Organizational Identifiers VAMC CONTROL QIC BEGDTE REVDTE Facility ID Control Number Abstractor ID Abstraction Begin Date Abstraction End Date Auto-fill Auto-fill Auto-fill Auto-fill Auto-fill Patient Identifiers SSN PTNAMEF PTNAMEL BIRTHDT SEX MARISTAT RACE Patient SSN First Name Last Name Birth Date Sex Marital Status Race Auto-fill: no change Auto-fill: no change Auto-fill: no change Auto-fill: no change Auto-fill: can change Auto-fill: no change Auto-fill: no change Administrative Data
21 vtesurg Was a surgical procedure performed using general or neuraxial anesthesia the day of or the day after hospital admission? 1,2 If 2 and vteprin is on Joint Commission Table 7.01, 8.1 or 8.2, go to icuvte; else if 2, auto-fill vtesurdt as 99/99/9999, and go to vtepro If unable to determine if the patient had a surgical procedure and/or whether general or neuraxial anesthesia was used from the medical record documentation, select “2.” Inclusion Guidelines for Abstraction: General Anesthesia: Inhaled gases, Intravenous, Endotracheal, Laryngeal mask airway, or anesthesia (LMA) Neuraxial Anesthesia; Spinal block, Epidural block, Spinal anesthesia, Subarachnoid blocks Exclusion Guidelines for Abstraction: Conscious sedation, Monitored anesthesia care (MAC), Local with sedation , Local with stand-by, Peripheral nerve blocks, Saddle block, Deep sedation 22 vtesurdt Enter the surgery end date. mm/dd/yyyy Will be auto-filled as 99/99/9999 if vtesurg = 2 Abstractor can enter 99/99/9999 If a patient leaves the operating room with an open incision (for closure at a later date/time), use the Surgery End Date of the initial procedure. Do NOT use the date the patient returns to the OR for closure. If unable to determine the surgery end date after reviewing the medical record documentation, enter 99/99/9999. VTE Prophylaxis
25 noadmpro Is there documentation of a reason VTE prophylaxis was not administered the day of or day after hospital admission (or day of surgery or day after surgery end date)? 1. Yes 2. No 95. Not applicable 1,2,95 Will be auto-filled as 95 if vteproA <> -1 Documentation of the reason for not administering VTE prophylaxis must be written by the day after hospital admission or Surgery End Date (for surgeries that start the day of or the day after hospital admission). It is not necessary to review documentation outside of this timeframe to answer this data element. Physician/APN/PA or pharmacist documentation of reason for not administering VTE prophylaxis is required with the EXCEPTION of nursing documentation of patient/family refusal or completion of a VTE risk assessment form by a nurse. A completed VTE risk assessment within this timeframe is an acceptable source for this data element. For patients on continuous IV heparin therapy the day of or day after hospital admission, select “Yes.” For patients on warfarin therapy prior to admission, but placed on hold due to “high INR”, select “Yes.” Both the pharmacological and mechanical approaches must be assessed to answer “Yes” to this data element. For example, if there is physician documentation of “bleeding, no pharmacologic prophylaxis needed”, there must also be documentation of a reason why no mechanical prophylaxis was administered to select “Yes.” If either type of prophylaxis was administered, then no reason is required. If documentation of “No VTE Prophylaxis needed” is written, then it will be inferred that both mechanical and pharmacological options were not indicated for the patient. Patient/family refusal may be documented by a nurse, but must be documented on the day of or the day after hospital admission. Patient/family refusal of any form of prophylaxis is acceptable to select “1”. For the purposes of this data element, physician/APN/PA, or pharmacist documentation that the patient is at low risk for VTE or explicit documentation that the patient does not need VTE prophylaxis is acceptable.
31 icusurdt Enter the surgery end date. mm/dd/yyyy Will be auto-filled as 99/99/9999 if icusurg = 2 Abstractor can enter 99/99/9999 Select the surgery end date with the associated surgical procedure performed the day of or the day after ICU admission or transfer. If a patient leaves the operating room with an open incision (for closure at a later date/time), use the Surgery End Date - ICU Admission of the initial procedure. Do NOT use the date the patient returns to the OR for closure. When the date documented is obviously invalid (not a valid format/range), ex: a date after the Discharge Date, before the Surgery End Date – ICU Admission, or in an invalid format and if no other documentation is found that provides the correct information, the abstractor should enter “99/99/9999.” Example: Patient expires on 02-12-20XX and documentation indicates the Surgery End Date was 03-12-20XX. Other documentation in the medical record supports the date of death as being accurate. Since the Surgery End Date – ICU Admission is outside of the parameter for care (after the Discharge Date [death]), enter “99/99/9999”. If the Surgery End Date is incorrect (in error) but it is a valid date and the correct date can be found and supported with other documentation in the medical record, use the correct date for Surgery End Date. If supporting documentation of the correct date cannot be found, the medical record must be abstracted as documented (at “face value”). Examples: The anesthesia form is dated 12-10-2007 and other documentation in the medical record supports that the correct date was 12-10-2009; use the correct date as the Surgery End Date. A Surgery End Date of 11-20-20XX and the Anesthesia Start Date was 11-10-20XX and no other documentation can be found to support the correct date for the Surgery End Date, then it must be abstracted as 11-20-20XX, at face value. ICU VTE Prophylaxis
53 dcovrlap Is there a reason documented by a physician/APN/PA or pharmacist for discontinuation of the overlap therapy? 1,2,95 Will be auto-filled as 95 if rxantidc = 1 Patient refusal may be documented by a nurse. Examples of reasons for discontinuing overlap therapy include, but are not limited to: active bleeding (gastrointestinal or GI bleeding, cerebral hemorrhage, retroperitoneal bleeding), bleeding risk, hemorrhage, risk of bleeding, thrombocytopenia Excluded Data Sources: Any documentation dated/timed after discharge, except discharge summary. IF DCDISPO = 1, 2, or 99 and WARFRXDC = 1, go to PTEDCOM; else go to end. Discharge Instructions