• Background
• Sub-populations
• Measures with exclusions and documentation requirements
• Quality Improvement
2

• New measure set that becomes a mandatory submission
• Beginning with January 1, 2013 discharges
• Developed via a project between the Joint Commission (TJC) and the National
Quality Forum (NQF)
• Measures have been tested and extensively studied
• Final measures endorsed by the NQF (National Quality Forum) in 2008
3

• Measures align with the Centers for Medicare & Medicaid Services
(CMS) quality initiatives
• Hospital Compare
• VTE measures will be posted December 2013
• Hospitals that do not report required quality data
• At risk for losing 2% of payments by CMS
• Private payers likely to follow
4

5

1. No VTE Sub-Population
• Patients with no ICD-9-CM Principal or Other Diagnosis Code as defined in
Appendix A, Tables 7.02, 7.03 and 7.04
• Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years
• Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days
6

2.
Principal VTE sub-population
• Patients with an ICD-9-CM Principal Diagnosis Code as defined in Appendix A,
Tables 7.03 and 7.04
• Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years
• Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days
7

3. Other VTE Only sub-population
• Patients with an ICD-9-CM Other Diagnosis Code as defined in Appendix A, Tables
7.03 and 7.04
• Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years
• Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days
• The patients cannot have a ICD-9-CM Principal Diagnosis Code as defined in
Appendix A, Tables 7.03 and 7.04
8

• VTE – 1 Venous Thromboembolism Prophylaxis
• VTE – 2 Intensive Care Unit Venous Thromboembolism Prophylaxis
• VTE - 3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
• VTE – 4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with
Dosages/Platelet Count Monitoring by Protocol or Nomogram
• VTE – 5 Venous Thromboembolism Warfarin Therapy Discharge Instructions
• VTE – 6 Hospital Acquired Potentially-Preventable Venous Thromboembolism
9

VTE 1 and 2
VTE 6
VTE 3,
4, and 5
10

11

12

13

• 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
14

• Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected
• The majority of fatal events occur as sudden or abrupt death
• It is expected that all medical and surgical patients will receive some form of VTE prophylaxis
• More than 2 million Americans develop a VTE each year 1
1 www.arqh.gov
15

• Approximately two-thirds of cases of DVT or PE are associated with recent hospitalization
• 30 days post hospitalization
• A recent analysis from the ENDORSE survey, which evaluated prophylaxis rates in 17,084 major surgery patients….
• Found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis and that rates varied by surgery type 1
• The Agency for Healthcare Research and Quality (ARQH) defined thromboprophylaxis against VTE as the "number one patient safety practice" for hospitalized patients
1 Cohen AT, et al. ENDORSE study: a multinational cross-sectional study. Lancet. 2008;371:387-394. 16

• Chances of complications from prophylaxis are small
• Prophylaxis is cost-effective
• Benefits outweigh the risks
• Fatal pulmonary emboli are prevented by thromboprophylaxis 1
1 Geerts WH, et al. . Prevention of venous thromboembolism.. Chest. 2008; 133:381S-453S. 17

18

• Patients who received VTE prophylaxis or have documentation why no
VTE prophylaxis was given:
• The day of OR the day after hospital admission
• The day of OR the day after surgery end date for surgeries that start the day of OR the day after hospital admission
• Excluded Populations - None
19

• All patients
• Excluded Patients
• Patients less than 18
• Patients with LOS less than 120 days
• Patients with Comfort Measures Only
• Documented on day of or after arrival
• Patients enrolled in clinical trials
• Patients directly admitted to the ICU, or transferred to the ICU the day of or the day after hospital admission with ICU LOS greater than or equal to one day
20

• Excluded Patients, continued
• Principal diagnosis of Mental Disorders
• Principal diagnosis of Stroke
• These patients should receive prophylaxis other than graduated compression stockings
• Any diagnosis of Obstetrics, VTE or Obstetrics VTE
• Principle procedure on Surgical Care Improvement Project (SCIP) tables
• Prophylaxis differs
• Cannot be in SCIP VTE and VTE-1
21

22

• Patient/family refusal
• May be documented by a nurse
• Must be in the same timeframe as prophylaxis
• Refusal of one type of prophylaxis covers all types
• Example - If refuse heparin, no need for the documentation of the refusal of mechanical prophylaxis
23

• “No VTE given”
• Cannot only state the condition, alone
• Thrombocytopenia
• Patient has IVC filter
• Acceptable examples
• “Active GI bleed, cannot give Lovenox”
• “Angiomax is sufficient and no VTE prophylaxis is needed”
• “Will not give enoxaparin”
• Must address both types of prophylaxis
24

