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JCAHO DVT Risk Assessment Measures

Henry I. Bussey, Pharm.D.
June, 2006

Recently the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) posted for open comment 19 proposed measures of DVT risk assessment, treatment, and outcomes. ClotCare encouraged its readers to provide their input. Although we have not seen information summarizing the public input on the 19 proposed measures, as of April, 2006, JCAHO has announced that 10 of the 19 proposed measures (listed below) will go forward with continued evaluation. Apparently, these will not take effect immediately because JCAHO plans to conduct an alpha test of these measures in the summer of 2006 and reassess the feasibility of implementing the measures and/or what modifications need to be made. The alpha test will be followed with a pilot trial in 2007. For more details of this process and related information to the development of these measures, visit the JCAHO website at http://www.jointcommission.org/
PerformanceMeasurement/PerformanceMeasurement/
National+Consensus+Standards+for+Prevention+and+
Care+of+Venous+Thromboembolism+(VTE).htm.

Risk Assessment/Prophylaxis

• Documentation of Venous Thromboembolism Risk Assessment (RA)/Prophylaxis within 24 Hours of Hospital Admission
• Documentation of Venous Thromboembolism Risk Assessment (RA)/Prophylaxis within 24 Hours of Transfer to ICU

Treatment

• Documentation of Inferior Vena Cava Filter Indication
• Venous Thromboembolism Patients with Overlap of Parenteral and Warfarin Anticoagulation Therapy
• Venous Thromboembolism Patients Receiving Unfractionated Heparin with Platelet Count Monitoring
• Venous Thromboembolism Patients with Renal Insufficiency that Received Reduced/Discontinued Anticoagulation Therapy
• Venous Thromboembolism Patients Receiving Unfractionated Heparin Management by Nomogram/Protocol
• Venous Thromboembolism Discharge Instructions

Outcome

• Venous Thromboembolism Patients with International Normalized Ratio > 6 After Initiation of Warfarin Therapy
• Incidence of Potentially Preventable Hospital-Acquired Venous Thromboembolism

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