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Covid-19 Interim Clinical Guidance - VTE Protocol and Patient Information for Acute Hospitals (CD19-120-001 04.05.22)

• Background

• Recommendations

• Patient Information

• VTE Prevention Protocol for In-Patients aged 16 or Over with COVID-19 or Medical Conditions

• Key References

• Next Review

• This guidance is to clarify current recommendations for prevention of VTE and patient information for hospitalised adult medical or COVID-19 patients.

VTE Protocol Development Group (version 1): C Kirke (Clinical Lead, Medication Safety Programme, National QI Team), F Ni Áinle (Consultant Haematologist, Rotunda and Mater), D O’Keeffe (Consultant Haematologist, University Hospital Limerick), C Bergin (Clinical Lead, Infectious Diseases, HSE and Consultant in Infectious Diseases, St James’s), V Hamilton (National Clinical Advisory and Group Lead, HSE Acute Operations and Consultant Anaesthetist, University Hospital Waterford), M Pate, A Cronin (Medication Safety Programme, HSE National QI Team). 

VTE Protocol Development Group (update, version 2): C Kirke, M Pate, G Molloy (Medication Safety Programme, National Quality & Patient Safety Directorate), F Ni Áinle (Consultant Haematologist, Rotunda and Mater), N O’Connell (Consultant Haematologist, St James’s Hospital), D O’Keeffe (Consultant Haematologist, UHL), C Bergin (Clinical Lead, Infectious Diseases, HSE and Consultant in Infectious Diseases, St James’s), M O’Connor (NCAGL, HSE Acute Operations and Consultant Geriatrician, CUH), A Nichol (Consultant in Critical Care Medicine, SVUH), N O’Hanlon (Chief II Pharmacist, Medicines Information, SVUH), B Cleary (Chief Pharmacist, Rotunda Hospital).

VTE Patient Information Development Group: AM O’Neill (CEO, Thrombosis Ireland), C Kirke, M Pate, A Cronin, F Ni Áinle.

Purpose: This guidance is to clarify current recommendations for prevention of VTE and patient information for hospitalised adult medical or COVID-19 patients.

Target Audience: All healthcare professionals in acute hospitals (protocol and patient information). All patients in acute hospitals (patient information).
 

Background

Venous thromboembolism (VTE) or blood clots led to or occurred during hospitalisation of 6,772 people in acute public hospitals in 2021. Up to 70% of blood clots associated with hospitalisation are considered to be potentially preventable with appropriate prophylaxis depending on patient and disease factors. COVID-19 is associated with an increased risk of VTE in hospitalised patients
 

Recommendations

The HSE VTE protocol template includes recommendations for adult patients admitted to acute hospitals with COVID-19, together with all adult medical patients. The template has been updated in April 2022 and should replace previous versions in use.

All adult patients admitted to hospital, including patients with COVID-19, require:

• Risk assessment of the patient’s risk of VTE and bleeding, with VTE prophylaxis prescribed and administered as appropriate.
• Patient information (including provision of HSE/Thrombosis Ireland VTE alert card).  

For patients deemed to be at high VTE risk (due to COVID-19 or Padua Prediction Score of 4 or greater), we suggest:

Prophylactic-intensity low molecular weight heparin (LMWH) or unfractionated heparin (unless contra-indicated due to bleeding risk), if the patient has:

• Severe COVID-19 infection (requiring critical care level treatment including high flow oxygen, invasive or non-invasive ventilation, vasopressors),
• Mild-moderate COVID-19 infection who do not have oxygen saturations of 93% or less on room air or low-flow oxygen, and who do not have an elevated bleeding risk.  This may include patients who test positive for COVID-19, who require admission from other medical illnesses,
• Medical patients with no evidence of COVID-19.

Therapeutic-intensity LMWH* may be considered in patients admitted to hospital because of moderate COVID-19** AND who have a low bleeding risk *for the purpose of reducing risk of death, invasive mechanical ventilation, non-invasive mechanical ventilation, or admission to ICU

**Moderate COVID-19 is defined as follows: admission to hospital ward level of care (i.e. not to ICU), not already mechanically ventilated, and not imminently requiring mechanical ventilation or critical care. We suggest that this therapeutic strategy be limited to patients who have oxygen saturations of ≤ 93% on room air due to COVID-19, or who require low-flow oxygen via nasal prongs or face mask to maintain normal oxygen saturations.                                                                                                            

This suggestion also applies to patients who are admitted for another reason but who progress to develop moderate COVID-19. The evidence supports prophylactic intensity LMWH for all other patients with COVID-19 (unless contra-indicated), including those with severe COVID-19.

Patients with COVID-19 should be re-assessed regularly, with VTE prevention adjusted if their condition or level of care changes.  Note that this may include a return to prophylactic-intensity LMWH if patient progresses to severe COVID-19.  