• Other methods to document proper prophylaxis
• Comfort Measures Only documented
• Documented on admit day/day after/day after surgery
• Patient received anticoagulants on day of admission for other reasons
• Cannot accept Plavix, Aspirin, Ticlid
• Must be correct order route
• Warfarin stopped due to high INR
25

• Patient has a documented contraindication to pharmacologic prophylaxis
• Mechanical prophylaxis not addressed
• Mechanical prophylaxis started 2 or more days after admission
• Ambulation inferred to be a reason for no prophylaxis
• Need documentation as to why both methods not used
26

27

VTE - 2
28

• 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 the initial admission (or transfer) to the
Intensive Care Unit, OR
• Surgery end date for surgeries that start the day of OR the day after
ICU admission (or transfer)
29

• ICU patients will receive some form of VTE prophylaxis
• Except if no overnight stay, OR
• Reason for no VTE prophylaxis given
• Starting on ICU admission date or day after admission
30

31

• Criteria for admission to the ICU itself, puts patients at an increased risk for developing VTE
• Subsequent increased risk of morbidity from PE
• Risk factors can be related to the acute illness present
• Risk factors may be acquired during the ICU admission
• From subsequent medical treatments
• Limitations of mobility
• Presence of central venous lines
• Mechanical ventilation and subsequent pharmacological paralysis
32

• Patients who received VTE prophylaxis, OR have documentation why no VTE prophylaxis was given
• The day of or the day after ICU admission (or transfer)
• The day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer)
• Excluded populations: None
33

• Patients directly admitted or transferred to ICU
• Excluded
• Patients less than 18 years of age
• Patients who have a hospital length of stay (LOS) less than two days and greater than 120 days
• Patients with Comfort Measures Only documented on day of or day after hospital arrival
• Patients enrolled in clinical trials
34

• Excluded, continued
• Patients with ICU LOS less than one day without VTE prophylaxis administered and documentation for no VTE prophylaxis
• Patients with ICD-9-CM Principal or Other Diagnosis Code of Obstetrics or VTE as defined in Appendix A, Table 7.02, 7.03, or 7.04
• Patients with ICD-9-CM Principal Procedure Code of Surgical Care Improvement
Project (SCIP) VTE selected surgeries as defined in Appendix A, Tables 5.17, 5.19,
5.20, 5.21, 5.22, 5.23, 5.24 that start the day of or the day after ICU admission or transfer
35

36

www.arqh.gov
37

38

• Assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous or subcutaneous) anticoagulation and warfarin therapy
• For patients who received fewer than five days of overlap therapy
• Should be discharged on both medications, OR
• Have a Reason for Discontinuation of Parenteral Therapy
• Overlap therapy should be administered for at least five days
• With an international normalized ratio (INR) greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy,
• Discharged on both medications, OR
• Have a Reason for Discontinuation of Parenteral Therapy
39

• Patients with an acute VTE
• Either principal (on arrival) or other diagnosis (in the hospital)
• Appendix A, Table 7.03 VTE
• Appendix A, Table 7.04 Obstetrics VTE
(Patients given Xarelto are excluded)
40

• Direct Thrombin Inhibitors:
• Agatroban (Acova), Bivalirudin (Angiomax), Lepirudin (Refludan)
• Low Molecular Weight Heparins (LMWHs):
• Dalteparin (Fragmin), Enoxaparin (Lovenox), Tinzaparin (Innohep)
• Unfractionated Heparin – IV or SQ
• Factor Xa Inhibitor:
• Fondaparinux Sodium (Arixtra)
41

• Oral Warfarin therapy AND
• Parenteral anticoagulants
• By either IV or subcutaneous route
• Appendix H, Table 2.3
42

43

• For patients who present with a confirmed acute VTE, parenteral anticoagulation is the first line of therapy
• Rapid onset of action
• Warfarin can be initiated on the first day of treatment after the first dose of a parenteral anticoagulant has been given
• Warfarin has a very slow onset of action
• Cannot be used as mono-therapy for acute VTE
44

• Recommendations to overlap parenteral anticoagulation with oral warfarin therapy in the initial treatment of VTE events
• Based in part on the known effect of warfarin on the coagulation cascade
• The early increase in the INR
• Often reflects the laboratory finding of initial reduction in clotting factors of the extrinsic pathway of coagulation resulting in prolongation of the INR
• The patient is still at risk of thromboembolic events due to persistent levels of coagulation factors of the intrinsic pathway and common pathways of coagulation
45

