C.1. VTE Prophylaxis Audit Form Designed To Evaluate a Sample of Inpatients
Reviewer_______________ Patient ID_______________ Date of review_________
Hospital Day #___________ Service______________ Ward/location_________
1. Is patient eligible for survey? (not on therapeutic anticoagulation or comfort care only)
Yes ______ No _____ If No, stop here and go to next patient.
2. Assign venous thromboembolism risk (see reverse side and circle category)
LOW MODERATE HIGH
3. Document current prophylaxis ordered
__ Sequential compression device: Are these in place and on? ______
__ Elastic stockings
__ Heparin 5,000 units subcutaneous q 12 hours
__ Heparin 5,000 units subcutaneous q 8 hours
__ Enoxaparin (Lovenox) 40 mg subcutaneous q day
__ Enoxaparin (Lovenox) 30 mg subcutaneous q day
__ Enoxaparin (Lovenox) 30 mg subcutaneous q 12 hours
__ Fondaparinux (Arixtra) 2.5 mg subcutaneous daily
__ Coumadin ______mg daily
4. If patient is at moderate or high risk and is not receiving anticoagulant prophylaxis: Does patient have contraindications to pharmacologic prophylaxis? (see reverse, circle appropriate category if present)
Yes No N/A
5. If patient has an indication for SCDs but does not have them ordered: Does patient have a contraindication for mechanical prophylaxis, such as edema, wound infection of legs, vascular compromise, or bilateral lower extremity amputation?
Yes _____ No _____ N/A _____
6. Is the patient receiving prophylaxis that matches the level of risk per protocol (see table on reverse)? Final judgment, was prophylaxis order for patient at the time of the survey appropriate? Remember that SCDs alone are appropriate for moderate- to high-risk VTE patients with contraindications to anticoagulant prophylaxis.
Yes No, patient is under-prophylaxed No, patient is over-prophylaxed
7. If prophylaxis was inappropriate per protocol, notify physician within 24 hours.
Physician notified ____________ Date/Time ____________
8. Did physician change order to align with protocol as a result of your intervention?
Yes _____ No _____ If no, list reason given.
(Reverse/Reference Side of the Data Collection Form)
DVT/PE Risk Level & Acceptable Choices Per Protocol
||Enoxaparin 40 mg SC q 24 hrs
Enoxaparin 30 mg SC q 24 hrs
(if renal insufficiency)
Heparin 5,000 units SC q 8 hrs
Heparin 5,000 units SC q 12hrs
(preferred over q 8 hrs age >75)
or (after bleeding risk subsides)
|Enoxaparin 40 mg SC q day
Enoxaparin 30 mg SC q 24 hrs
(if renal insufficiency)
Heparin 5,000 units SC q 8 hrs
Enoxaparin 30 mg SC q 12 hrs
Fondaparinux 2.5 mg SC q day
Warfarin, target INR 2–3
Note: For patients at moderate or high risk for VTE with bleeding contraindications, sequential compression devices are the preferred mode of prophylaxis.
Bleeding Risk Factors and Contraindications to Anticoagulant Prophylaxis
* Leeway times: 24 hours maximum for most general surgery and orthopedic surgery patients.
s/p Transplant or multiple major trauma to clear bleeding risk: 48 hours.
s/p spinal cord open surgery: 5 days leeway.
- The audit form is designed for use on sampled active inpatients.
- The level of VTE risk as scored by the reviewer is recorded. The audit tool is used to determine if the current prophylaxis is consistent with the VTE risk level.
- Contraindications for prophylaxis are determined.
- Over-prophylaxis, as well as under-prophylaxis, can be determined.
Variations and Other Comments
- The VTE risk level, choices for prophylaxis, contraindications for prophylaxis, and surgical leeway times should all be aligned with order sets and protocols being used by the ordering provider.
- This audit form is merely an example and should be revised to reflect each individual institutional protocol.
- The case scenarios in Appendix B, along with real patient cases, should be used to pilot the audit tool (comparing results from different observers).