Medical patients and patients with COVID-19 assessed to be high-risk for VTE but with contra-indications to LMWH or heparin should receive mechanical VTE prophylaxis unless contra-indicated. Measure and select the appropriate size(s). Assess fit, compliance and skin integrity at least daily.

Patient information

Hospitals are asked to ensure patients in all high-risk groups receive the information in these cards.

Blood clot alert cards are available to download from www.safermeds.ie and supplies of alert cards are available from safermeds@hse.ie. Patient and public information as well as alert cards are available translated into multiple languages from www.thrombosisireland.ie.

VTE Prevention Protocol for In-Patients aged 16 or Over with COVID-19 or Medical Conditions

Key References

1. Barbar, S. et al. The Padua Prediction Score. J Thromb Haemost 2010; 8:2450-7
2. UKCPA HAT Committee QA326.2. Doses of thromboprophylaxis in extremes of body weight. Feb 2017
3. Summaries of Product Characteristics, www.hpra.ie
4. The ATTACC, ACTIV-4a, and REMAP-CAP Investigators. Therapeutic Anticoagulation with Heparin in Critically Ill Patients with Covid-19. N Engl J Med, 2021. 385(9): p. 777-789.
5. The ATTACC, ACTIV-4a, and REMAP-CAP Investigators. Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19. N Engl J Med, 2021. 385(9): p. 790-802.
6. Sholzberg, M., et al. Effectiveness of therapeutic heparin versus prophylactic heparin on death, mechanical ventilation, or intensive care unit admission in moderately ill patients with covid-19 admitted to hospital: RAPID randomised clinical trial. BMJ, 2021. 375: p. n2400.
7. Spyropoulos, A.C., et al. Efficacy and Safety of Therapeutic-Dose Heparin vs Standard Prophylactic or Intermediate-Dose Heparins for Thromboprophylaxis in High-risk Hospitalized Patients With COVID-19: The HEP-COVID Randomized Clinical Trial. JAMA Intern Med, 2021.
8. Lopes, R.D., et al., Therapeutic versus prophylactic anticoagulation for patients admitted to hospital with COVID-19 and elevated D-dimer concentration (ACTION): an open-label, multicentre, randomised, controlled trial. Lancet, 2021. 397(10291): p. 2253-2263.
9. Sholzberg, M., et al., Randomized trials of therapeutic heparin for COVID-19: A meta-analysis. Res Pract Thromb Haemost, 2021. 5(8): p. e12638.
10. British Thoracic Society. Guidance on venous thromboembolic disease in patients with Covid-19. 2021. Available from: https://www.brit-thoracic.org.uk/document-library/quality-improvement/covid-19/bts-guidance-on-venous-thromboembolic-disease-in-patients-with-covid-19/
11. National Institute of Health. Statement on anticoagulation in hospitalized patients. 2022. Available from https://www.covid19treatmentguidelines.nih.gov/therapies/statement-on-anticoagulation-in-hospitalized-patients/
12. Stevens SM, Woller SC, Baumann Kreuziger L, et al. Executive summary: antithrombotic therapy for VTE disease: second update of the CHEST Guideline and Expert Panel Report. Chest. 2021;160(6):2247-2259. doi:10.1016/j.chest.2021.07.056
13. American Society of Hematology. COVID-19 and VTE/Anticoagulation: Frequently Asked Questions. 2022. Available from https://www.hematology.org/covid-19/covid-19-and-vte-anticoagulation
14. National Institute of Health. Antithrombotic Therapy in Patients With COVID-19. 2022. Available from https://www.covid19treatmentguidelines.nih.gov/therapies/antithrombotic-therapy/
15. REMAP-CAP Writing Committee for the REMAP-CAP Investigators. Effect of Antiplatelet Therapy on Survival and Organ Support–Free Days in Critically Ill Patients With COVID-19: A Randomized Clinical Trial. JAMA. Published online March 22, 2022. doi:10.1001/jama.2022.2910https://jamanetwork.com/journals/jama/fullarticle/2790488
16. Moores LK, Tritschler T, Brosnahan S, Carrier, M, et al. Thromboprophylaxis in Patients With COVID-19. A Brief Update to the CHEST Guideline and Expert Panel Report. Chest. Published online Feb 12, 2022. DOI: https://doi.org/10.1016/j.chest.2022.02.006

Next review

September 2022.

Content will be kept under regular review. Please check website for COVID-19 HSE Clinical Guidance and Evidence for most recent update

Covid-19 Interim Clinical Guidance - VTE Protocol and Patient Information for Acute Hospitals (CD19-120-001 05.05.22) (DOWNLOAD PDF)