• Overlap warfarin with parenteral anticoagulants until
• 5 days of overlap therapy AND
• INR >= 2.0
• If INR < 2.0 after 5 days, continue overlap therapy
• The recommendation that heparins and warfarin overlap for a five-day period is based on pharmacokinetic, pharmacologic, pathophysiologic, and clinical evidence 1
1 Wittkowsky AK. Why warfarin and heparin need to overlap when treating acute venous thromboembolism. Dis Mon 2005; 51:112-115. 46

• Patients who received overlap therapy (warfarin and parenteral anticoagulation):
• Five or more days, with an INR greater than or equal to 2 prior to discontinuation of parenteral therapy, OR
• Five or more days, with an INR less than 2 and discharged on overlap therapy, OR
• Less than five days and discharged on overlap therapy, OR
• With documentation of reason for discontinuation of parenteral therapy, OR
• With documentation of a reason for no overlap therapy
• Excluded: None
47

• Patients with confirmed VTE who received warfarin
• Discharges with an ICD-9-CM Principal or Other Diagnosis Codes of VTE as defined in Appendix A, Table 7.03 or 7.04
48

• Excluded Population
• Less than 18 years of age
• Length of stay greater than 120 days
• Comfort Measures Only documented
• Patients enrolled in clinical trials
• Patients discharged to a health care facility or home for hospice care
• Patients who expired
• Patients who left against medical advice
• Patients discharged to another hospital
• Patients without warfarin therapy during hospitalization
• Patients without VTE confirmed by diagnostic testing
49

• Venography
• Pelvic, femoral and other lower extremity veins
• Computed Tomography with Contrast
• Chest, abdomen, pelvis, lower extremity veins
• Pulmonary arteriography/angiography
• MRI/MRV
• Chest, abdomen, pelvis, lower extremity veins
• Nuclear Medicine Studies – High probability ONLY
• Compression Ultrasound
50

• Radiology reports
• Physician documentation stating acceptable VTE location
• Records can come from outside source
• Physician or nurse must document the VTE is present
• Cannot come from billing documentation
51

• Pulmonary Embolism
• Proximal Lower Extremity Veins
• Inferior Vena Cava
• Iliac Veins
• Femoral Veins
• Popliteal Veins
52

• Isolated calf vein thrombosis
• Upper extremity thrombosis
• Intracranial thrombosis
• Hepatic, portal, splenic, mesenteric thrombosis
• Renal vein thrombosis
• Ovarian vein thrombosis
• Chronic VTE
53

• Sample reasons why overlap therapy was not used
• Surgical procedure
• Bleeding complications
• Patient refused overlap therapy
• Sources for overlap therapy
• Physician documentation
• Nursing documentation
• Medication administration record
54

55

56

• Description:
• Measure assesses the number of patients diagnosed with confirmed VTE who
• Received intravenous (IV) UFH therapy dosages, AND
• Had their platelet counts monitored using defined parameters such as a nomogram or protocol
57

58

• Heparin is commonly involved in adverse drug events
• Sub-therapeutic and supratherapeutic levels can lead to thromboembolic or bleeding complications that may increase the patient’s length of stay
• The use of weight-based nomograms has increased the likelihood that a therapeutic partial prothromboplastin time (aPTT) will be achieved within the first 24 to 48 hours of therapy
59

• Heparin-induced thrombocytopenia (HIT) occurs more commonly in patients who receive UFH than in those who receive low molecular weight heparin 1
• Platelet counts generally begin to fall 5-10 days after the initiation of heparin therapy
• Prompt recognition of HIT is important so that heparin can be discontinued and the risk of venous and arterial thrombosis minimized
• To detect HIT, platelet count monitoring is recommended for all patients treated with UFH 2
.
1 Martel, N., Lee, J., and Wells, P.S. Blood . 2005 June; 106:2710-2715.
2 Warkentin TE, et al. Chest 2008 . Jun; 133(6 Suppl):340S-80S
60

• Patients who have their IV UFH therapy dosages AND platelet counts monitored according to defined parameters such as a nomogram or protocol
• Excluded population - None
61

• Patients with confirmed VTE receiving IV UFH therapy
• ICD-9-CM Principal or Other Diagnosis Codes of VTE as defined in Appendix A, Table
7.03 or 7.04
62