- The importance of clear operational definitions for terms such as “reduced mobility” becomes clear, and audit results should be reviewed by the improvement team for adjudication until definitions are clear.
C.2. Sample Completed Red/Yellow/Green or “Stoplight” Algorithm and Sample Data Collection Form
Data Collection Algorithm
Algorithm courtesy of Dignity Health, Tamra O’Bryan.
VTE Prophylaxis Audit Data Collection Form
Unit Description: Medical floor
Primary Unit: Yes
Month/Year of Audit: 01/2011
We recommend NOT using actual Patient ID numbers. Please review explanations and definitions on reverse of form.
|Please answer 1 and 2 if no Mechanical prophylaxis;
Please answer 1-3 if no Pharmacologic or Mechanical prophylaxis
|Patient ID||Pharmacologic Prophylaxis?||Mechanical Prophylaxis?||1. Low Risk?||2. Pharmacologic Contraindication?||3. Mechanical
Definitions and Explanations
Green = on pharmacologic alone or with mechanical
Yellow = on mechanical only
Red = on nothing
Is the patient low risk?
- Ambulating Independently with 0-1 risk factors.
- Expected LOS <48 hours.
- Minor surgery with NO risk factors.
Does patient have any obvious contraindication to pharmacologic prophylaxis?
- Active hemorrhage now or within last 3 days.
- Postoperative bleeding concerns (within 24 hours for most surgeries; within 48 hours of transplant surgery or major trauma).
- Platelet count under 50,000; INR >1.8; known bleeding disorder; Hgb <8.0.
- Concern over CNS bleeding (brain or spinal cord surgery in last week, recent intracranial hemorrhage, proximity in time to epidural insertion or removal, for example).
- Hypertensive urgency/emergency.
- Comfort care only patient.
Does patient have any obvious contraindication to mechanical prophylaxis?
- Documented refusal.
- Peripheral arterial disease/ischemia of the lower extremities.
- Open wounds/ulcerations of both lower extremities.
A patient has "adequate VTE prophylaxis" if he or she is:
- OR Yellow AND Question 1 response is "yes" OR if Question 1 reply is "no" AND Question 2 is "yes".
- OR Red AND Question 1 response is "yes" OR if Question 1 reply is "no" AND BOTH Questions 2 and 3 are "yes".
- This type of report begins with simply recording what prophylaxis the patient is on.
- Yellow (mechanical prophylaxis) and Red (no prophylaxis) patients are rapidly identified for closer scrutiny.
- The algorithm is used to further classify each patient as having adequate versus not adequate prophylaxis.
- The color code remains indicative of the prophylaxis the patient is receiving, whether adequate or inadequate for the patient. Adequate prophylaxis can be quickly calculated by adding up all the adequate prophylaxis categories in the algorithm.
- This particular example depicts a paper version that could be used on a sampling basis—or used on every unit, everyday.
- This kind of measurement lays the foundation for concurrent intervention to address inappropriate prophylaxis in real time (aka measure-vention).
Variations and Other Comments
- This example is based on the classic 3 bucket model of VTE risk.
- The model can be modified to accommodate a wide range of other VTE risk assessment models.
- Variations can address detection of over-prophylaxis as well as under-prophylaxis.
- Automation and bringing in other discrete data elements can make this process more efficient.
- More sophisticated variants are depicted in Appendixes C.3 and C.4.
C.3. Automated/Electronic Stoplight Report of VTE Prophylaxis—UC San Diego
- This is a more sophisticated version of the stoplight report shown in C.2.
- Patient identifiers are captured but not depicted here.
- Service and provider are captured.
- VTE risk level chosen by provider in order set is captured. "No Risk Category" response in this field implies the standardized admission/transfer order set was bypassed, allowing rapid identification and remediation of the situation.
- Anticoagulant (if present), absence/presence of sequential compression devices (SCDs), and several lab contraindications (low platelet count, low hemoglobin, or elevated INR) are all captured and available for the reviewer.
