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Anticoagulation Practice Patterns in COVID-19: A Global Survey

Dear Participant,

The knowledge of the venous thromboembolic (VTE) complications associated with coronavirus disease 2019 (COVID-19) has evolved since the pandemic began. The survey below will discuss how your hospital is preventing VTE in patients with COVID-19 and if patients have experienced bleeding or thrombotic complications.

Although you will not get personal benefit from taking part in this survey, your responses will help inform the global community about current practice patterns. Of course, you have a choice about whether or not to complete the survey, but if you do participate, you are free to skip any questions or discontinue at any time.

Your response to the survey is anonymous which means no names will appear or be used on research documents or be used in presentations or publications. The research team will not know that any information you provided came from you.

The survey will take about 5-10 minutes to complete.

If you have any questions regarding the purpose of this study or the use of the data, you may contact the investigators at (rprosovsky@mgh.harvard.edu).

This survey has received exemption from ethics approval by MGH IRB (IRB protocol # 2021P001197). If you’d like to speak to someone not involved in this research about your rights as a research subject, or any concerns or complaints you may have about the research, contact the Mass General Brigham IRB at (857) 282-1900.

Please complete the survey below.

Thank you!

Check all of the patient groups with COVID-19 that anticoagulation as VTE thromboprophylaxis (ie to prevent VTE) is currently being recommended at your institution.
(check all that apply)

No anticoagulant prophylaxis recommended

Non critically ill Hospitalized COVID-19 patients (ie wards)

Critically ill hospitalized patients (ie Intensive care unit)

Post discharge COVID patients

Fulfills criteria for prophylaxis based on my institution's VTE guideline

D-dimer or other inflammatory marker elevation

All patients with COVID-19 (outpatients and inpatients)

Other

Please specify

Expand

Check all of the anticoagulation regimens you are recommending for prophylaxis in critically ill hospitalized (ie intensive care unit) COVID-19 patients.
(do not consider heparin induced thrombocytopenia or adjustments for renal function, check all that apply)

Prophylactic fixed dose low molecular weight heparin

Intermediate dose low molecular weight heparin

Therapeutic low molecular weight heparin

Prophylactic fixed dose unfractionated heparin

Weight adjusted unfractionated heparin

Therapeutic unfractionated heparin

Prophylactic dose Fondaparinux

Therapeutic Fondaparinux

Prophylactic Direct oral anticoagulant

Therapeutic Direct oral anticoagulant

Low dose Aspirin

Full dose Aspirin

Other

Please specify

Expand

Check all of the anticoagulation regimens you are recommending for prophylaxis in non- critically ill hospitalized (ie wards) COVID-19 patients.
(do not consider heparin induced thrombocytopenia or adjustments for renal function, check all that apply)

Prophylactic fixed dose low molecular weight heparin

Intermediate dose low molecular weight heparin

Therapeutic low molecular weight heparin

Prophylactic fixed dose unfractionated heparin

Weight adjusted unfractionated heparin

Therapeutic unfractionated heparin

Prophylactic dose Fondaparinux

Therapeutic Fondaparinux

Prophylactic Direct oral anticoagulant

Therapeutic Direct oral anticoagulant

Low dose Aspirin

Full dose Aspirin

Other

Please specify

Expand

In which patient populations are you recommending escalation to intermediate dose anticoagulation for prophylaxis (ie to prevent VTE)?
(check all that apply)

None

All hospitalized patients

Critically Ill (i.e. Intensive Care Unit)

Elevated SOFA score (specify threshold level in "other" field)

Elevated Sepsis Induced Coagulopathy Score (specify threshold level in "other" field)

Elevated DIC Score (specify threshold level in "other" field)

D-dimer 2-3X Upper limit of normal

D-dimer 4-5X Upper limit of normal

D-dimer >6X Upper limit of normal

Elevated fibrinogen (specify threshold level in "other" field)

Elevated ferritin (specify threshold level in "other" field)

Rising high-sensitivity troponin (specify threshold level in "other" field)

Obese patients

Additional VTE risk factor (i.e. Cancer, prior VTE)

Other

Please specify

Expand

In which patient populations are you recommending escalation to therapeutic dose anticoagulation for prophylaxis (ie to prevent VTE) ?
(check all that apply)

None

All hospitalized patients

Critically Ill (i.e. Intensive Care Unit)

Elevated SOFA score (specify threshold level in "other" field)

Elevated Sepsis Induced Coagulopathy Score (specify threshold level in "other" field)

Elevated DIC Score (specify threshold level in "other" field)