• Excluded Populations:
• Patients less than 18 years of age
• Patients who have a length of stay greater than 120 days
• Patients with Comfort Measures Only documented
• Patients enrolled in clinical trials
• Patients discharged to a health care facility for hospice care
• Patients discharged to home for hospice care
• Patients who expired
• Patients who left against medical advice
• Patients discharged to another hospital
• Patients without UFH Therapy Administration
• Patients without VTE confirmed by diagnostic testing
63

• IV Heparin only
• Need documentation of administration
• Medication administration record
• Nursing notes
• Emergency Department record
• Progress notes
• Ambulance record – added to sources effective January 2013
64

65

VTE - 5
66

• Assesses the number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin
• With written discharge instructions that address all four criteria:
• Compliance issues,
• Dietary advice,
• Follow-up monitoring, AND
• Information about the potential for adverse drug reactions/interactions
67

• In anticoagulation therapy programs, patient education is a vital component to achieve successful outcomes, and reducing hospital readmission rates
• Warfarin is commonly involved in adverse drug events
• Subtherapuetic clot formation
• Supratherapeutic hemorrhage
• The use of standardized practices for anticoagulation therapy that includes patient/caregiver involvement 1
• May reduce the risk of adverse drug events
1 Van Walraven, C.,et al. Chest 2006; 129; 1155-1166. 68

• Patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin that addressed all of the following:
• Compliance issues
• Dietary advice
• Follow-up monitoring
• Potential for adverse drug reactions and interactions
• Excluded population: None
69

• Patients with confirmed VTE discharged on warfarin therapy
• Included Populations:
• Discharges with an ICD-9-CM Principal or Other Diagnosis Codes of VTE as defined in Appendix A, Table 7.03 or 7.04
• Discharged to home, home care or court/law enforcement
• Discharged to home for hospice care
70

• Excluded Populations:
• Patients less than 18 years of age
• Patients who have a length of stay greater than 120 days
• Patients enrolled in clinical trials
• Patients without Warfarin Prescribed at Discharge
• Patients without VTE confirmed by diagnostic testing
71

• Must be written materials to take home
• Oral discussion is not enough
• Can assume a copy was given to the patient if the material has
• Patient’s name
• Medical record number
• Signature – from nurse and patient
• The patient can refuse instructions, but this must be documented
72

• Must advise the importance of both
• Taking warfarin as instructed, AND
• Monitoring warfarin intake with scheduled INR checks
73

• Must advise both of the following
• May consume a “consistent amount” of foods with Vitamin K
• Rather than avoidance of them
• Avoidance of a major change in diet or consulting a health professional before a change
74

• Must document the plan to monitor warfarin after discharge
• Office, clinic, home health
• Scheduled date of next INR check
75

• Adverse Drug Reactions and Interactions
• Required statements
• Diets and medications can affect the INR
• Do not start or stop any medications except on the advice of a physician or pharmacist
• Warfarin increases the risk of bleeding
76

• Copy of instructions given
• Require an documentation the patient had a copy to take home
• Signature not required except to show the patient received a copy
• Copy of pre-printed material in the record
• Requires documentation the patient had a copy to take home
• Statement that written instructions were given
• Must be signed by a nurse
• Must list individual areas of instruction
• Beware of empty check boxes (infers not done)
77

78

79

• Assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission)
• Who did not receive VTE prophylaxis between hospital admission, AND
• The day before the VTE diagnostic testing order date
80

81

• The incidence of preventable VTE among hospitalized patients is overwhelming
• Contributes to extended hospital stays and the rising cost of health care
• Zhan 2003 1
• The second most common medical complication of postoperative patients,
• The second most common cause of excess length of stay, AND
• The third most common cause of excess mortality and excess charges
1 Zhan, C., Miller M.R. Excessive length of stay, charges and mortality attributable to medical injures during hospitalization. JAMA 2003; 290:1868-1874. 82

• Preventable VTE is defined as objectively diagnosed Deep Vein
Thrombosis or Pulmonary Emboli that occurred in a setting in which thromboprophylaxis was indicated but was either 1
• Administered inadequately, OR
• Not administered at all
• In spite of formal guidelines, and recommendations for preventative care, pulmonary embolism is still the most common preventable cause of death among hospitalized patients 2
1 Arnold DM, et al. Chest. 2001 Dec;120(6):1964-71.
2 Wachter, R, et al. JAMA 2003; 290:1868-1874.
83

• Patients who received no VTE prophylaxis prior to the VTE diagnostic test order date
• Excluded Population: None
84

• Patients who developed confirmed VTE during hospitalization
• Included: Discharges with an ICD-9-CM Other Diagnosis Codes of VTE as defined in Appendix A, Table 7.03 or 7.04
85