- Color coding is added to enhance ease of use. Green represents the presence of an anticoagulant, yellow represents SCDs, and red represents patients with no VTE prophylaxis. The orange represents patients with a lab contraindication within the last 2 days who are on mechanical prophylaxis only.
- Automation allows monitoring of virtually every inpatient on a daily basis, rather than focusing only on the first hospital day or a relatively small subset of patients captured by sampling techniques.
- Attention can quickly be focused on those who are at highest risk of under-prophylaxis, namely those in the red and yellow categories.
Variations and Other Comments
- In some settings, this kind of report can display real-time reporting; in others, the report can only be generated once or twice per day. Interventions triggered by the report, in that case, would need to be initiated as soon as possible.
- This report captures what is ordered for prophylaxis. Variants or additions to this report could also display what is actually being administered.
- The degree of activity/ambulation can sometimes be captured as discrete data from the Braden decubitus score or other sources.
C.4. Stoplight Report—Banner Good Samaritan Regional Medical Center Example
Courtesy of Lori Porter, D.O.
- In this variant, all the individual unit reports can be rolled up to depict the prophylaxis patterns in place on any given unit and across the entire medical center.
- Blue represents patients on combination mechanical and anticoagulant prophylaxis, while gray represents patients without prophylaxis but with an elevated INR.
- The pie chart for each unit can be converted into a patient roster listing the prophylaxis in place for each, allowing targeting of patients for remediation of under-prophylaxis.
Variations and Other Comments
- This site aggressively addressed adherence to ordered mechanical prophylaxis using these reports.
- More information on strategies used by this very successful site are available in Chapter 5.
C.5. Suggested Method for Tracking Key Metric #2: Incidence of Hospital-Associated VTE
Administrative data are imperfect for tracking outcomes, but coding changes in October 2009 improved administrative coding to reflect acute versus chronic deep vein thrombosis, superficial versus deep vein thrombosis, and other refinements. For most medical centers, this is the most practical method of tracking hospital-associated VTE (HA-VTE).
The term "hospital-associated VTE" is used in favor of the term "hospital-acquired VTE" for two reasons:
- VTE is often due to underlying illnesses or injuries, rather than specific events during the hospital stay.
- VTE associated with hospitalization may not present until after the index admission, often causing a readmission.
This strategy will capture patients who develop VTE during an admission as well as patients who were discharged from an index admission without VTE diagnosis but return to the hospital to be readmitted with a newly diagnosed VTE.
Since October 2007, medical centers must report one of these indicators on diagnostic codes:
- Y = yes (present at the time of inpatient admission).
- W = clinically undetermined (provider is unable to clinically determine if condition was present on admission).
- N = no (not present at the time of inpatient admission).
- U = unknown (documentation insufficient to determine if condition was present on admission).
For most conditions, Y and W codes define hospital-associated conditions, while N and U codes are considered community-acquired conditions. Here, this categorization is refined to capture all VTEs that are associated with hospitalization as follows:
- The denominator is all adult inpatients discharged from the services tracked in a given timeframe, while the numerator will contain all cases with HA-VTE.
- The numerator is patients from the denominator population with a VTE diagnostic code (detailed below) who did not have VTE signs or symptoms on admission (POA indicator N or U)
Patients readmitted within 30 days for new diagnosis of VTE on readmission with a POA indicator of Yes (Y) or clinically undetermined (W). The word “new” is emphasized to avoid double counting of patients who are readmitted with a VTE that was already detected in the prior index admission. Capturing these patients who are readmitted with newly diagnosed VTE is very important, as a very substantial portion of HA-VTE patients present as readmissions, particularly in the medical population.
The incidence of HA-VTE should generally be reported as the number of patients in the numerator per 1,000 discharged cases in the denominator.
VTE Diagnostic Codes To Include
Improvement teams should at a minimum track lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE). Also tracking upper extremity DVT is advisable as this is a significant source of morbidity. However, upper extremity events are predominantly catheter related, and the evidence for efficacy of chemical prophylaxis is unconvincing for upper extremity DVT. Thus, hospitals may want to track these separately, as efforts to improve upper extremity DVT might focus on reducing inappropriate central venous catheter use as much as on increasing pharmacologic prophylaxis.
