This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission

These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty

Measure specifications are in the Public Domain.

LOINC(R) is a registered trademark of the Regenstrief Institute.

This material contains SNOMED Clinical Terms(R) (SNOMED CT(C)) copyright 2004-2017 International Health Terminology Standards Development Organization. All rights reserved.

Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary emboli. Screening all patients is the only evidence based practice in reducing incidence of disease. All hospitalized patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated.

Geerts  WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of venous thromboembolism. The Eighth ACCP Conference on antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S

Guyatt, G.H., Akl, E.A., Crowther, M., Gutterman, D., Schunemann, H. Antithrombotic Therapy and Prevention of Thrombosis, 9th edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012; 141(2)(Supp):7S-47S

Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th Edition: American College of Chest Physicians Evidence-based Clinical Practice Guidelines. CHEST 2012 Feb; 141(2) (Supp):e419S-94S.

National Quality Forum. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism: Policy, Preferred Practices, and Initial Performance Measures. A Consensus Report. Washington, DC. NQF; 2006

Shojania KG, Duncan BW, McDonald DM, et al. (Eds.). (2001). Making healthcare safer; A critical analysis of patient safety practices (Evidence Report/Technology Assessment No. 43). Prepared by the University of California at San Francisco-Stanford Evidenced-based Practice Center under Contract no. 290-97-0013 (AHRQ Publication NO.01-E058). Rockville, MD:Agency for Healthcare Research and Quality.

When low dose unfractionated heparin is administered for VTE Prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.

Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."

Patients who received VTE prophylaxis:
- the day of or the day after hospital admission
- the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission

Patients who have documentation of a reason why no VTE prophylaxis was given:
- between arrival and hospital admission
- the day of or the day after hospital admission
- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)

All patients in the initial population

Patients age 18 and older discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period

* Patients who have a length of stay less than 2 days
* Patients with comfort measures documented anytime between arrival and the day after hospital admission
* Patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission
* Patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day
* Patients with a principal diagnosis of mental disorders or stroke
* Patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries