[CQM-7138] CMS 108 & CMS 190- General or Neuraxial Anesthesia- timing Created: 07/26/24  Updated: 03/06/25  Resolved: 07/31/24

Status: Closed
Project: eCQM Issue Tracker
Component/s: None

Type: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals Priority: Moderate
Reporter: Cari Ann Jones Assignee: Mathematica EH eCQM Team
Resolution: Answered Votes: 0
Labels: None

Attachments: PNG File image-2024-08-01-07-37-18-561.png    
Contact Name: cari jones
Contact Email: cari.jones@integrishealth.org
Contact Phone: 4054738842
Institution/Name: integris healthcare
Solution: Thank you for your question on CMS108/VTE-1 and CMS190/VTE-2. The time part of General or Neuraxial Anesthesia performed dateTime is not considered during the evaluation, as long as they are on the same day. But please note the measure is looking for
1. VTE Prophylaxis was given between the day of arrival "Hospitalization" and the day after hospital admission (IP admission).
2. If a patient had a surgery, the measure is look for VTE Prophylaxis was given on the day of or day after the surgery, only when the General or Neuraxial Anesthesia end on the day after inpatient admission date for VTE-1 / day after ICU admission for VTE-2.
Solution Posted On:
2024 Reporting Period EH/CAH eCQMs:
CMS0108v12
Last Commented Date:

 Description   

Is there a scenario where GEN or Neuraxial Anesthesia element would not be considered because the timing of the surgery was prior to the IP status? 

If a patient had surgery and then was admitted as IP to the hospital, when does the "hospitalization" begin and when does the "encounter" begin? 

 Comments   
Comment by Joelencia Leflore [ 08/08/24 ]

Thank you for the follow-up question. The answers to your questions.
 

  1.  The anesthesia occurs must end the day after end the day of OR the day after IP/ICU admission. When the Anesthesia ends on the day of IP or ICU admission, the timing condition will be the same as the timing of "VTE Prophylaxis Received on Day of or Day After IP /First ICU". When the anesthesia ends on the day AFTER IP/ICU will make difference, which "VTE Prophylaxis Received on Day of or Day After Procedure". For example, 1).  ICU admission on 1/2/2024, Anesthesia ends on same day on 1/2/2024, VTE Prophylaxis must be given on 1/2/2024 or 1/3/2024 to meet the numerator. 2). ICU admission on 1/2/2024, Anesthesia end on 1/3/2024, VTE Prophylaxis given on 1/4/2024 will also meet the numerator in addition given on 1/2/2024 or 1/3/2024.
  2. The example given above answers your question #2.
  3. Both relevantDateTime and relevantPeriod is used in the logic express because of   the function "NormalizeInterval"(), where given a datetime and a period, returns the period (if a period is provided) or the interval beginning and ending on the datetime (if a datetime is provided). 

To learn more about VTE measures and logic, please explore our webinar content here  https://www.jointcommission.org/measurement/quality-measurement-webinars-and-videos/expert-to-expert-webinars/#sort=%40resourcedate%20descending

Comment by Joelencia Leflore [ 08/01/24 ]

Thank you for the follow-up question. We will review your ticket and provide a response as soon as possible.

Comment by Cari Ann Jones [ 08/01/24 ]

Thank you so much.  You stated, "..., only when the General of Neuraxial Anesthesia end on the day after inpatient admission date for VTE-1 / day after ICU admission for VTE-2."  This sounds like the patient has to be admitted to IP or ICU first and then has a procedure that ends the day after.

1) To clarify, are you saying that the procedure for which this anesthesia occurs must end the day after the inpatient/ICU admission?

Or can end the day of OR the day after IP/ICU admission? 

2) Am I correct in that the time of the General or Neuraxial Anesthesia is irrelevant to the measure requirements.  It's strictly looking for what VTE interventions occurred day of or day after a Procedure that ended no later than the day after IP/ICU admit? 

3) I'm having trouble understanding the following logic and how it pertains to this particular question.  Please elaborate

 

 

 

Comment by Joelencia Leflore [ 07/29/24 ]

Thank you for submitting your question. We will review your ticket and provide a response as soon as possible.

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