• Excluded
• Patients less than 18 years of age
• Patients who have a length of stay greater than 120 days
• Patients with Comfort Measures Only documented
• Patients enrolled in clinical trials
• Patients with ICD-9-CM Principal Diagnosis Code of VTE as defined in Appendix A,
Table 7.03 or 7.04
• Patients with VTE Present at Admission
• Patients with reasons for not administering mechanical and pharmacologic prophylaxis
• Patients without VTE confirmed by diagnostic testing
86

• Those who often do not receive adequate VTE prophylaxis
• Moderate risk patients
• Emergency admissions
• Conservatively managed patients
87

• VTE – 6 captures adverse outcomes
• Goal is 0% on this measure
• Numerator
• Those patients who went on to develop a VTE
• Because of no or insufficient prophylaxis
• Patients who develop a VTE despite prophylaxis do NOT count against the hospital
• Placed in the denominator
88

• Physician, NP, PA must document that the VTE was diagnosed or suspected on admission
• Patient can be admitted on VTE treatment
• Diagnostic test ordered on admit date
• Cannot document present on admission if past the admission period
89

• Physician, PA, NP, Pharmacist
• Must address contraindications to both mechanical and pharmacologic prophylaxis
• Patient refusal of prophylaxis can be documented by the physician, nurse, or in the medication administration record
• Must clearly link the reason prophylaxis was not used
• For both types
• Mechanical prophylaxis must address both extremities
90

• What does not count as a reason why prophylaxis was not given
• History of bleeding
• Bleeding risk noted in informed consent process
• Reinfusion of blood products through a blood recovery system
• “Patient at low risk for VTE”
• “VTE prophylaxis not needed”
91

92

VTE Prophylaxis: Actual Failure Modes from the University of California,
San Diego Medical Center and Emory University Hospitals
Differing opinions exist on what is appropriate, even among experts.
Noncompliance with mechanical prophylaxis exists.
Platelet monitoring is haphazard when heparin is ordered.
Transfers out of intensive care units may cause VTE prophylaxis to be dropped.
Prophylaxis is stopped at discharge even when risk continues in some patients.
Widely different impressions are held for when it is safe to start anticoagulation peri-procedure and post trauma

94

http://www.ahrq.gov/qual/vtguide/vtguide.pdf
95

http://www.ahrq.gov/qual/vtguide/vtguide.pdf
96

Quality Improvement Strategy Category
Provider education
Provider reminder systems
Facilitated relay of clinical data to providers
Audit and feedback of performance to providers
Specific Ideas for VTE Prevention
• Didactic sessions on VTE prevention (e.g., noon conference or grand rounds)
• Distributed educational materials (e.g., pocket cards with VTE risk factors)
• Prompts nested within paper admission, transfer, or post-op order sets supported by VTE risk assessment as decision support (VTE protocol)
• Prompts using computerized physician order entry with risk assessment as decision support (VTE protocol)
• Stickers on charts or posters in order-writing areas
Alerts to physicians by means other than medical records (e.g., page, electronic alert, phone call, or email regarding VTE prophylaxis oversights)
Feedback of VTE prophylaxis performance to individual providers or groups of providers with or without benchmarking to top performers
97

Quality Improvement Strategy Category
Patient education
Organizational or operational change
Incentives, regulation, and policy
Specific Ideas for VTE Prevention
Discrete disclosure to patients of increased risk for VTE
(e.g., pamphlets, physician or nurse teaching of patient or caregiver, closed-circuit television program in patient rooms)
• Administrative support personnel dedicated to ensure constant stocking of VTE protocol order sets
• Clinical support personnel dedicated to ensure and document that mechanical prophylaxis is worn by patients
• Hospital-wide or unit-specific teams or individuals with regular responsibility to ensure each patient is receiving appropriate VTE prophylaxis (e.g., physician, nurse, pharmacist)
• Recognition of highest performers
• Financial incentives based on achievement of VTE prophylaxis performance goals
• Punitive actions for failures to meet minimum performance (e.g., suspension of privileges)
• Enforced policy mandating use of VTE protocol (e.g.,
“hard stops” in processing of admission, or transfer, that fail to prescribe VTE prophylaxis)
98

99

Howard Shaps, MD, MBA
Medical Director, Health Care Excel
1941 Bishop Lane
Suite 400
Louisville, Kentucky 40218 hshaps@hce.org
502.454.5112 x 2202
This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Kentucky, under contract with the Centers for Medicare & Medicaid Services
(CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Created on March 1, 2013
10SOW-KY-INDPAT-13-004
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