D-dimer 2-3X Upper limit of normal

D-dimer 4-5X Upper limit of normal

D-dimer >6X Upper limit of normal

Elevated fibrinogen (specify threshold level in "other" field)

Elevated ferritin (specify threshold level in "other" field)

Rising high-sensitivity troponin (specify threshold level in "other" field)

Obese patients

Additional VTE risk factor (i.e. Cancer, prior VTE)

Other

Please specify

Expand

If you are using therapeutic dose for thromboprophylaxis in COVID-19 patients, what regimen are you recommending?
(do not consider heparin induced thrombocytopenia or adjustments for renal function, check all that apply)

Low Molecular Weight Heparin

Unfractionated Heparin

Fondaparinux

Direct oral anticoagulant

Vitamin K antagonist

Intravenous Direct Thrombin Inhibitor (i.e. bivalirudin or argatroban)

Other

Please specify

Expand

In which patient populations are you recommending extended VTE prophylaxis ?
(i.e. after hospital discharge, check all that apply)

I am not recommending VTE prophylaxis after hospital discharge

Critically ill (ICU) patients

All hospitalized patients

Based upon age (note age cut off under other)

D-dimer >2X upper limit of normal

History of VTE

History of Cancer

Combination of risk factors used in clinical trials (e.g. MARINER, APEX, etc)

Obesity

Pregnancy

Other

Please specify

Expand

Which prophylactic anticoagulant are you recommending for extended VTE prophylaxis?
(check all that apply)

Apixaban

Rivaroxaban

Betrixaban

Low molecular weight heparin

Edoxaban

Dabigatran

Warfarin

Other anticoagulant

Please specify

Expand

For how long are you recommending prophylactic anticoagulant for extended VTE prophylaxis in COVID-19 patients being discharged from the hospital?
(check all that apply)

7 days

30 days

60 days

90 days

Other

Please specify

Expand

In which COVID-19 patients does your hospital perform compression ultrasound to screen for deep vein thrombosis in hospitalized patients?
(check all that apply)

All patients upon hospital admission

All ICU patients

Only patients with clinical symptoms of deep vein thrombosis (extremity swelling/pain, line malfunction)

Based on D-dimer results

Ultrasound not possible because of patient isolation

Other

Please specify

Expand

In which situations would you initiate empiric treatment for VTE in case objective tests such as CTPA, VQ scan, or CUS were not available? (check all that apply)

High risk based on assessment by clinical scoring tools (e.g. Wells, YEARS, Geneva)

Unilateral extremity swelling

Intravenous line malfunction

Worsening respiratory status (oxygenation, respiratory rate)

Hemodynamic decompensation (hypotension, tachycardia)

Rising D-dimer elevation

Require Prone positioning

Change in dead space fraction during mechanical ventilation

Right heart strain on bedside echocardiogram

Other

Please specify

Expand

Which of the following tests are you getting at baseline in COVID-19 patients?
(check all that apply)

CBC

Basic metabolic panel

Comprehensive metabolic panel

D-dimer

Creatinine kinase (CPK)

PT/INR

aPTT

Fibrinogen

Thromboelastography (TEG) or ROTEM Antithrombin activity

Ferritin

C-reactive protein

Sedimentation rate (ESR)

Procalcitonin

Lactate dehydrogenase

Lactate/lactic acid

IL-6

ADAMTS-13

von Willebrand factor activity

Antiphospholipid antibodies

Other

Please specify

Expand

Which of the following tests are you monitoring in COVID-19 patients 3 or more times a week?
(check all that apply)

CBC

Basic metabolic panel

Complete metabolic panel

D-dimer

Creatinine kinase (CPK)

PT/INR

aPTT

Fibrinogen

Thromboelastography (TEG) or ROTEM Antithrombin activity

Ferritin

C-reactive protein

Sedimentation rate (ESR)

Procalcitonin

Lactate dehydrogenase

Lactate/lactic acid

IL-6

ADAMTS-13

von Willebrand factor activity

Other

Please specify

Expand

Which bleeding complications have your patients with COVID-19 experienced?
(check all that apply)

None of my patients have had bleeding

Minor bleeding

Major bleeding (i.e. overt bleeding with hemoglobin dropped at least 2 gram/dL or requiring transfusion of 2 units PRBC, bleeding in critical site such as intracranial, retroperitoneal, intraspinal, fatal bleeding)

Clinically relevant non-major bleeding (i.e. requires intervention not meeting major bleeding criteria)

In what sites have bleeding occurred in COVID -19 patients at your institution?
(check all that apply)

