Non ICU patients only in "ICU" named location-VTE 1 and VTE2 location logic

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Tammie Trefz
    • 785-331-9973
    • CommonSpirit Health
    • Hide
      Thank you for your inquiry on CMS108v13, Venous Thromboembolism Prophylaxis, and CMS190v13, Intensive Care Unit Venous Thromboembolism Prophylaxis. Boarding inpatients in the ICU due to bed availability will put those patients in the VTE-2 measure's denominator and assess the ICU location LOS in the VTE-1 denominator exclusion.
      However, for the circumstance you described, this unit is no longer providing ICU care and used to care for telemetry patients. Therefore, we recommend re-mapping this unit location to the appropriate/proper location type to prevent non-ICU patients from being evaluated in the VTE-2 measure.
      Show
      Thank you for your inquiry on CMS108v13, Venous Thromboembolism Prophylaxis, and CMS190v13, Intensive Care Unit Venous Thromboembolism Prophylaxis. Boarding inpatients in the ICU due to bed availability will put those patients in the VTE-2 measure's denominator and assess the ICU location LOS in the VTE-1 denominator exclusion. However, for the circumstance you described, this unit is no longer providing ICU care and used to care for telemetry patients. Therefore, we recommend re-mapping this unit location to the appropriate/proper location type to prevent non-ICU patients from being evaluated in the VTE-2 measure.
    • CMS0190v13
    • Accurate location logic

      An organization has a unit with "ICU" in the name. The organization has made the decision to use this unit to care for telemetry patients that are overflow from another unit and state no ICU patients are being taken care of on this unit. 

      They state "We have a program flex through the health department for this location to be Telemetry. " Hospital will place of telemetry patients in (unit name) - in consideration of infection prevention and health and safety of the patients and others in each room. The patients in this area will be under the oversight of nursing and medical leadership for telemetry services."

      In review of the guidance in the VTE-02 specifications, "The definition of an ICU for the purpose of the measures noted above is that used by the CDC in the NHSN Patient Safety Project. An intensive care unit can be defined as a nursing care area that provides intensive observation, diagnosis, and therapeutic procedures for adults and/or children who are critically ill. An ICU excludes nursing areas that provide step-down, intermediate care or telemetry only and specialty care areas."

      With this information, is it appropriate to adjust mapping of this location so that it is not considered an ICU location by the VTE-1 and VTE-2 measure logic, even though it has "ICU" in the name?

      Additionally, if appropriate to change mapping of this location so that it is not considered an ICU location, and the organization is selected for validation, would additional information need to be provided to CDAC for each VTE case that was in this location?

      Thank you

            Assignee:
            Augustine Weber
            Reporter:
            Tammie Trefz
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