaxis must be addressed.

Question:

Is there physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered on the day(s) between arrival and the day before the VTE Diagnostic Test order date?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is physician/APN/PA or pharmacist documentation why mechanical AND pharmacological VTE prophylaxis were not administered on the day(s) between arrival and the day before the VTE Diagnostic Test order date.

N (No) There is no physician/APN/PA or pharmacist documentation why mechanical AND pharmacological VTE prophylaxis were not administered on the day(s) between arrival and the day before the VTE Diagnostic Test order date, or unable to determine from medical record documentation.

Notes for Abstraction:

To select “Yes” for this data element, documentation of a reason for not administering mechanical AND pharmacological VTE prophylaxis must be dated between hospital arrival and the day before the VTE Diagnostic Test order date. Refer to the data element VTE Diagnostic Test for a list of acceptable tests.
Reasons for not prescribing 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 to select “Yes.” For example, “patient refused heparin,” select “Yes.”
- A validated risk assessment may be documented by a nurse, but should be documented within the same time frame as the reason for no administration of VTE prophylaxis.
- For patients receiving anticoagulant therapy, including continuous IV heparin infusion, between arrival and the day before the VTE diagnostic test order date, select “Yes.” Disregard IV heparin administered to flush/maintain patency of a line or dialysis equipment and IV heparin administered during an interventional procedure, e.g., cardiac cath.
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 documentation of bleeding risk, review the chart for documentation about reasons for no mechanical AND no pharmacological VTE prophylaxis.

Documentation that a formal risk assessment was administered, AND the results indicated that there was no risk or low risk for VTE is acceptable as a reason for not administering VTE prophylaxis.
- If a copy of the validated risk assessment is included in the medical record along with the results, select “Yes.”
- Documentation of a low risk score without a copy of the validated risk assessment is acceptable, if the validated risk assessment tool used is mentioned in the note. See Inclusion Guidelines for Abstraction.
- Documentation of low risk or no risk without mention of a score and the validated risk assessment tool, select “No.”
If two physicians/APN/PA or pharmacist document conflicting or questionable needs for prophylaxis, select “No.”

Suggested Data Sources:

ONLY PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION OF A REASON FOR NOT ADMINISTERING VTE PROPHYLAXIS

Anesthesia record
Consultation notes
Emergency department record
History and physical
Physician orders
Physician progress notes
Transfer form

SUGGESTED DATA SOURCES FOR PATIENT REFUSAL (other than physician/APN/PA or pharmacist) documentation of a reason for not administering VTE prophylaxis as above):

Medication administration record
Nurses notes

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

Explicit documentation that the patient does not need VTE prophylaxis

ALL INCLUSIVE VALIDATED RISK ASSESSMENTS:

Caprini DVT Risk Assessment
Padua Prediction Score
International Medical Prevention Registry on Venous Thromboembolism (IMPROVE)

LOW RISK SCORES:

Caprini score of 0 (zero) – no need for prophylaxis.
IMPROVE score of 0 (zero) or 1 (one); or a probability of less than 1.5%
Padua score of less than 4 (0-3)

Refer to Appendix H, Table 2.7 Anticoagulation Therapy

Risk Assessment tools other than Caprini, Padua, and IMPROVE

Specifications Manual for Joint Commission National Quality Measures (v2023A1)
Discharges 01-01-23 (1Q23) through 06-30-23 (2Q23)

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