Mucous membranes (i.e. epistasis, gum bleeding)

Skin (i.e. bruising or line related)

Lungs (i.e. hemoptysis or alveolar hemorrhage)

Gastrointestinal (i.e. hematemesis, melena, hematochezia)

Genitourinary (i.e. hematuria, vaginal bleeding)

Intracranial or intraspinal

Retroperitoneal

Other

Please specify

Expand

At what dose of anticoagulation have bleeding complications occurred in COVID -19 patients at your institution? (check all that apply)

No anticoagulation

Prophylactic dose

Intermediate dose

Therapeutic dose

Which thromboembolic complications have occurred in your COVID-19 patients?
(check all that apply)

None of my patients have had thromboembolism

Pulmonary embolism

Lower extremity deep vein thrombosis

Upper extremity deep vein thrombosis

Superficial vein thrombosis

Intracardiac thrombosis

Splanchnic vein thrombosis

Cerebral vein thrombosis

Dialysis or Continuous Renal Replacement Therapy (filter loss or line occlusions)

Mechanical circulatory support (i.e. ECMO, VAD; oxygenator or cannula thrombosis)

Myocardial infarction

Ischemic stroke

Peripheral artery embolus

Sudden death with concern for thrombosis

High clinical suspicion for VTE but unable to undertake diagnostic testing

Other

Please specify

Expand

What is the approximate incidence of VTE in all hospitalized COVID-19 patients at your institution?

1-5%

6-10%

11-15%

16-20%

21-30%

31-40%

41-50%

>50%

I don't know

reset

What is the approximate incidence of VTE in ICU patients with COVID-19 at your institution?

1-5%

6-10%

11-15%

16-20%

21-30%

31-40%

41-50%

>50%

I don't know

reset

At what dose of anticoagulation have thromboembolic complications occurred?
(check all that apply)

No anticoagulation

Prophylactic dose

Intermediate dose

Therapeutic dose

Which COVID VTE guidelines do you follow?
(check all that apply)

I follow no guidelines

American College of Chest Physicians (ACCP)

American College of Cardiology (ACC)

American Society of Hematology (ASH)

NIH COVID-19 guidelines

Anticoagulation Forum (ACF)

Center for Disease Control (CDC)

International Society of Thrombosis and Hemostasis (ISTH)

NICE guidelines

World Health Organization guidelines

My institution's developed guidelines

Other

Please specify

Expand

Have you been involved in developing any COVID VTE guidelines?
(Check all that apply)

I am not involved in developing guidelines

American College of Chest Physicians (ACCP)

American College of Cardiology (ACC)

American Society of Hematology (ASH)

NIH COVID-19 guidelines

Anticoagulation Forum (ACF)

Center for Disease Control (CDC)

International Society of on Thrombosis and Haemostasis (ISTH)

NICE guidelines

World Health Organization guidelines

My institution's guidelines

Other

Please specify

Expand

Where do you learn about the most up to date information related to COVID and VTE?
(Check all that apply )

Colleagues

Facebook

Twitter

Medical journals

Medical conference

Newspapers/TV News

Doximity

Webinars

Other

Please specify

Expand

Are or have there been any COVID-19 thromboprophylaxis trials conducted at your institution?
(check all that apply)

None are open at my institution

Outpatient thromboprophylaxis trial

Inpatient thromboprophylaxis trial

Post discharge thromboprophylaxis trial

Not sure

Other

Please specify

Expand

Have you adopted any other practices related to the evaluation or treatment of COVID-19 patients for hematological issues?

Expand

How many COVID-19 patients have been admitted to your hospital since the start of the pandemic?

<100

100-250

251-500

501-1000

1001-3000

>3000

I don't know

reset

How many COVID-19 patients have you taken care of personally or been consulted on since the start of the pandemic?

<10

11-25

26-50

51-100

101-250

251-500

>500

reset

In what country do you practice?

Please specify

What region of the United States do you practice?

Northeast

Southeast

Midwest

South

Northwest

Southwest

Other

reset

Please specify

How many years have you been in practice?

< 5 years

5-10 years

11-15 years

16-20 years

21-25 years

26-30 years

31-35 years

>35 years

reset

What types of patients do you see?

Pediatrics

Adults

Both Pediatrics and Adults

reset

What is your specialty?
(check all that apply)

Hematology

Medical Oncology

Vascular Medicine

Cardiology

Pulmonary/Critical Care/Intensivist

General Internal Medicine/Hospitalist

General Pediatrics

Other

Please specify

What is the name of your hospital?
(this is so we can identify experience within or between institutions)

Expand

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