Administrative Coding Data Validation
When feasible, hospitals may want to validate the coding with manual chart reviews on a sampling of patients, excluding cases diagnosed by screening ultrasound.
Potentially Preventable Hospital-Associated VTE
Situations arise in which recommended thromboprophylaxis was not in place prior to VTE diagnosis. This is in contrast to the definition for The Joint Commission Measure VTE-6, which states that an HA-VTE is not preventable if the patient was ever on ANY prophylaxis prior to diagnostic study used to detect VTE. For this measure, VTE prophylaxis consistent with a medical center’s protocol should be in place in the days preceding VTE diagnosis.
ICD-9i Codes for Lower-Extremity DVT and PE
|415.1||PE and infarction|
|415.11||Iatrogenic PE and infarction|
|415.13||Saddle embolus of pulmonary artery (effective 10/1/2011)|
|415.19||Other PE and infarction|
|451.11||Phlebitis and thrombophlebitis of deep vessels of lower extremities,femoral vein|
|451.19||Phlebitis and thrombophlebitis of deep vessel of lower extremities, other|
|451.2||Phlebitis and thrombophlebitis of lower extremities, unspecified*|
|451.81||Phlebitis and thrombophlebitis of other sites, Iliac vein*|
|451.9||Phlebitis and thrombophlebitis of unspecified site*|
|453.2||Other venous embolism and thrombosis of inferior vena cava|
|453.40||Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity|
|453.41||Acute venous embolism and thrombosis of deep vessels of proximal lower extremity|
|453.42||Acute venous embolism and thrombosis of deep vessels of distal lower extremity|
|453.89||Acute venous embolism and thrombosis of other specified veins*|
|453.9||Other venous embolism and thrombosis of unspecified site*|
|997.2||Phlebitis or thrombophlebitis during or resulting from a procedure*|
ICD-9 Codes for Upper-Extremity DVT
|451.83||Phlebitis and thrombophlebitis of deep veins of upper extremities|
|451.84||Phlebitis and thrombophlebitis of upper extremities, unspecified*|
|451.89||Phlebitis and thrombophlebitis of other sites|
|453.82||Acute venous embolism and thrombosis of deep veins of upper extremity|
|453.83||Acute venous embolism and thrombosis of upper extremity, unspecified|
|453.84||Acute venous embolism and thrombosis of axillary veins|
|453.85||Acute venous embolism and thrombosis of subclavian veins|
|453.86||Acute venous embolism and thrombosis of internal jugular veins|
|453.87||Acute venous embolism and thrombosis of other thoracic veins|
*Some of these events may represent superficial VTE or, in the case of 997.3, complications other than VTE. Further chart review is desirable for these codes.
Codes for obstetrics-related VTE are included in this appendix. Tracking these events is optional and can be pursued if your medical center has high volumes of obstetric patients.
ICD-9 Codes for Obstetrics VTE
|634.60||Spontaneous abortion complicated by embolism, unspecified|
|634.61||Spontaneous abortion complicated by embolism, incomplete|
|634.62||Spontaneous abortion complicated by embolism, complete|
|635.60||Legally induced abortion complicated by embolism, unspecified|
|635.61||Legally induced abortion complicated by embolism, incomplete|
|635.62||Legally induced abortion complicated by embolism, complete|
|637.60||Unspecified abortion complicated by embolism, unspecified|
|637.61||Unspecified abortion complicated by embolism, incomplete|
|637.62||Unspecified abortion complicated by embolism, complete|
|638.6||Failed attempted abortion complicated by embolism|
|639.6||Complications following abortion and ectopic and molar pregnancies, embolism|
|671.30||Deep phlebothrombosis, antepartum, unspecified|
|671.31||Deep phlebothrombosis antepartum, delivered|
|671.33||Deep phlebothrombosis, antepartum|
|671.40||Deep phlebothrombosis, postpartum, unspecified|
|671.42||Deep phlebothrombosis, postpartum, delivered|
|671.44||Deep phlebothrombosis, postpartum|
|671.50||Venous complications in pregnancy and the puerperium, Other phlebitis and thrombosis, unspecified|
|671.51||Venous complications in pregnancy and the puerperium, Other phlebitis and thrombosis, delivered|
|671.52||Venous complications in pregnancy and the puerperium, Other phlebitis and thrombosis, delivered with mention of postpartum complication|
|671.53||Venous complications in pregnancy and the puerperium, Other phlebitis and thrombosis, antepartum|
|671.54||Venous complications in pregnancy and the puerperium, Other phlebitis and thrombosis, postpartum|
|671.90||Unspecified venous complication of pregnancy and the puerperium, unspecified|
|671.91||Unspecified venous complication of pregnancy and the puerperium, delivered|
|671.92||Unspecified venous complication of pregnancy and the puerperium, delivered with mention of postpartum complication|
|671.93||Unspecified venous complication and the puerperium, antepartum|
|671.94||Unspecified venous complication and the puerperium, postpartum|
|673.20||Obstetrical pulmonary embolism, unspecified|
|673.21||Obstetrical pulmonary embolism, delivered|
|673.22||Obstetrical pulmonary embolism, delivered with mention of postpartum complication|
|673.23||Obstetrical pulmonary embolism, antepartum|
|673.24||Obstetrical pulmonary embolism, postpartum|
C.6. Strategy To Monitor for Bleeding Complications With Administrative Codes
- Exclude those <18 years of age, length of stay <2 days.
- Include only diagnoses with a present on admission (POA) indicator of N (No) or U (Undetermined).
- Patients readmitted within 30 days with POA = Y (Yes) (May want to exclude these readmitted patients if looking exclusively at prophylactic anticoagulant adverse drug events [ADEs].)
- Patients who were exposed to anticoagulant of interest—unfractionated heparin, low molecular weight heparin (enoxaparin, tinzaparin, dalteparin), warfarin, fondaparinux, rivaroxaban, dabigatran, argatroban, bivalrudin, and lepirudin. Customize the list of anticoagulants and doses as required, based on your formulary, and whether you want to capture ADEs from prophylactic anticoagulation, therapeutic anticoagulant, or both.
ICD-9 Codes Associated With Inpatient Hemorrhage (Principal and Secondary Codes)
|432.X||Other and unspecified intracranial hemorrhage|
|569.3||Hemorrhage of rectum and anus|
|578.1||Blood in stool|
|578.9||Hemorrhage of gastrointestinal tract, unspecified|
|964.2||Poisoning by anticoagulants|
|E858.2||Accidental poisoning by agents primarily affecting blood constituents|
|E934.2||Anticoagulants causing adverse effects in therapeutic use|
- Adult discharges with ICD-9 codes indicative of significant hemorrhage are limited to those patients who were also exposed to pertinent anticoagulant medications during their stay.
- The same limitations of accuracy of ICD-9 coding seen with HA-VTE apply to this measure.
- Monthly chart review is recommended for those using this strategy.
- Chart review should focus on validating that a hemorrhage occurred and, if so, determining whether the anticoagulant could have conceivably contributed to the hemorrhage. Note that it is difficult to determine if the anticoagulant exposure preceded the diagnosis of hemorrhage by electronic means alone (i.e., without manual review). Finally, if harm did occur in the presence of an anticoagulant, undertake a review to determine if the anticoagulant was being used appropriately—and a search for potentially remedial causes.
Variations and Other Comments
- Bleeding events can be categorized as being associated with therapeutic versus prophylactic doses of anticoagulation.
- Since bleeding events can occur in the absence of anticoagulation, attributing the bleeding event to prophylactic doses of anticoagulation with any accuracy is difficult. However, conducting case review and tracking the overall rate of anticoagulant-related hemorrhage over the course of a VTE prevention effort can be useful.
- Which anticoagulants to include may vary by protocol and the underlying focus of the improvement team.
- Different methods for monitoring bleeding may be complementary.